Readers Write: Prioritize the Patient Experience to Turn Short-Term Telehealth Solutions into Long-Term Ones

Prioritize the Patient Experience to Turn Short-Term Telehealth Solutions into Long-Term Ones
By Ray Costantini, MD, MBA

Ray Costantini, MD, MBA is co-founder and CEO of Bright.md of Portland, OR. This article recaps a recent video conversation he had with Ries Robinson, MD, SVP/chief innovation officer of Presbyterian Healthcare Services of Albuquerque, NM.

When the coronavirus first spread through the US, fears of exposure and lockdown mandates kept patients at home and forced providers to pivot almost exclusively to deliver care virtually. I don’t know of any health systems that navigated that process smoothly and easily, though for the healthcare systems that had already implemented a robust digital strategy, that transition was less painful than for others.

Systems rushed to implement telehealth tools, often repurposed consumer video platforms like Zoom, FaceTime, or Hangouts. This was a reasonable solution for the short term. But after more than seven months of quarantine, doctors and health systems are more comfortable using digital tools for care, and it’s clear that patients will use and expect virtual care options beyond the pandemic. 

So how does a system turn a short-term solution into a long-term one? By prioritizing the patient experience. Here are four ways you can use digital tools to support patients through their journey to receive care, beyond a quick implementation of video tools. 

Provide Free Online Screening

To keep both patients and healthcare workers safe by keeping as many people as possible out of high-contagion areas like the ER and urgent care clinics, one large healthcare system made a free, high-quality, online coronavirus-screening tool available to anyone in the state. Patients who showed potential COVID-19 symptoms or exposure would then be advised to take a test. Everyone else received guidance and education about the virus and any other steps they should take for self-care at home. 

At drive-through testing sites, there were billboards with a QR code that, when scanned, led patients to the online screener they could take while waiting in their cars. One executive at the system noticed many cars leaving the line. Assuming the patient had grown frustrated with the long wait, he approached a few cars to ask why they were leaving. Many of them said after taking the online exam and receiving feedback from a provider, they felt comfortable their symptoms were not COVID-related.

It’s a great example of using a digital tool ahead of an in-person appointment, providing real value for patients and minimizing any frustration for those who didn’t need to wait for a full test.

Bridge the Digital Divide

For some patients, connecting with healthcare providers via video was reassuring and convenient. For many others, though, the digital divide has only grown larger during the pandemic. 

When a healthcare system we work with found that 30% of their patient population was unable to conduct a video visit due to a lack of hardware, bandwidth, affordability, comfort with tech, or language barriers, they implemented digital tools that allowed them to more easily access care. Today, patients need as little as a 3G network connection and can conduct their healthcare interview in Spanish or English.

Ensuring equitable access to virtual care is critical for a successful long-term implementation of digital tools. 

Understand what Patients Want

If 2020 was the year of virtual care, then 2021 will be the year of the patient experience. As the coronavirus crisis changed everyone’s lifestyle and habits, new direct-to-consumer competitors gained traction, and in many cases, the convenience exceeded patient expectations. Health systems are increasingly aware of the need to retain their patients, and re-engage those who they’ve lost to these digitally forward, new-entrant competitors.

The good news for healthcare systems is that patients still trust their own doctor over retail medicine or big tech. As one chief innovation officer at a large health system told me, “If you’re in the business of delivering on patient satisfaction and high-quality care, you’re in a better position of fighting off the competition.”

For the long term, offer care when and how your patients want it: immediately, online, and for not too much money.

Help Providers Focus on Patients

It’s not news that healthcare workers have been severely impacted by the pandemic, whether they are in an ER in a COVID hotspot or struggling to manage a household while delivering care remotely. The stress has led to early retirements and leaves of absence, compounding an already severe physician resource shortage.

Healthcare systems that have managed the crisis well have used digital tools to create elasticity for their providers, giving clinicians more control over their time and from where they can deliver care. Virtual care delivery solutions that automate administrative tasks can also reduce the amount of time it takes to deliver care, so clinicians can help you prioritize the patient experience, instead of focusing on the technology of an appointment. 

It sounds counterintuitive, but a thoughtful implementation of digital tools humanizes healthcare: letting computers or software do the tasks that require repetition, precision, and consistency so that humans are free to do what we’re good at: critical thinking, problem solving, listening patiently, and responding compassionately.

Readers Write: TechQuity: Influencing Health Literacy, Equity, and Disparities in Spanish-Speaking Communities

TechQuity: Influencing Health Literacy, Equity, and Disparities in Spanish-Speaking Communities
By Alejandro Gutierrez, MPH

Alejandro Gutierrez, MPH is team lead, customer success at Activate Care of Boston, MA.

If Hispanics in the United States were a country, they would be the second-largest Spanish-speaking country in the world, and with $1.5 trillion in buying power, the 15th largest consumer economy in the world. According to the latest US Census data, last year marked the first year that more than half of the nation’s population under the age of 16 identified as a racial or ethnic minority. Among this group, Latino or Hispanic and Black residents together comprise nearly 40% of the population. 

The nation is diversifying faster than ever, and Latino and Hispanic communities are at the forefront. Yet we know that language barriers to accessing essential health and social services exist for all non-English speaking populations.

Recently, a study of nearly 20,000 inpatient admissions revealed patients who requested an interpreter were granted access to one only 4% of the time, and that is just for inpatient hospital care. Imagine the situation for outpatient care and social services. As a nation and healthcare system, we must do better. 

These language barriers have a negative impact on the health and well-being of the Hispanic community. Hispanic women contract cervical cancer at twice the rate of white women. Hispanics are more likely to be diagnosed with diabetes and are twice as likely to die of the disease compared to non-Hispanic whites. The stats go on. The outcomes continue. Physicians are less likely to detect depression in Hispanics, and Hispanics are 50% less likely to receive mental health treatment or counseling.

How can the healthcare system work to fix these issues? For starters, with the use of technology, healthcare providers can improve language equity. That will enable the Hispanic patient populations to become part of the majority receiving quality health and social services. 

As a member of the Hispanic community and a current member of a company working to identify SDOH (social determinants of health) in at-risk patients and provide proper care, I understand how complicated navigating healthcare systems can be for native Spanish speakers. I chose to go into public health because of my experience working and living in St. Louis, Missouri. I worked for a non-profit called Athletic Scholars Academy that ran school-based programs in under-resourced communities to promote healthy eating, physical activity, and academic achievement.

For those four years of my life, I listened to the everyday experiences of students, parents, teachers, administrators, and other school community members and learned more than I ever could in a classroom. I was regularly reminded that so many communities around the US do not have access to resources or opportunities for people to be mentally, physically, socially, and economically healthy. I learned that these differences in health are avoidable and are rooted in injustices that disproportionately affect Black and Latino communities. Working to address these avoidable differences in health became my “why” in public health.

My father is Colombian, but grew up in Spain. My mother is Indian, but grew up in Kenya. I am half Indian and half Colombian. My parents were first-generation immigrants when they came to the United States as college students and have been here ever since.

I am a first-generation American, but hearing from my parents and grandparents about the inequities in Kenya, Colombia, and India, I could draw parallels to the inequities – avoidable differences in distribution of resources and opportunities – that disproportionately affect Blacks and Latinos in America. This further reinforces why I wanted to get involved in public health. I continue to use the privilege I have been given from my grandparents and parents to do more to address health inequities in the US.

One of the first things I am lucky to have is my ability to understand and speak Spanish fluently. With that ability, I can help one of the biggest barriers Latinos face. Speaking to Spanish speakers in their native language is the first step in showing Latinos that we in the healthcare industry understand and care about them.  

As a millennial, I see the power that technology can provide in the public health space. We know that many issues of health equity are often embedded in the disconnections between healthcare and social services. Technology can offer a new chance to connect these services across the continuum of care, and can provide a more efficient and secure way of sharing and communicating information across teams that are often disconnected.

Communities across the country are taking ownership of their own abilities to exchange data across sectors. This includes healthcare, but expanding the network to include social services, behavioral / mental health services, schools, jails and courts, government agencies, managed care organizations, and more. These vanguard communities recognize that it is not enough to simply refer individuals back and forth amongst their various organizations; they have to share in the work of the interventions. Screen-and-refer approaches simply move problems from one place to the next. Screen-and-intervene approaches – built around community information exchange, care coordination, and data-driven quality improvement – are key to reducing health disparities, improving health literacy in vulnerable populations, and achieving the health outcomes we all want to see.

Readers Write: Technology Augmented by Behavioral Science Theory Leads to Improved Health

Technology Augmented by Behavioral Science Theory Leads to Improved Health
By Rhea Sheth

Rhea Sheth is a clinical and marketing intern at Carium and an undergraduate student at the University of California, Berkeley studying integrative human biology.

Behavioral science is the study of human behavior. It asks the question: why do we act the way that we do? The simplicity of this question masks a complex science that underlies it.

Understanding human behavior has many invaluable applications in our society. If we can better understand human behavior, we can shape our policies in a way that will better engage individuals or present public health information in a way that will lead to an increased compliance rate.

The intersection of behavioral science and technology is an area of huge opportunity. With the rise of technology, there has also been a rise in the number of opportunities to move healthcare away from a fee-for-service model and instead move towards a value-based approach. The incorporation of behavioral science theory into mobile health platforms can help facilitate the movement towards more patient-centric care and improved health outcomes.

Research-backed behavior change techniques should be intentionally incorporated in digital health platforms to help individuals manage chronic disease. Influencing behavior change in chronically-ill patients is a crucial public health intervention. According to the CDC, 6 in 10 adults in the US have a chronic disease and 4 in 10 adults in the US have two or more chronic diseases.

Smartphone apps are a convenient, cost-effective way to provide behavioral interventions at the appropriate times. In addition, they help reduce healthcare disparities by increasing reach to populations who were previously unreachable due to demographic, socioeconomic, and geographic barriers.

Behavior change techniques can be woven into virtual healthcare tools to help users identify and manage negative behaviors that may be contributing to worsened health outcomes. Self-monitoring is one of the techniques that enable this type of positive behavior change and has been found to lead to reduced hospitalization and readmission rates.

In the context of healthcare, this includes tracking metrics indicative of health-related behaviors such as calories eaten, weight change, and blood pressure levels, often collected through devices such as wearables and fitness trackers. Through digital health platforms, users can track their desired metrics in which they can also see short-term and long-term trends in their health data. This data can be shared with care teams and providers can then keep track of their patients’ health metrics through remote patient monitoring (RPM).

According to the American Heart Association, through RPM, providers can obtain a more holistic view of the patient’s health through data, gain insight into a patient’s adherence to treatment, and develop a deeper patient-provider relationship. RPM can also help reduce healthcare costs by enabling timely health interventions before a patient’s health deteriorates to the point of requiring a costly procedure.

Before the rise of mobile health, self-monitoring was done primarily through paper journal methods, where participants would manually record entries such as calories eaten, blood pressure readings, and blood sugar levels. With recent advances in mobile technology, there are opportunities for more convenient, real-time self-monitoring. Rather than having to carry around a bulky paper journal, individuals can simply enter their data into a mobile device and see their short- and long-term trends.

For an individual with diabetes, taking a daily measurement of blood sugar can help increase awareness about their positive or potentially harmful behaviors. Seeing a huge spike in blood sugar one morning can cause the individual to, first of all, be aware that there is a change in their health, and then reflect on what actions could have caused that. They might remember that they ate three fudge sundaes last night and did not go on their daily walk. The question is, are they now likely to change their behavior?

Here’s where behavioral science comes in again. The act of self-monitoring has increased the probability of behavior change by making the individual aware that there is a change in their health. However, the act of self-monitoring does not guarantee that someone will change their behavior. The next day, the individual may have a craving for ice cream and engage in harmful behavior again.

While they may be aware now that eating ice cream is affecting their blood sugar in such a drastic manner, there may be other underlying factors that cause the individual to perpetuate a negative behavior. It may be that the individual does not understand the consequences of having high blood sugar because they haven’t received information regarding its risks. It may be that they are lonely and feel like no one cares about their health because they do not have frequent access to a healthcare professional. Or, it may be that the individual has a goal of reducing blood sugar but does not know how to achieve that goal and thus becomes demotivated.

To help mitigate the risk of perpetuated negative actions, mHealth apps can integrate different behavior change techniques with self-monitoring to enhance user engagement and increase the probability of behavior change, such as secure messaging and educational materials. Secure messaging is one way for providers and patients to interact and strengthen their relationship, and learning materials such as diabetes-self management education also help improve health outcomes.

Studies show that self-monitoring is more effective in improving health outcomes when used in conjunction with other behavior change techniques in this manner. Self-monitoring was also found to lead to reduced hospitalization and readmission rates.

Making sure technology caters to the complexity of a human being is imperative. Behavior change techniques help us do that. There is no one-size-fits-all solution for behavior change, but intentionally designing technology based on research-backed behavior change techniques has been shown to improve health outcomes. In this way, we make movement away from episodic transactional healthcare and instead towards mutually beneficial, patient-centered, and holistic healthcare.

Much like having a trainer at the gym can motivate people to reach their fitness goals and feel stronger, more confident, and successful, having a digital health platform with specific behavior techniques such as self-monitoring, health coaching, prompts / reminders to take medication, and motivational messages can help patients achieve their health goals.

Readers Write: Remember the Opioid Crisis?

Remember the Opioid Crisis?
By  Peter J. Plantes, MD

Peter J. Plantes, MD is physician executive with HC1 of Indianapolis, IN.

The last few years have ushered in significant progress on the opioid crisis containment front. Acknowledging decades-long misinformation shortfalls, negligence, and improper prescribing patterns, the healthcare industry took important steps on national and state levels to get out in front of devastating statistics.

A March 2020 report suggested the needle was finally pointing in the right direction. The Centers for Disease Control and Prevention (CDC) reported a 13.5% decrease in opioid overdose deaths from 2017 to 2018.

Unfortunately, that report was quickly overshadowed by the global pandemic that brought the nation to its knees. Opioid misuse, like many other critical healthcare priorities, took a back seat to COVID-19. The fallout is notable. A recent analysis points to a spike in opioid overdose cases by 18% since the start of the pandemic.

It’s not just overdose rates that have many across the industry concerned about the current state of the opioid epidemic. Public health officials also report a surge in relapse rates due to limited access to treatment.

The reality is that 2020 has delivered a perfect storm of factors that are contributing to a problematic front for opioid misuse, including mass unemployment and the isolation created by stay-at-home orders that interrupted existing care plans and contributed to an increase in mental health issues. In addition, studies reveal that opioid prescription rates for procedures such as hip and knee replacements continue to rise. Prescription rule changes aimed at helping patients during the pandemic may also have had negative effects by opening the door to increased fraud and “doctor shopping.”

Amid alarming trends, today’s providers face a complicated front at the intersection of increased addiction and appropriate opioid prescribing. Within what is now a highly regulated framework, healthcare organizations must ensure that they are optimizing patient safety by following prescribing guidelines and adhering to ongoing monitoring processes to detect misuse.

This is especially true for patients covered under a population management program of health insurance (ACOs, Medicare Advantage, and HMOs.) Neglecting this opioid substance abuse patient population can result in poor financial performance as well as regulatory scrutiny. NCQA issued additional opioid abuse management measures that are required to be reported as part of HEDIS 2020 standards. These will encourage both:

• Timely “Follow-up After High-Intensity Care for Substance Use Disorder” (FUI), and
• Sustaining “Pharmacotherapy for Opioid Use Disorder” (POD) patients.

In late 2020 and heading into 2021, there is much at stake with the opioid crisis. Healthcare organizations should reprioritize efforts now and increase their engagement to get the opioid trajectory moving in the right direction. It will not be easy, as accessing the right data and complying with guidance remains complex for the average resource-strapped provider.

At a minimum, healthcare organizations need to address the problem by:

1. Taking into account the public health emergency declared by HHS Secretary Alex Azar. This move on January 31, 2020 subsequently lead to the March 18, 2020 clarification from the US Department of Justice Drug Enforcement Agency (DEA) that healthcare professionals can now prescribe a controlled substance to a patient using telehealth technology.
2. Improving leadership through opioid stewardship committees. The Joint Commission mandated that all healthcare facilities implement leadership teams and performance improvement processes in 2018 to address safe opioid prescribing. Opioid stewardship committees can advance best practices by identifying existing gaps and implementing processes that meet best-practice guidelines that include risk assessment, using state implemented Prescription Drug Monitoring Program (PDMP) data, laboratory testing, and patient education. 
3. Conducting optimal patient risk assessments, monitoring, and education. Comprehensive risk assessments seek answers to the following questions: 1) Was a patient assessed for potential risk of misuse prior to a procedure or prescription? 2) Did the provider and patient have an open and honest discussion about whether opioids were the right choice? 3) Did a patient receive monitoring during follow-up care to ensure appropriate use of opioids? 4) Was a patient counseled on proper procedures for disposing unused opioids? These risk assessment standards should especially be part of telehealth-based opioid prescribing.
4. Accessing the right data in the most efficient way possible. Access to PDMP data is a critical first step, but it doesn’t always provide the full picture, especially in cases where patients are doctor-shopping across state lines. Healthcare organizations can extend the value of this data by combining it with dispensing records from multiple states and intelligent drug consistency assessment via laboratory testing to support precision prescribing.

Smart prescribing and oversight of opioid risk is more important than ever, as is equipping providers with easy access to the right patient data for monitoring. Technology that efficiently brings together the right data and delivers it in an actionable way to providers is improving this outlook. Technology that does not hinder the doctor-patient encounter is especially important for effective delivery of safe opioid prescribing practices. The technology must assist the physician in rapidly and completely engaging all required regulatory expectations without creating an administrative bottleneck in the daily practice setting.

Readers Write: Debunking Price Transparency Myths to Enable True Progress

Debunking Price Transparency Myths to Enable True Progress
By Kyle Raffaniello

Kyle Raffaniello, MSHA is CEO of Sapphire Digital of Lyndhurst, NJ.

For years now, the US has had the highest healthcare costs in the world. While high medical costs are nothing new, these costs, in combination with the financial impact of the COVID-19 pandemic, could turn healthcare from unaffordable to unattainable for many Americans. Now more than ever, we must kick the nation’s price transparency conversations into overdrive to increase industry competition and lower the cost of care.

Increasing price transparency in healthcare is not a new goal by any means. The term has been used for years to not much avail, but has gained headlines in recent months because the Trump administration is making it a health policy focus and has announced multiple rules aimed at increasing transparency. However, confusion and uncertainty still linger around what transparency truly means for healthcare and whether it really works.

The truth is that it’s the foundation to making healthcare more affordable for Americans. Unfortunately, several common transparency myths muddy the waters for all:

Myth #1: Transparency Doesn’t Work

Transparency not only works, it is essential to lowering healthcare prices in our country and saving money for consumers and employers. For example, a hospital in Kentucky recently heard about the success Kentucky Employee Health Plan (KEHP) was having helping members find cost-effective facilities for their care when they used digital shopping solutions. Now the hospital wants to lower its prices and be more competitive in order to keep local business, as consumers had been going to get procedures done at more cost-effective facilities. Market forces will compel high-cost facilities to lower their prices to compete.

Myth #2: Cost Equates to Quality

An age-old adage, cost equating to quality, is simply not true when it comes to healthcare. Through the use of the right digital shopping tools, consumers can compare cost options and quality to find and select low-cost facilities that have high marks on quality, equating to high-value care. It’s time we all understand that quality doesn’t need to be compromised for cost or vice versa – this isn’t an either-or scenario.

Myth #3: Industry Stakeholders Don’t Want to Support Transparency

A common misconception is that not everyone in healthcare supports transparency because it’s not in their best interest. The truth is that most industry stakeholders do support transparency — they simply have differing views on how to achieve it. We must accept that different parts of the industry have different viewpoints when it comes to strategy and focus on the ways we can come together to achieve the common goal.

A recent survey found that nearly half (47%) of Americans age 18-64 surveyed are more concerned about the cost of healthcare now than they were before COVID-19. That same percentage of people also said they plan to change how they access care as part of our “new normal.” It’s clear that consumers want to shop for care and the market wants to increase transparency. In order to align stakeholders and ignite change in healthcare, companies in the transparency space must educate consumers about the right tools, support, and information to compare care options and engage the consumer in actively shopping for that care.

When we talk about the right information, this goes well beyond publishing a list of prices for procedures online, as these lists are not true to what patients will pay out of pocket. True transparency involves digital shopping platforms that can present consumers with a look at how much they will individually owe based on their insurance provider and individual health plan. Additionally, the listing of prices does not provide insight into the quality of care at a particular hospital or medical facility.

Digital tools will include the important qualitative information consumers can’t get elsewhere to ensure they’re not only choosing low-cost care, but high-quality care as well. Offering incentives to help consumers go beyond their research and actively shop for their procedures is important, too. Some digital shopping tools offer cash rewards, as a share of the savings, for consumers who choose high-value care.

Everyone needs and deserves access to low-cost, high-quality care, and we need to work together as an industry to make that happen. Through raising awareness of these tools, more consumers will become empowered and incentivized to use them, ultimately making more informed and confident decisions about their care. Additionally, there will be healthy competition among hospitals and medical facilities in the industry, driving down costs for the entire healthcare ecosystem.

The need for robust transparency that presents an easy healthcare shopping and comparison experience for consumers has never been more important following the impacts from COVID-19. As facilities reopen and begin rescheduling appointments, we must put the pedal to the metal and bring true transparency to the healthcare industry. Transparency is no longer an option, but a necessity for the livelihood of the industry and the consumers who power it.

Readers Write: Food for Thought About Apple and Google COVID-Tracing Technology

Food for Thought About Apple and Google COVID-Tracing Technology
By Robin Cavanaugh

Robin Cavanaugh is chief technology officer of GetWellNetwork of Bethesda, MD.

The recent announcement by Apple and Google to move to the next phase of their contact tracing initiative is a positive step for both the general public as well as application developers and data users. Any effort to embed this type of capability directly into the OS of the mobile device — versus relying on a user locating, downloading, and registering an application — will result in a massive increase in the adoption rate of contact tracing. Further, lowering barriers to data exchange will likely have a positive effect on data collection and, in turn, help halt the transmission of current (or future) infections.

Contact tracing in countries like ours, where privacy cannot easily be bypassed by our government, is complicated for those wanting it and suspect for those who are being traced. Tracking and tracing, while preserving anonymity, require carefully architected controls and the lulling of a wary “what’s in it for me” public by extolling the virtues of these large datasets in a way that will clearly benefit them.

The initial phase of this contact tracing API, at least for Apple, was limited to government health organizations or developers who have been endorsed and approved by a government health organization. This was done to ensure the security and privacy of the data collected through this protocol. 

Having just come from a visit to the state of Vermont for a college drop-off, I was witness to the low-tech solution implemented as an alternative to this technology, which was in place at every eating establishment we visited: “Hi, before we can serve you, please fill out your name, email address, and cell phone number on this piece of paper.”

Can I trust this kid earning minimum wage to safely process, store, and dispose of my personal information? Would I like fries with the spam I am undoubtedly going to receive as a result of this disclosure? Which of my enemies’ contact info should I use instead of my own? 

These and many other questions caused me to wonder whether my privacy was worth the “world’s best double bacon cheeseburger?” I could imagine instead that this paper was collected by the staff and likely put in a large pile somewhere for later use. I had serious doubts that this information would be entered into any kind of searchable, accessible database, or that I would actually be notified should one of the many diners in this restaurant present with COVID-19 symptoms. 

Manual processes such as these pose a significant privacy and security concern for all participants. Traceability and accountability for entities like Apple and Google that are collecting this data are critical to gaining the trust of the people, and to avoiding a tremendous amount of manual effort and false data. Instead, embedding this capability ubiquitously in the cell phone of every user with little or no action required by them to support it — coupled with a modicum of additional trust in those entities over an unregulated and ad-hoc process — will be a boon to the entire operation. Leveraging the contact tracing protocol as implemented by Apple and Google would be a significant improvement in a number of ways, including security, expediency, accuracy, and convenience.

As the need for this data evolves, and it can be safely and securely exchanged and leveraged by other organizations and entities, there are hundreds of uses that could be derived. As it relates to this pandemic, we could use the determined potential exposure not only as a data point, but as a trigger to educate people on what to do with this new realization that they could have been exposed. 

We could help mobilize a user’s support and care circle to help ensure that they are following the required protocols. We could predict other likely exposure, not dissimilar to the “Six Degrees of Kevin Bacon” phenomenon, and arm users with means of notifying their community to help keep them safe. The data could be used to get ahead of the transmission model and help with deployment of PPE or planning for spikes in testing or visits to health centers or providers. 

Certainly Apple and Google and others will need to ensure that the appropriate privacy controls are in place to avoid misuse of this information, but this is an important next step in the process. In short, more data, collected with greater ease across a wider base, can only lead to better outcomes.

Readers Write: Five Strategies to Ensure Cybersecurity During COVID-19 And Beyond

Five Strategies to Ensure Cybersecurity During COVID-19 And Beyond
By Patrick Yee

Patrick Yee is chief technology officer of Ensocare of Omaha, NE.

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To quote New Zealand-born novelist and playwright Anthony McCarten, “We’re living in extraordinary times.” To which I’ll personally add, “that call for extraordinary security measures.”

In March, the Office for Civil Rights (OCR) at the US Department of Health and Human Services (HHS) issued COVID-19 HIPAA waivers to promote data sharing and telehealth, relaxing laws over the good faith use and disclosures of protected health information (PHI). The resulting explosion of COVID-19 demonstrates that providers need fast access to tools that identify, collect, track, and exchange data on the flux of infected patients.

Protecting the privacy and security of patient data is the health IT industry’s fundamental civic duty during a nationwide public health crisis. While a hospital’s core competency has never been and will never be information technology (IT), taking care of patients is.

As providers rightfully focus on saving lives, their IT teams have undergone a massive shift to working from home while tackling first-time coronavirus related challenges and juggling data security maintenance. Compounding the situation are short-staffed medical facilities where IT resources are needed the most.

Here are five strategies to help you protect and secure your organization’s patient data and network from cyber attacks.

Make sure your escalation procedures are sound.

A healthcare worker who spots a questionable issue must be free to report their concern so it can be addressed swiftly. Most every IT department has in place a reporting process, either a formal ticketing system or an on-call employee who accepts phone calls. Once the IT staffer quickly escalates the issue to the appropriate leader or medical professional, the healthcare worker can resume their day job. Whether the issues involve coronavirus or basic security breaches, e.g., an email phishing attack from an unfamiliar source, all team members, even those on the clinical side, should be empowered to bring up potential dangers to the appropriate parties.

Instruct your IT team to be extra diligent investigating unknown emails, links, and websites.

Cyberattacks targeting hospitals, practices, and healthcare organizations are on the rise dramatically, which can be at least partially be attributed to the exploitation of the coronavirus.

Unfortunately, remote workers are also being singled out. A recent McAfee report uncovered a correlation between the increased use of cloud services and collaboration tools during the COVID-19 pandemic, along with an increase in cyberattacks targeting the cloud. External attacks on cloud accounts grew 630% from January to April. Cisco WebEx, Zoom, Microsoft Teams, and Slack saw an increase of up to 600% in usage over the same period.

Healthcare staff members working remotely are more vulnerable and understandably distracted supporting COVID-19 patient care, which could make them easy prey for cybercriminals. The pandemic represents a huge opportunity for bad actors to compromise your systems with things like phishing emails that include faulty links and websites, ransomware attacks, and intrusions on sensitive data. Regularly remind your remote workforce to report suspicious activities by following your organization’s security protocols.

Review your intrusion detection strategy (IDS) or continue to monitor if you already have one.

An IDS is a network security technology that was originally built for detecting vulnerability exploits against a target application or computer. Intrusion prevention systems (IPS) add the ability to block threats in addition to detecting them, and have become the dominant deployment option for IDS technologies. More broadly, think of intrusion protection as personal computer security, but in a format that can look between different servers and flag suspicious activity. You should be reviewing and updating your technology and strategy regularly to ensure that you’ve kept up with all applicable best practices.

Ensure that your remote employees have corporate VPN and two-factor authentication services.

This telework protocol should already be part of your business continuity plan. It should be reviewed and updated periodically to ensure traffic is handled securely.

Home internet networks simply are not as secure as your office network. VPN and two-factor authentication services are recommended for remote connection to support the goal of making remote work as seamless as possible. Be aware that, short of completing mission-critical projects, at-home internet outages will not necessarily cause a security issue. A larger issue is whether the remote worker has the right modem installed to handle many different in-home users.

Encourage employees to use corporate laptops with encrypted hard drives that are not shared with family members.

Keep doing all of the good things you were doing before the pandemic.

Everything in your systems security plan is still valid with some possible changes for critical business continuity that should be maintained and exercised. HIPAA compliance might be relaxed, but security protocols remain doubly important in our current health crisis.

Readers Write: CMS’s E-Notifications Condition of Participation: Three Topics to Know

CMS’s E-Notifications Condition of Participation: Three Topics to Know
By Jay Desai

Jay Desai, MBA is CEO and co-founder of PatientPing of Boston, MA.

In March 2020, the Centers for Medicare and Medicaid Services (CMS) finalized the new Interoperability and Patient Access Rule, which creates a new Condition of Participation (CoP) that requires hospitals, psychiatric hospitals, and Critical Access Hospitals to share electronic Admission, Discharge, Transfer (ADT) based event notifications (e-notifications) with other providers across the continuum of care whenever patients have inpatient or emergency department care events.

To help these organizations prepare for the e-notifications CoP, a recent hospital executive survey was conducted to gauge industry awareness about the regulation (the survey results can be found in an online e-book called “The Route to Compliance. A Simplified Pathway”). Responses from hospital CIOs and compliance executives collected through dozens of conversations, virtual focus groups, and webinars revealed three key areas that need more awareness.

#1: The Requirements

According to the survey, which was conducted in May and June of 2020, just 17% of hospital CIOs or compliance personnel are familiar with the e-notifications CoP. The goal of the new CoP is to increase information sharing across the care continuum as a way to enable better care coordination leading to improved patient outcomes. This compliance requirement will go into effect on May 1, 2021 and adds to the list of CoPs hospitals must fulfill to successfully maintain their CMS provider agreement and certification. The fact that CMS used its most consequential regulatory lever, a CoP, to create the new e-notification requirement underscores the importance the agency places on increasing provider access to needed information.

Hospitals should answer how they or their third party intermediary solution will comply with the following requirements:

• Identify and send e-notifications to post-acutes.
• Meet cross-regional provider notification needs.
• Ensure appropriate data sharing rights, security, and trust.
• Send notifications in real time.
• Manage continuous provider-patient relationship changes.
• Demonstrate compliance to meet survey requirements.
• Ensure community-based providers have excellent user experience.
• Meet compliance by the May 1, 2021 deadline.

#2: Provider-Requested Notifications

This topic is particularly important to health systems with large provider and post-acute referral networks. Hospitals must send e-notifications to community-based providers that have established care relationships with patients and that need the information for treatment, care coordination, or quality improvement activities. This includes primary care practitioners, Federally Qualified Health Centers, Accountable Care Organizations, other entities identified by the patient as primarily responsible for their care, and post-acute providers (skilled nursing facilities, home health agencies, etc.). Identifying which providers have established care relationships is critical and requires that hospitals, or their intermediary, possess two foundational capabilities:

• Ability to collect patient-identified provider information at the point of care.
• Ability to obtain care relationship information from providers through a patient roster and notification request process.

The first capability allows hospitals to determine any providers with whom the patient wants their information shared by giving patients the ability to identify providers at the point of care. The second capability allows hospitals or intermediaries to determine any additional practitioners, groups / entities, or post-acutes that need to receive notifications for treatment, care coordination, or quality improvement activities. The roster and notification request process allows providers to identify their care relationships through rosters, e.g. patient panels or census lists, and receive e-notifications based on hospital care events that match to patients on those rosters. Having both of these capabilities gives hospitals the ability to determine the required providers that need notifications thereby eliminating e-notification gaps that would lead to non-compliance.

#3: Health Information Exchanges (HIEs) as Intermediaries

Hospitals have the option to use an intermediary, such as an HIE or vendor, to fulfill the e-notification function under this CoP. In the survey cited above, 60% of respondents familiar with the rule somewhat agree with the statement, “that their local HIE will ensure 100% compliance with the CoP.” Just 17% fully agreed with that statement. Given that HIE capabilities vary widely by state and region, compliance will depend on whether the HIE can fulfill the minimum requirements specified within the final rule. Those requirements include:

• Event types and timing. Notifications must be sent at the time of patients’ inpatient admission, discharge, and transfer and at emergency department presentation and discharge.
• Notifications recipients. Established PCPs, practice groups / entities, and post-acutes irrespective of geographic location that request notifications for treatment care coordination, or quality improvement activities.Practitioners, practice groups / entities, and post-acutes irrespective of geographic location that are identified directly by patients as primarily responsible for their care.
• Notifications content. Notifications must include, at minimum, patient name, treating practitioner name, and sending institution name.

Notifications also need to be sent in accordance with patients’ privacy preferences and applicable federal and state laws and regulations. Additionally, to minimize security incidents and inaccurate notifications, a high accuracy match rate is needed to ensure notifications are sent to appropriate providers. Ultimately, hospitals are accountable to meet compliance requirements even when e-notification functions are delegated and they should therefore ensure all minimum compliance requirements are met.

Given the significance of the new e-notifications CoP, hospitals should take time to carefully assess and validate internal or third-party capabilities against the new requirements to ensure they can meet compliance by May 1, 2021. With the proper solutions in place, hospitals can share real-time patient data with other community providers to support treatment and care coordination efforts, bolster value-based care initiatives, and, most important, improve health outcomes for patients while achieving e-notifications CoP compliance.

Readers Write: Achieving True Interoperability Transparency May Depend on Adopting a National Patient Identifier System

Achieving True Interoperability Transparency May Depend on Adopting a National Patient Identifier System
By Kevin Hutchinson

Kevin Hutchinson is CEO of Apervita of Chicago, IL.

Let me say one thing right out the gate: I am typically not a fan of forcing industry-wide uniformity via burdensome and overly instructive government mandates. However, sometimes there’s too much at stake in healthcare and the private sector just can’t agree on standards on their own. So was the case with e-prescribing over 15 years ago, and so is the case now with interoperability.

When I was founding CEO for Surescripts and before I was a member of the inaugural ONC-created National Health Information Technology Standards Committee, it was hard to get stakeholders to agree on standards, as the EHR industry was generally slow to adopt anything. However, after we created the initial standards for e-prescribing via the National Council for Prescription Drug Programs (NCPDP), set firm deadlines, and CMS tied e-prescribing to MIPPA incentives, the different factions within the healthcare industry (all of whom had different agendas) came together and abided by a system that largely still works today.

So it makes sense for CMS and ONC to impose strict mandates and timelines — albeit with some COVID-caused relaxation — for interoperability compliance, because the fragmentation of health records is as dangerous as it has ever been to patients. But while each deadline moves us closer to a more integrated and transparent system, it’s not until the payer-to-payer interoperability deadline in January 2022 where we’ll finally be in our best position to eliminate costly problems created by siloed health data. We may finally see some health record consolidation.

However, like all kinds of sweeping reforms, the devil is in the details. I believe that it might not be as “successful” as we expect it to be unless the federal government steps up and mandates a national patient identifier (NPI) system.

Just because one’s health insurer is sharing data with their previous insurer doesn’t ensure a holistic record. It’s not outlandish to think that any American could have up to 10 different health insurers over their lifetime, especially given rising health costs, socioeconomic inequities, and an increasingly volatile job landscape. That’s 10 different organizations with 10 different technology infrastructures, data protocols, and health IT standards. Not to mention the complexity of a patient’s health record strewn across multiple EHR systems, that change over time, as well as patients changing doctors creating new patient chart IDs and no standardized format for those patient chart IDs.

Who is responsible for making sure IDs match up? Who is responsible for identifying potential health record duplication errors? These are small data nuances that can have life-or-death consequences.

I can tell you first hand that even after national standardization, there have been instances in e-prescribing when records for John Doe I were assumed to be a part of John Doe II’s record, which could have resulted in life-threatening medical errors if not caught and corrected. NPIs would make life easier and safer for patients, payers, and providers, but yet they still aren’t part of the interoperability equation.

The NPI debate isn’t new. In fact, it’s been around for more than 20 years. But it seems like now we may actually be moving in the right direction. Late last year, representatives from many NPI-supporting organizations signed on to a letter urging Congress to take action, arguing, “The absence of a consistent approach to accurately identifying patients has also resulted in significant costs to hospitals, health systems, physician practices, long-term post-acute care (LTPAC) facilities, and other providers, as well as hindered efforts to facilitate health information exchange.” As a result, the House of Representatives voted to remove the ban on funding NPI organizations.

As for payers, some would likely argue that NPIs would help them as well. Many within the payer community think NPIs could improve member safety, reduce overutilization and fraud, and help them understand how members performed in previous payer’s quality-based programs.

However, NPI opponents will often counter with concerns over privacy and security, higher costs, and serious medical errors due to human error. The costs, they argue, would be incurred from building a new IT system from scratch while also having to align on policies and standards to govern it. To that argument, I would just remind critics that there have already been huge costs incurred because we haven’t achieved full interoperability yet, and then ask them to imagine the wasted money if all current mandates and compliance initiatives ended up not solving the core problems.

As for the medical errors argument, fragmented health records are much more dangerous. Again, I don’t think we can be as successful with interoperability without an NPI system.

But it’s that last and most prevalent argument on privacy and security that makes me raise an eyebrow. We constantly hear that we can’t have NPIs because if the number is compromised, the patient’s entire health record would be accessible in one location. That argument falls a bit flat for me. There are already medical record numbers on pretty much everything. In today’s interoperability world, we use easily accessible patient information (names, address, gender, dates of birth, etc.) to create a universal patient ID and match disparate patient information the best we can.

The whole argument on NPIs should really be fought on the cybersecurity front. Why not implement data encryption standards that lock data down to the field level, so that each piece of information in an NPI record is its own walled garden? We’ve already seen the mistakes made by other consumer industries such as banking, which many have responded with increasingly deep levels of data encryption. It’s completely logical and viable for the healthcare industry to implement the same level of security available in other industries to ensure our sacrosanct health information is protected. If we did, then that would be good for all and put an end to the security debate on NPIs.

Readers Write: Five ICU Lessons COVID-19 Has Taught Us

Five ICU Lessons COVID-19 Has Taught Us
By  S. Ram Srinivasan, MD, MBA

S. Ram Srinivasan, MD, MBA is chief medical officer of Advanced ICU Care of St. Louis, MO.

Since March, critical care teams across the country have been stretched to the limit as they rushed to care for the surge of COVID-19 patients in their ICUs. They were forced to deal with an unknown threat that would infect an unknown number of patients and require as yet undefined treatments.

In reflection over the past few months, telemedicine has proved its continuing value for them, providing additional care support during the pandemic. Implemented as a collaborative care model, tele-ICU leverages remote intensivist-led clinical teams and sophisticated technology-enabled care services to deliver a virtual front line of 24 x 7 care in support of clinicians that are at the bedside of critically ill COVID-19 patients.

We have learned these five key lessons so far with regard to ICU care of COVID-19 patients.

COVID-19 has thrust virtual care into the spotlight overnight, with no sign of slowing down.

Telemedicine adoption, which was steadily gaining traction over the past few years, has been quickly recognized as an essential, efficient, and effective element of our healthcare ecosystem. Across inpatient and outpatient environments, patients and providers have embraced virtual care during the COVID-19 pandemic as a convenient tool that enables care access despite distance, shelter at home, and threat of infection.

For critical care, telemedicine enables highly skilled, technology-enabled care teams to reach ever-larger patient populations and do so with significant demonstrated clinical efficacy. In the course of the pandemic, tele-ICU has provided critical support to both bedside teams and their patients across the country.

COVID-19 is a pandemic consisting of regional impacts. Almost no one faces the “average” pandemic impact.

During the peak of pandemic impacts in April, we had partner hospitals that were urgently adding ICU capacity. At times, they had all of their critical care patients on ventilators and remained braced for an overwhelming deluge that never came. Our care to a set of hospitals experiencing this full range of pandemic impacts enabled us to leverage the regional differences. We were able to dedicate significant real-time care to high-volume situations and help other hospitals learn from the hotspots and prepare accordingly.

Telemedicine access to external expert resources is a powerful force multiplier, especially during crisis.

At the outset of the pandemic, we fielded urgent requests for ICU care services from a range of hospitals and other entities. A variety of accelerated response capabilities, including rapid implementations of standard tele-ICU installations and utilization of surge-compatible technology solutions, were quickly introduced. Over the course of one month alone, more than 50 of our partner hospitals initiated, expanded, or extended tele-ICU capabilities in response to the unprecedented demands resulting from the COVID-19 pandemic.

Further, the opportunity to leverage skills that were not already on site and were not already overwhelmed, without waiting for updated licensure or to recruit volunteers from other regions, provided immediate assistance to care teams most at risk and those that were exhausted. In some cases, this ready access to critical care expertise allowed local teams to enlist other specialists in critical care under the coaching of remote specialists, relieving overworked personnel and immediately expanding their available staff.

The benefits of tele-ICU during the pandemic extend beyond outstanding clinical care.

The multiple threats of the COVID-19 crisis caused hospitals and hospital systems to significantly rethink how to deliver critical care support to their patients under trying conditions. For example, tele-ICU service extended beyond specialized care and also became a means of reducing clinician exposure to the disease and preserving personal protective equipment (PPE). In these instances, hospitals equipped with these remote clinical capabilities relied on the telemedicine team to utilize video to “visit” the ICU room virtually to assess a patient, rather than have a bedside nurse or provider don PPE and enter the patient’s room.

In addition, we have found that tele-ICU outreach by critical care clinicians is well suited to comfort patients by providing social interaction during their isolation. Remote teams can help make a scared and lonely patient more comfortable – and less frightened.

Concerns such as a lack of ventilators came and disappeared quickly, as COVID-19 proved to be a fast-moving disease with rapidly evolving care protocols.

COVID-19 was initially viewed primarily as a severe respiratory illness and was treated as such. However, further treatment experience revealed that the virus was a much more complicated threat than a respiratory illness. Since then, the critical care community has found that proning patients – that is, placing them on their stomachs for prolonged periods of time – helps increase the amount of oxygen that gets to their lungs. In fact, in many instances proning the sickest coronavirus patients, accompanied by alternative methods of supplying oxygen, became a preferred solution to the initial plans for accelerated intubation. Similarly, various medication regimens were tested and evolved.

In our role as critical care specialists, it was our responsibility to our partner hospitals and clinicians to continue to keep abreast of these rapid developments. Drawing on information across multiple sources and geographies, we then quickly provided this clinical intelligence to those in a hot spot while updating mutual care protocols.

Readers Write: Enabling Clinically Intelligent EHRs

Enabling Clinically Intelligent EHRs
By David Lareau

David Lareau is CEO of Medicomp Systems of Chantilly, VA.

A key takeaway from John Glaser’s recent article in the Harvard Business Review, “It’s Time for a New Kind of Electronic Health Record,” is that it is time for EHRs to leverage clinical intelligence for analysis of patient data and to address clinicians’ usability concerns.

Current systems were designed to track transactions to generate and justify billable events. They are, in fact, organized as a set of separate “buckets,” with different sections for procedures, medications, therapies, encounters, diagnoses, etc. There is no clinical coherence or correlation between the sections, so providers must search in multiple places to find information relevant to a problem.

Clinicians are highly trained knowledge workers whose expertise in determining what is clinically relevant is acquired through education and experience. They are trained to know what to look for, but current EHRs make it difficult to get a clinically cognitive view of relevant information.

The new kind of EHR advocated by Glaser will require a clinical relevancy engine that can filter a patient record in real time to identify data for any known or suspected condition or diagnosis. This “clinically coherent view” should include medications, lab orders and results, co-morbidities, therapies, symptoms, history, and physical exam findings. Ideally, it should support diagnostic filtering of dictated or free-text notes, as well as coded data such as SNOMED-CT, ICD10, CPT, LOINC, RxNorm, UNII, CVX, CTCAE, DSM5, and others.

It must do so quickly, on demand, with a single click at the point of care.

This new cognitive clinical computing approach requires a radically different method for organizing clinical data. First, data must be organized to support a clinician’s diagnostic thought process. Second, because of the need to process hundreds of thousands of potentially relevant data points and the relationships between them in sub-second times, graph database technologies must be used. Relational databases cannot provide the computational efficiency that is required to support highly trained clinical knowledge workers.

A clinical relevancy engine that is organized around clinical conditions or diagnoses will have millions of potential links between diagnoses and related clinical data points. Relational databases that join tables together were not designed to support data structures with millions of interconnected nodes. Graph database technologies, which are used for complex, connected data, are used by Amazon, Facebook, Google, and others to support large, evolving data structures.

A purpose-built clinical relevancy engine that uses graph database technology will support the clinical thought process by linking clinical concepts (or “nodes”) to each other, with relevancy scoring that enhances clinical decision-making and integrates with systems to maximize physician workflows. This engine enables a clinical user to get an instantaneous view of all information related to any patient presentation in a single view, incorporating both coded data and data points derived from chart notes by using diagnostic natural language processing (NLP) applied to free-text notes.

The old ways of building EHRs to support tracking of transactions for billing will not suffice in the world of value-based care, clinical risk mitigation, and outcomes-oriented reimbursement. Glaser’s proposed new kind of electronic health record must be built on a foundation of clinical intelligence.

Readers Write: Major Trade Shows Continue to Cancel or Go Virtual, So Now What?

Major Trade Shows Continue to Cancel or Go Virtual, So Now What?
By Jodi Amendola

Jodi Amendola is founder and CEO of Amendola Communications of Scottsdale, AZ.

As major healthcare and health IT conferences such as HIMSS, AHIP, RISE, MGMA and others continue to cancel their live events or go virtual, marketers and sales leaders are now faced with the new challenge of where to put the money that was originally slated for sleek exhibition booths, networking events, and all of the promotional activities leading up to these in-person events.

For many companies, trade shows eat up half of their marketing budget, so the decision about if and how to reallocate those dollars requires careful consideration in these uncertain, unprecedented, and budget-conscious times.

Trade shows get more expensive and more arduous to prepare for every year. But they are also one of the highest-value ways to network and to build new business relationships while renewing old ones. They can be a source of good leads that move the needle to influence important buying decisions. Importantly, for many companies, trade shows are where companies go to be seen.

Trade shows will eventually return, although when and in what form is still an unknown. In the mean time, they are not the only path to visibility and credibility with prospects, or even the most effective. What follows are some recommendations for re-allocating your trade show spend.

Public Relations

Most B2B sales have larger price tags and longer sales cycles than consumer products. Before making an investment in health IT, providers, health plans, and government agencies need to trust that a purchase will answer a need or solve a problem.

Coverage in credible media outlets is still where you get the biggest bang for your buck in B2B.

Peer-to-peer endorsements carry a lot of weight with buyers, and customer success stories — especially if you make the story almost entirely about the customer — are media gold. The same story can be approached from a number of angles to make it appealing to various media outlets with different audiences that align with your target markets.

You should also aim for getting thought leadership coverage—bylines, commentary, and other contributions on the big issues of the day. Thought leadership is most effective when it’s authentic and not afraid to take a stand, so avoid corporate-speak.

HIT leaders are increasingly interested in how PR impacts share of voice against the competition, and what the sentiment is in earned media coverage—positive, neutral, or negative. That can be measured, even by specific topics, with media monitoring and tracking tools such as Meltwater.

This measurement can help you understand how you’re dominating (or not) the most pressing conversations in the industry and media landscapes. Right now, the most pressing topic is of course COVID-19. You can assess your media reach compared to the competition on specific topics such as the pandemic. You can drill down even further on subtopics such as vaccine development, predictive analytics, and primary care that relate to COVID-19.

You can extend the shelf life of media wins by promoting your media placements to decision-makers and key influencers across social media and on your website, and by leveraging for lead gen and nurturing via e-newsletters, emails blasts with landing pages, electronic reprints for virtual conferences, and more.

Lead Generation Campaigns

Gated content, which requires whoever is interested to give up their name and email to obtain it, can capture far more qualified leads than those picked up at a trade show by a “claw” who really just stopped by for your cool giveaways. Examples of high-value content that can be placed behind a form for lead gen includes case studies, smart briefs, white papers, major reports and study results. and on-demand webinars, to name a few.

Targeted digital ad campaigns that promote the right content to the right audiences also are a powerful lead gen tool. One of the most exciting capabilities of digital advertising is how specifically you can target your outreach (as political campaigns like to do), but A/B testing is still needed. This is an area that often comes up short when trade shows need to be paid for, but now would be a great time to leverage those unused dollars to test these campaigns until they hit the right mark.

Marketing Asset Development

If there’s a bright spot in the time we’ve spent sheltering in place, it’s the interesting videos and podcasts we’ve discovered. For many of us, listening to a podcast at a certain time every day will be a permanent part of our schedule post-pandemic. Simply produced Zoom interviews are also likely to be a mainstay, having been validated by broadcast news channels while studios were closed.

Why not spend a portion of your newly freed trade show budget on commissioning some of these assets yourself? Over time, a series of thought leader podcasts or videos with provocative themes can elevate brands and thought leadership.

Surveys are another marketing asset to check off your marketing bucket list. Not only do they give you a current read on target audience sentiment, the findings can be newsworthy enough to promote via media outreach and nab more coverage.

When it comes to trade shows, nothing replaces human interaction. But now is the time to strategically reallocate those unused marketing dollars to take advantage of alternate strategies that can increase awareness and generate leads for your business.

Readers Write: An Interoperability Data Challenge — Out and Back Demonstrating Reflection

An Interoperability Data Challenge — Out and Back Demonstrating Reflection
By Brody Brodock

Brody Brodock is a principal with AdaptTTest Consulting of Raleigh, NC.

I want to offer up a challenge that will express the current state of interoperability within regional systems. The challenge involves the top N most frequently used values within domains, exchanged via C-CDA within your community of practice, reconciled and incorporated, then returned to the sender, where the originating sender then reconciles and incorporates the returned items.

This should be a simple task that any certified EHR can accomplish with 100% accuracy. However, if you get better than 80% success in the first part of the exercise, I will be greatly surprised. If you can successfully exchange above 50% on the second round, I will be impressed. I would even argue that two systems from the same vendor will be challenged.

We should keep this to the required domains: medications, problems, and medication allergies. Other domains should be left out to reduce complexity. This gets messy really quickly.

You will need to gather from your system:

• Problems. Problem text, problem code, problem code set, status, date added, date updated, and onset date.
• Allergies. Allergy category, allergy severity, reaction, reaction severity, allergy dates with specificity, status, and the codes for allergy and allergy reaction.
• Medications. This might get trickier as some systems load meds into different table sets depending on the order type (prescription or order). But essentially you need the medication name, medication code, status, date of entry, order expiration date, dose, dose form, frequency, SIG, PRN, and DAW.

Once you gather these extracts, (you might need to limit the period), you should slice and dice the data to tell you what the most frequently used (MFU) items are. You don’t generally need to associate the metadata to other data elements. Knowing that the top medication allergy is penicillin is sufficient, the top reaction might be hives — they don’t need to be associated in this round.

HIPAA note: watch out for names in the SIG, and purge any “zzz” names you come across.

Now that you have your list, take the top 10 from each and add them to your new patient. Then another set of patients that reflect the metadata objects: status, dates, reactions, severity, PRN, DAW, etc. If you have the ability to add free text med allergies, then submit a patient safety defect report to your vendor, but send the free text allergy anyway. Try “pentillacillian” with “anti fylaktic” — yes, I have seen that.

Medications should be a mix of your top 10 prescriptions, plus your next 10 with your top SIG, plus the next top 10 with all of your statuses. Add a couple that are tapered dose, vaccines with multiple dosages, and multiple formulations (albuterol syrup, pill, and rescue inhaler) all active.

Your CDS/DUR systems are supposed to alert for for all of these domains. Once you reconcile and incorporate these items into your system, pick a couple of items like penicillin with anaphylaxis and attempt to prescribe that. You should get an alert. A significant battery of CDS/DUR tests should be done with this data.

Now that you have built up the patients, have your development team automate them so they can be duplicated on demand. If you don’t have an automation team, ask your vendor for their scripts. These tests should be part of your standard operational and production qualification tests — OQ/PQ.

Now send these patients via a summary of care or a transfer of care (try both — they should be different) to your geographic neighbors. Whichever systems from which you receive transfers, referrals, and notes. They will be ambulatory, acute, ED, SNF, and specialty facilities. But more importantly, they will be different systems, or at least different configurations of like systems.

Take these C-CDAs and send them through your Direct HISP, email, or sneaker net (HIPAA rules apply and these must be fake patients). You can name them “MedicationTest-xxx” where xxx is an alpha counting scheme: aaa is the first, aab the second, all the way to zzz being patient 676. If you can create patients with numbers in them, I would be surprised, but go ahead and try one of those patients too. “Patient 0” shouldn’t be possible, so it will probably blow up on the receiving end.

The receiving facility should then bring in the C-CDA and perform reconciliation of the listed domains. Problems, medication allergies, and medications should now be in this patient’s record.

The expected result is 100% accuracy in the exchange. No conversions, no substitutions, no increased or decreased specificity, no “go fish” in presenting the user with a series of options to reconcile. These are the most frequently used, so there should be no problem.

Your actual results will not be even close to 100%. You will have allergies that switch category, reactions that aren’t recognized, medication APIs that are switched to brands, problems that are either more specific or less specific than the incoming problem, dates that will increase specificity from year or null to DD/MM/YYY:Time, and multiple formulations that will be considered duplicates (three albuterol formulations).

Now without further modification, the receiving facility should create the same type of C-CDA and return it to the originating facility. A full round trip. The record that is returned will look like a completely different patient than the one that you sent out. Statuses and dates will be converted to something else and your medication intolerance will suddenly become a medication allergy. All sorts of fun here.

This is why healthcare interoperability singlehandedly enables the fax industry.

This is the first part of a long and complex set of tests, a simple out and back. Yet the exchange will demonstrate how badly the industry needs to get its data house in order. The results will not change just because you were using different technology. If you are using FHIR to write data back into your solution, you are going to have the same problems.

Readers Write: Hospital Vital Signs: The EHR Doesn’t Know Everything

Hospital Vital Signs: The EHR Doesn’t Know Everything
By Keith Boone

Keith “Motorcycle Guy” Boone is informatics adept and SANER Project leader for Audacious Inquiry of Baltimore, MD.

In the fight against COVID-19, it is imperative to understand and monitor the vital signs of our healthcare system – the hospitals and health systems that are playing a critical role –  to ensure that we can provide patients with unfettered care as this global pandemic plays out.

To this end, numerous agencies at the local, state, and federal levels are attempting to monitor the pulse, EKG, respiration rate, and chemical balance of hospitals across the country for a better assessment of whether the hospitals we rely on to keep people safe are themselves up to the task. This information is needed to rapidly identify the hospitals that need supportive care as they face COVID-19 head to head.

Today’s data collection efforts are focused on extracting data from the EHR, which focuses on data elements such as bed numbers and bed types, ventilator use, and death rates. While this is a great place to start, the EHR is just one critical information system within a hospital.

Similar to how the body has many flows — or as these were once explained, humors — a hospital also has a network of systems that manage its overall wellbeing and operations.

• Asset tracking solutions monitor the physical inventory in a facility, and asset management systems can both pinpoint the location of a ventilator or anesthesia system and report its present operational status.
• Bed management solutions help a hospital streamline patient flow, ensuring that patients are getting into beds as fast as possible. They identify if beds that need cleaning are being turned around quickly and whether patients are being discharged efficiently.
• ICU and central monitoring solutions keep track of patient telemetry inside the ICU, bringing signals from the monitors and medical devices at the patient’s bedside to the central nursing station, possibly long before the information is available in the EHR.
• Inventory management solutions keep track of consumable medical supplies – simple service parts such as ventilator tubing,  medicines, lab test reagents, personal protective equipment, and the cleaning and disinfectant supplies that a hospital goes through faster than your most germophobic relative.
• Workforce management solutions track the flow of staff and are often linked with identity management solutions that grant privileges, identify credentials, and monitor access points.
• Some hospitals have command centers into which many essential data elements flow. These have compelling visual displays, dashboards, and teams of staff who manage hospital capacity, but they are rare outside of larger academic medical centers, and even the most advanced command centers may not be able to readily share data outside their own system. 

The list goes on and on. These systems collectively determine the pulse or heart rate of a hospital.

While a hospital’s EHR system may be considered the brain of an organization by many who think about hospital information systems – and that’s probably not a bad analogy – a critical failure in any one of these other systems can be debilitating to hospital operations. Though EHRs may be the highest level as the most business-critical decision-making element of a hospital, they cannot track all the functions of an organization that are essential for efficient and prolonged patient surge operations.

To truly understand the health of a hospital and its level of readiness for taking in a surge of critically ill patients requires tracking more than just what is going on in its brain. In our analogy, the heart, the lungs, and liver represent a hospital’s staff, supplies, and equipment. All of these are tracked by other systems.

Some of these systems connect to the EHR, and extracting data via the EHR rather than from the system directly is possible. However, in these instances, speed and clarity may be sacrificed for simplicity. The originating systems often know something well before it is shared with the EHR, just as your stomach responds to food without your brain having to decide how to handle it. Some of these data sources may have no direct connection to the EHR at all, yet their importance to the overall vitality of the system remains undiminished.

As we experience our 100-year pandemic event, the healthcare industry is learning that it didn’t think of everything that hospital leaders might need to know considering equipment or critical supply or staffing shortages. The magnitude of this response has drawn national attention to the critical infrastructure deficiencies in our healthcare, public health capacity, and surveillance systems.

But a silver lining in this endeavor is the rapid progress that is being made by passionate and committed individuals and organizations coming together to solve these complex data sharing and interoperability challenges. HL7 International is doing a tremendous job supporting their members by enabling the secure and rapid transfer of information about hospital bed capacity and availability of critical resources during public health emergencies. From May 13-15, they held a virtual connectathon to demonstrate projects in development. It is promising to see such rapid progress being made through data standardization using FHIR-based APIs.

As an industry, we need to support standards across the many information systems inside a hospital. We need to expose the critical vital signs these systems have to hospital leaders so they can work with public health and emergency response agencies to ensure that appropriate measures are being taken to address this pandemic. While we don’t yet have a consistent approach to sharing data from disparate sources within the healthcare system, it can be achieved.

Readers Write: Have You Lost Your Job?

Have You Lost Your Job?
By Jim Gibson

Jim Gibson is a recruiter with Gibson Consultants of Wilmington, NC.

I remember the first time I lost my job. It was terrifying. I was the sole breadwinner, with three small children and a mortgage.

If you’ve recently lost your job, I know how you feel and I hope the tips below will help.

In the days following my job loss, my emotions followed the usual course: surprise, hurt, anger, acceptance, and finally determination. That is, determination to find another job, a good one, one that would allow me to feel good about myself again. Although I had convinced myself that I was mentally tough, my ego was bruised – badly.

The days seemed like weeks and the weeks like months, but ultimately I got a better job, and it didn’t really take that long.

Then I became a recruiter and saw many others enjoy the same good fortune after enduring the pain and anxiety of a job loss. Not all, but many.

This includes 2008 – 2010, when a global economic collapse had many fearing another Great Depression.

People at all levels and in all industries were losing jobs. Companies were folding, retirement accounts were being depleted, and housing values were falling, for many their largest source of equity.

Financially healthy companies were laying off tens of thousands in anticipation of a recession. Talk about a self-fulfilling prophecy! Of course, the media were piling on, fanning the flames of fear and misery.

It was maddening,  and a hard time to be optimistic.

Yet, it ended. People found jobs and many were thrilled about where they ended up.

There are differences between then and now, but there are also similarities. We feel the weight of uncertainty, but we also believe this too shall pass. I do, and I believe many will end up in better positions.

It’s hard to account for why some people land on their feet more quickly than others, but you can improve your odds by keeping the following in mind.

• Self-agency. This is listed first because it’s the most important. You must believe that you have the power to improve the current situation.
• Clear your head. A mental transition from having a job to looking for a job takes a little time. It’s critical to decompress, find enjoyable distractions, spend time with loved ones, and get negative feelings under control before beginning a job search.
• Goal of two. Have a goal of choosing between two good job offers. This eases the pain if a prospective job opportunity disappears. It also can shorten the search by suppressing the temptation to go easy while the “sure thing” plays out … or doesn’t.
• View it as a job. A job search is a job. It’s good to clear the head, but when the search starts, it is your full-time job.
• Start with your brand. A career is usually the result of opportunities presented and accepted, not intentional paths. Being unemployed is a chance to change that by thinking carefully about what you enjoy and are good at, and what you don’t enjoy and don’t do well.
• Perhaps a couple of options. You may know what your next job will look like, or you may have the flexibility to do either of a couple of things (e.g., operations or a client-facing role, remaining in a hospital or joining a health plan.) More than one option requires different versions of your resume, cover letter, etc.
• Don’t rely on recruiters. Approaching recruiters is an inefficient approach. Most work on a limited number of open positions, so it’s hit-or-miss.
• Two-pronged approach. After identifying your ideal role(s), work your network and contact employers.
• Your network. This shows the value of your LinkedIn network. It’s also a great time to make new connections. Remember to spoon-feed connections with specifics about desired roles, organizations, etc.
• Employers. Build a comprehensive list of potential employers and hiring managers. Corporate websites and LinkedIn are good starting points, as are trade group sites (HIMSS, AHIP, etc.) If targeting vendors, the exhibitor page of the annual convention site is a gold mine.
• Don’t apply to job listings. Some will disagree, but I find this to be a colossal waste of time. People do get jobs this way, but it’s a low percentage activity. It’s so easy for people to apply that the number of applicants can be staggering. Even the perfect candidate’s application may get buried and never seen.
• A numbers game. This is a numbers game. Think 150-200 targets, not 20-25.
• Get organized. Developing a system for staying organized is essential. It allows for a methodical approach to managing a high volume of contacts.
• Physical activity. A job search is intense. Incorporating a regular regimen of physical activity will help periodically clear the mind in order to stay strong and on top of your game.
• Only one job is needed. This is a good thing to remember, especially as opportunities progress slowly and sometimes disappear.
• Expect to be ghosted. Anyone who has looked for a job knows that the most agonizing part is waiting while the other party remains silent and inaccessible. Expecting this, while pursuing other opportunities, eases the strain a bit.
• Don’t take it personally. Sometimes conversations stop abruptly or jobs mysteriously disappear without an explanation. It’s often because of events beyond your control. Don’t beat yourself up over this.
• Some days it will just plain stink These days need to be kept to a minimum, but they will happen. Shutting down the computer and taking the afternoon off is sometimes the smartest move.
• This is your career, but it’s not you. As difficult as it may be at times, you must try to keep your self-esteem intact. Looking around at your loved ones and surroundings can reinforce a sense of gratitude and perspective.

Finally, even though difficult in more ways than one, this can be a fulfilling challenge. After all, you’re selling the most irresistible product around – you!

Happy hunting.

Readers Write: How Health Systems Use Technology in New Ways to Adapt to COVID-19

How Health Systems Use Technology in New Ways to Adapt to COVID-19
By Terry Zysk

Terry Zysk is CEO of LiveProcess of Chelmsford, MA.

Saving the lives of patients and protecting care providers during the COVID-19 pandemic is an unprecedented healthcare management challenge. Unlike a hurricane that passes in a few days, COVID-19 could be with us for quite a long time.

Some of the innovative US hospitals I work with are solving pandemic-related problems by repurposing already deployed or quick-to-deploy technology. Creativity is allowing these health systems to adapt to the COVID-19 crisis.

According to McKinsey & Company, as major events occur, responsive healthcare organizations focus on five areas to ensure access to care delivery: workforce protection, supply chain and resource stabilization, customer and staff engagement, stress testing, and nerve center integration.

Similarly, health systems on the front lines of COVID-19 are using technology with roots in hospital emergency management to dynamically rebalance business operations, share information, and collaborate in virtual command centers.

A public health emergency response creates large-scale logistical issues. Hospitals are changing protocols, rethinking workflows, repurposing clinical areas and redistributing staff to adapt to a shift in demand.

All of these changes require intense coordination and collaboration.

To replace rumors and stress with accurate and timely information, health systems are pushing information out to engage healthcare workforces. They are reaching employees at all facilities at once while also developing proficiency in minimizing alert fatigue throughout a long-duration event.

As more masks and gowns are needed to protect the healthcare workforce, hospitals and healthcare coalitions are using emergency management technology to share guidance on the use of PPE, request PPE from community partners, and coordinate and track regional inventory.

CDC requirements for monitoring employee health involve daily communication with healthcare providers. One health system is performing virtual health checks by reaching out to hundreds of affected personnel with survey technology, and then displaying the results on a quickly developed business intelligence dashboard.

At another hospital, human resources specialists used event sidebar communications in emergency management technology to collaborate in a virtual command center and optimize the redistribution of staff.

When converting hospital rooms or even entire floors into other types – such as negative pressure and isolation rooms and reconfiguring spaces create more ICU beds — a healthcare coalition electronically surveys its 18 facilities on their room and bed inventory. With automatic roll ups, leadership teams are producing up-to-date daily reports with minimal labor and a short turnaround time.

Staffing coordinators are using trackable one-to-many notifications with multiple choice response options to fill high-demand roles quickly and efficiently, leveraging tools typically used for mobilization and coordination in natural disasters.

In these many ways, health systems and coalitions are adapting to the current situation with new processes and proficiencies by using existing technology in new ways. Their experiences may spur ideas that help your own health system improvise and adapt to COVID-19 and other disruptive situations.

Readers Write: Healthcare Crisis Underscores Strategic Importance of Strong IT Support

Healthcare Crisis Underscores Strategic Importance of Strong IT Support
By Rob Dreussi

Rob Dreussi is CIO of HCTec of Brentwood, TN.

Take a moment to thank those who work on the IT service desk. Who knew they would play an essential role in maintaining operational continuity and getting our patients and providers up and running on telehealth?

Every large-scale crisis exposes shortfalls and creates opportunities for improvement in healthcare. The COVID-19 pandemic has highlighted the need for hospitals to think differently and more strategically about their IT service desks.

EMR patient portal usage has increased as telehealth and other patient-facing solutions are being rapidly deployed. Maximizing that kind of technology, keeping it running, and supporting it properly requires people with specialized HIT skills, training, and experience. Technology may be the tool, but people and solid operating processes are required to make it work.

This crisis is a powerful reminder of the IT service desk’s higher purpose—helping providers and patients by either resolving their immediate problem or finding the best next-level person to assist them. A mature IT service desk employs a diverse team of experts, including agents, coaches, trainers, workforce analysts, quality analysts, and related technology SMEs. Collectively, this team enables healthcare providers and patients to leverage technology rather than be hindered by it.

However, IT service desks have struggled to meet the increased demands related to the COVID-19 pandemic because their resourcing plans are based on historical support volumes. Who could have predicted:

• Call volumes that are doubling and tripling.
• Supporting new applications almost overnight that typically would have been deployed over months.
• Assisting end users while they shifted in mass to working from home.
• Continuing to deliver services while the IT service desk itself shifted to working from home.
• Onboarding and training new agents 100% virtually.

Keeping up with all the change has been really hard.

The pandemic has put a spotlight on how the technical and user-facing skills that are needed for effective IT support have increased dramatically over the last decade. The demand for this dual skillset will only continue to increase as hospital clinical and overall operations grow increasingly reliant on technology. Already Meaningful Use and the movement toward value-based care have driven the adoption of complex clinical and business systems that require constant maintenance and inspire far greater security concerns.

Simultaneously, the expectations of providers and patients alike are rising, as we all have become accustomed to customer-friendly, tech-savvy support from companies like Amazon and American Express. As a result, the IT service desk’s role now includes representing the voice and brand of the health system. Delivering a strong overall experience — whether to patient, provider, or administrative user — is more critical than ever. In this new environment, the staffing, required skills and management of the IT service desk requires a more advanced and strategic approach.

It’s no surprise that COVID-19 has forced HIT support personnel to work overtime, late nights, and weekends. Their efforts are essential to ensuring that healthcare providers and their patients receive the support they need to improve delivery of care in a time when people need it most.

COVID-19 has made painfully obvious to a broader audience what we have always known — technology doesn’t always work as designed. It has also made it glaringly apparent that in healthcare we need people who understand how to effectively support technology so that patients and providers alike can leverage its power to improve care and outcomes.