Readers Write: Uniting the Full Continuum of Care for the Individual: Why Digital Technologies Must Embrace Holistic Patient Engagement

Uniting the Full Continuum of Care for the Individual: Why Digital Technologies Must Embrace Holistic Patient Engagement
By Mary Kay Thalken, RN, MBA

Mary Kay Thalken, RN, MBA is chief clinical officer of Ensocare of Omaha, NE.

More than half of healthcare professionals believe digitization is transforming the healthcare industry. Of adults 55+, 85% believe technology will improve healthcare in the next five years by delivering faster and more accurate diagnoses, curing diseases, and predicting and preventing diseases and conditions before they happen. However, 35% of seniors feel their health plans do not use any technology to improve access, information, or care, and they want more tech-enabled solutions.

Though the first two survey findings from 2017-2018 are encouraging, the third speaks loudly to this need: payer organizations as well as provider organizations must examine what is lagging in their technology offerings to better serve our biggest generation of people spanning the birth years of 1946 to 1964. From politics to fiscal projections, it’s reasonable to predict that Baby Boomers will have an outsized influence on the healthcare technology landscape for years to come.

The projected growth of this population has also caught the eye of Washington. In March, the US Task Force on Research and Development for Technology to Support Aging Adults and the Committee on Technology of the Science & Technology Council released the “Emerging Technologies to Support an Aging Population Report.” It identified six primary functional capabilities as being critical to individuals who wish to maintain their independence as they age and for which technology may have a positive impact:

• Key activities of independent living
• Cognition
• Communication and social connectivity
• Personal mobility
• Transportation
• Access to healthcare

Unquestionably, digitization is penetrating healthcare, including the burgeoning post-acute acute marketplace. In my role, I converse with leaders reshaping the patient’s continuing health recovery, from discharge to home health and hospice centers, skilled nursing facilities, rehab facilities, long-term care hospitals, or home. As a former nurse and provider business executive, it’s an exciting time to work in innovation on behalf of end users and patients who will benefit from enabling technology that unites the full continuum of care.

Why holistic patient engagement matters

Still, national survey results that look at the opinions of the senior population are a serious wake-up call, warning us all that a lot more work must be done – particularly in the critical area of patient engagement.

Granted it seems marginally small that only 35% of seniors think their health plans do not use technology to improve access, information, or care and have a desire for more tech solutions. Now consider this survey result in the context of the aging boomer population and their share of national health expenditures, which is expected to reach $6 trillion in less than 10 years. This powerful moment of clarity challenges the status quo, moving us forward in making tech-enabled patient engagement for adults 55+ a top priority.

Connecting digital technologies to the patient starts with a holistic view of that person’s entire care engagement experience. Subsequently, to unify the patient’s entire care experience through the use of technologies, we must zero in on what’s important to that person in terms of social determinants of health at every touch point. In short, we must create a tech-enabled, personalized experience specific to each patient’s individualized care and other needs, starting from within the hospital to discharge post-acute care facility or home.

The patient’s recovery or chronic care journey doesn’t stop there. Providers can address and integrate comprehensively the needs of patients who are spending more time outside instead of inside the brick-and-mortar walls of the hospital. We can effectively manage those patients — coordinate, personalize, individualize, and enrich their care alias tying all the disparate pieces together — to improve overall their experience, the goal of wellness, and outcomes.

Recommended best practices

On October 2, 2018, 48 health IT leaders from provider and vendor organizations gathered outside of Salt Lake City for one day to collaborate with KLAS Research. Participants developed a framework of key patient engagement initiatives and took part in discussions about best practices either observed or used. The following is those most often cited successful practices focused on the individual that healthcare organizations can use as a planning tool.

Technology

• Create easy-to-use apps
• Create cloud-based software solutions
• Adopt telehealth capabilities

Analytics

• Gather and analyze social determinants of health
• Gather and analyze behavioral habits (travel patterns, transportation)

Convenient Care

• Enable 24/7 access to care team
• Enable communication with care team (text, email, phone, video)
• Enable communication with patient (text, email, phone, video)
• Enable families to communicate with care team (text, email, phone, video)
• Allow patients to choose how they want to communicate

Right Care Setting

• Direct patients to the appropriate care setting (nurse practitioner, urgent care, or primary care physician)
• Let patients go to the care setting at which they will be best served
• Bring the right care to the patient (24-hour nurse line, telehealth)

Personalized Care

• Provide patient education and personalized discharge instructions
• Assign health buddy or care manager to patients as they leave
• Include patients in the process of setting goals and choosing interventions
• Enable physicians and nurses to engage with patient during the encounter
• Incent patients to participate in wellness activities and make healthy lifestyle choices

Provider Organization

• Develop a patient engagement vision and road map
• Adopt effective change management when implementing patient engagement strategies

Our industry is facing a colossal transformation over the next 30 years as value-based healthcare solidifies and Baby Boomers dominate the use of healthcare services. Despite their collective differences and perceptions, multi-generations—including the largest groups, the Boomers, Generation X, Millennials and Generation Z—working together creates the potential for creativity, community, coordination, and optimization of enabling technology solutions to enhance quality of life.

No doubt about it, a seismic shift to management and engagement of individuals is underway. To not prepare begets gaps in care that lead to poor outcomes and tremendous waste and spending.

Readers Write: Systems Integration with SMART on FHIR ─ We’ve Come So Far, Yet …

Systems Integration with SMART on FHIR ─ We’ve Come So Far, Yet …
By Dan Fritsch, PhD

Dan Fritsch, PhD is chief applications architect at First Databank of South San Francisco, CA.

When we first launched Meducation in 2009, we realized that we would have to integrate the application with electronic health records if we wanted clinicians to use it with their patients. The good news? Through our efforts, we’ve become industry leaders in such integration. The burst-our-bubble reality? Despite our success, even after 10 years, many integration challenges remain.

Because electronic health record (EHR) systems were not originally designed to accommodate third-party apps, we have found ourselves taking up the integration cause ever since we initially developed our cloud-based solution that enables healthcare providers to dynamically create fully personalized patient medication instructions in more than 20 languages.

While the integration nut is difficult to crack, we’ve experienced quite a bit of success. Case in point: In 2011 we won an Office of the National Coordinator for Health IT contest for our use of Substitutable Medical Apps and Reusable Technology (SMART) – an open, standards-based technology platform – to integrate our product with other systems.

Yet we weren’t able to fully utilize what we had developed. This SMART integration didn’t allow us to leverage real-time data, but instead required data to be transformed and stored in an alternative format. While we had established ourselves as a systems integration trailblazer, we still didn’t experience the live integration needed.

To make integration work, we had to custom-code the product for each EHR, to accommodate each unique data access framework and each underlying data model. This meant starting from scratch with each new integration. Because of this complexity, we often found ourselves relying on outside systems integration specialists for assistance, which is a costly proposition.

When Health Level Seven International (HL7) introduced the Fast Health Interoperability Resources (FHIR) standard, SMART developed code to support it. As such, we were able to run the product in this new SMART on FHIR architecture environment. This integration model made it possible to use the same FHIR resources to implement our product on various EHR platforms without having to significantly modify code. So, if we wanted to integrate our app into 10 EHRs, we didn’t have to reinvent the wheel with each one.

At the most recent American Medical Informatics Association (AMIA) conference in San Francisco, we demonstrated how a mature SMART on FHIR integration enables us to run an app on various EHR systems, something that many other app developers are still striving to accomplish. AMIA members ranked our demonstration as the top presentation at the conference and recognized us with the AMIA/HL7 FHIR App Showcase Award.

Yet, like all app developers, we are still struggling with a variety of integration challenges, such as:

• Optimal workflow placement within the EHR. While some vendors allow our app to be launched in an optimal place – such as at the top of the discharge screen – others bury the app launch in the user interface menu, making it burdensome for an end user to find and use at the right time in workflow. We are constantly working to align with our EHR partners to realize that our application is valuable, not a threat to their autonomy.
• Juggling multiple versions of FHIR. FHIR is a young and rapidly evolving standard. Since its introduction, three versions have been adopted and implemented by various EHR vendors. Each of these standards uses a slightly different data model. As an app developer, we have to know which version each EHR vendor is using so we can modify our code to support that particular iteration.
• Coping with vendors’ interpretations of resources. To function optimally, our app needs to know the patient’s medication list at the point of discharge, which requires specific resources (specific pieces of information). This information is represented in FHIR by either the “Medication Order” resource or the “Medication Request” resource, or sometimes by a combination of both. As such, we often need to query both of those resources and run an algorithm that gives us the discharge medication list that we need. As FHIR becomes more mature, there will be more agreement among the vendors on what the resources mean, but for now, we need to continue to find ways to deal with each vendors’ interpretation.
• Dealing with costs. As a developer, we have to cope with fees to enter developer programs; certification costs; legal fees associated with intellectual property protection; costs that sometimes arise when developers need additional integration assistance from vendors; and royalties paid to EHR vendors. These fees are costly and are prohibitive to many smaller companies.

So while we have been able to establish ourselves as integration leaders, especially around SMART on FHIR, we still, like all other app developers, have our work cut out for us. We look for forward to continuing to pave the way and challenging the status quo.

Readers Write: File-Sharing And HIPAA – How You Can Keep Health Data Secure in an Era of Collaboration

File-Sharing And HIPAA – How You Can Keep Health Data Secure in an Era of Collaboration
By Tim Mullahy

Tim Mullahy is executive vice-president and managing director at Liberty Center One of Royal Oak, MI.

Collaboration is at the heart of modern workflows, and file sharing is at the core of collaboration. That’s as true in the health industry as it is anywhere else. The difference with healthcare, of course, is that the risks of doing file sharing improperly — of distributing files without due attention to security — are higher.

File-sharing and collaboration are necessary for effective patient care. Medical and support staff alike need to be able to openly and readily share patient data with one another, communicating seamlessly both within hospital environments and without. The problem, of course, is enabling such collaboration without violating HIPAA.

After all, Protected Health Information (PHI) is some of the most sensitive data in the world. The penalties, should it fall into the wrong hands, are rightly strict. That isn’t to say that enabling file-sharing is impossible,  just that it needs to be done while keeping a few things in mind.

Encrypt all files

Although HIPAA doesn’t mandate file encryption (it’s recommended, not required), encrypting all data both in-motion and at rest is critical if you’re going to ensure that your files can be shared securely. In the event that a device containing HIPAA is in some way compromised, encryption will ensure that the data it contains remains safe.

I’d advise that you use SSL encryption and use some form of VPN or secure tunnel to keep your files protected when they’re shared across external networks.

Assign unique IDs to all staff

Every user with access to your file-sharing and collaboration platform needs a unique identifier. In addition to being useful for the purposes of authentication, these IDs will allow you to track data access and usage. The idea is that you need to know what data each of them have accessed and what they’ve done with that data at any point in time.

Implement multi-factor authentication

Usernames and passwords are an important component of access control, but they represent only a partial solution. To keep both your files and the platforms through which staff collaborate secure, you’re going to want multiple means of ensuring people are who they say they are. These could include:

• Biometric (fingerprint scanners, facial recognition, voice identification, retinal scanners)
• Behavioral (common login locations, common access and browsing habits, etc.)
• Hardware-based (device recognition, hardware tokens)

Implement auto-logoff

Here’s one directly from the HIPAA guidelines. Any file-sharing or collaboration solution you use needs to have a timeout process built in. After a set period of inactivity (10 to 15 minutes is probably a safe bet), an employee account should be automatically logged out. This protects against unauthorized access via unattended devices.

Ensure that all software is HIPAA-compliant

Last but certainly not least, for each collaboration solution you implement, check with the vendor to ensure that it complies with HIPAA’s regulatory guidelines. Most vendors that support HIPAA compliance will be open about it. Moreover, their solutions will provide full logging and auditing functionality, alongside all the other security controls necessary to stick to HIPAA.

HIPAA need not represent an obstacle to effective collaboration. Provided you incorporate a compliant solution and take all the necessary measures to keep your data safe, you can enable your clinicians, support staff, and everyone else who needs access to collaborate for better, faster patient care.

Readers Write: To Douse the Flames of Physician Burnout, Target the Four Biggest Time-Wasters in the EHR

To Douse the Flames of Physician Burnout, Target the Four Biggest Time-Wasters in the EHR
By David Butler, MD

David Butler, MD, is principal at Calyx Partners and interim CMIO at Guthrie Health in Sayre, PA.

There’s no question that physician burnout is one of healthcare’s most pressing problems: Forty-four percent of physicians report feeling burned out. It affects everyone to varying degrees: specialties, employed vs. self-employed, men and women.

The Number 1 contributor? Too many bureaucratic tasks such as charting and paperwork. The bottom line, according to Mayo Clinic Proceedings, is that physicians who aren’t comfortable using EHRs are more likely to reduce their working hours or leave the profession altogether.

We all agree on the challenge, but what’s not as obvious is the solution. Many hospitals are investing in scribes and assistants like they’re a sustainable solution. Individual providers have stated they have higher satisfaction, but the evidence isn’t showing that this is always the case.

Other organizations are placing the burden on other docs, creating physician-led training teams to improve EHR efficiency in their facilities. This can provide some level of peer-to-peer efficiency when thoroughly implemented with the correct support staff, in-room support, and focused curriculum based on user specific metrics. Otherwise, instead of slowing one doc down, you’ve merely doubled your inefficiency.

Mindfulness, yoga, and other self-care strategies are problematic. They take time—of which physicians are already short – but more importantly as this recent whitepaper on burnout points out, they fail to address the root cause and put the responsibility of burnout on individual physicians.

We’re all responsible for burnout. In my experience as a CMIO and EHR implementation and optimization strategic advisor to various healthcare delivery systems, the key to reducing frustration with the EHR and physician burnout is practical tactics that actually give doctors time back in their day.

These are the four biggest time wasters in the EHR and how to address them.

1. Searching for Clinical Data

When you think about search in the consumer world, companies like Netflix and Amazon may come to mind. They use various degrees of artificial intelligence (AI) to serve up what you’re likely to be interested in based on your past searches to streamline what you see.

Unfortunately, EHR search isn’t quite that intuitive yet. Searching for clinical data will happen during every patient visit, making it one of the biggest EHR pain points for physicians. Until the leading vendors incorporate focused AI and machine learning, the average physician should use these tips to filter through the sea of patient data more easily:

• Default to search over navigation. I just described that EHR search is far from perfect. However, it is infinitely better than browsing and clicking your way through the interface. Sure, I know how to navigate to a WebEx site to join the meeting. Do I ever do that? No. Not when typing “Join WebEx Meeting” into Google gets me there much faster. Similarly, I always tell docs to search the chart. Let the system look for you by using the search bar. Once the page loads, typically Ctrl+F will open another more specific search box to find keywords within long patient reports of clinical data. Remember to use quotation marks around words that you want an exact match, i.e. “chest pain” versus just typing chest pain. Most EHRs will not suggest a correction like Google and ask, “Did you mean: chest pain” (correct spelling). So, learn your search tricks like: quotations, NOT, OR, AND, parentheses around multiple terms, etc.
• Save your filters. When you listen to music on your app of choice via your phone or in the car, in order to rapidly get to what you want to listen to, you still have to either download albums, bookmark your favorite playlists, and/or save your top radio stations as presets. If you’re looking for the same type of data over and over again, be certain to treat the EHR in the same manner by saving your most common searches as a filter in chart review (labs, notes, imaging, etc.). Treat the filters like playlists. Create a cardiac playlist for all lipids, cardiac enzymes, and any other labs that brings the patient’s cardiac status into full view for the way you practice medicine based on your specialty and training.
• Create disease- and symptom-specific reports. The majority of physicians in the U.S. are specialists and routinely need to zero in on the same disease, condition, or symptoms. Your EHR teams can easily create elegant patient summary reports that will pull data to you, i.e. all diabetes-related meds, labs, studies, referrals, etc. Most of the time you will have to agree on this with a group of clinicians within the same department, but roughly 20 percent are customizable at the individual level. Remember, just use newly created Maroon 5 “Sugar” playlist for the rest.

2. Managing the Inbox

Have a full Outlook inbox or an IMessage app with a permanent notification icon or badge? The EHR inbox is like that for physicians, but on steroids. InBasket is the name for the inbox for Epic users, but regardless of your EHR vendor, managing the flood of messages can be a struggle, and with greater interoperability, it will only get worse. Here’s what I tell physicians (and IT folks who want to help them) to personalize the InBasket to their workflow and get it under control:

• Rearrange and sort. Many docs don’t realize that there are filters and sort logic available to always keep their most critical messages at the top (for example, abnormal test results, patient calls, refills, etc.). Fight your OCD and move to the top only the folders that you need to address to get the heck out of the office: results, patient messages, billable chart co-signs, refills, etc. Deal with the rest later, as they likely are not important and are just automatically sent to you because they always have been.
• Remove and relocate buttons. Healthcare can take a lesson from the airline industry here. Just like in the cockpit, buttons and alerts should be presented in a logical, easy-to-read, color-coded format. Just like in other programs you use, such as Microsoft Office, you’re able to customize your user interface to increase your focus with no IT team required. Kick the clutter by deleting buttons that are never used and move ones that are frequently used to more convenient locations. Just look for any sort of wrench, bolt, pliers, or other icon on your screen, which typically means you can move things around.
• Maximize your view. Treat your EHR view like you would your physical office and Marie Kondo the heck out of it until it’s most comfortable for you. Adjust the preview panes, sidebar, and the even the order that the report displays in to see as much information as possible at one time. For example, you may have the top half of your screen display your messages and the bottom half display reports about the particular patient to save you time from going to chart review. Maybe the EHR won’t quite spark joy for you, but it will definitely be less painful.
• Create macros / QuickActions. I’ve encountered very few physicians who have created InBasket macros. These are simple, rote tasks / words / clicks that one does over and over based on a specific type of message. These are worth investing in as they offer significant time savings, a 60 to 70 percent time savings per message type for some. For example, you can create a macro that notifies a patient via the patient portal that (1) your labs were abnormal, yet not serious; (2) my office will contact you; (3) route to your nurse/team; (4) add a small note to yourself; and (5) close the lab message–all in ONE CLICK. Spend a few days watching for things that you do over and over, then try one. I suggest refill and normal result labs to start. They’ll give you hours back in your life over time.

3. Entering Orders

Does Amazon have order sets? Sure it does. When you order a new smart TV, it will automatically suggest the recommended HDMI cable, remote keyboard, etc. That’s an order set.

I’ve always wanted an Amazon-oid EHR. When I order the latest back pain (chief complaint) for my patient, I would like for the EHR to then make recommendations based on my patterns, my colleagues’ patterns, and other patients like this one. I’d like to see it display useful information that says something like “other internists like you who have seen patients with similar complaints have done X, Y, and Z.” I’m smart enough to know if I care to follow the pack or click and see what the latest evidence-based data is from the literature.

Until this occurs, here are a few tips you can use today.

• Save your faves. Not saving your favorite orders is like not using bookmarks for your favorite websites when browsing the internet … not cool! Similar to the above macros and filters, these are key to faster ordering common things. Record dosage tapers and save multiple preferences for the same med, lab, or imaging with pre-fills. These are common, especially with chronic diseases, so save yourself from typing it or searching for it an infinite number of times. Some techie docs may already have these saved and may be willing to share with you if you ask nicely. Meds: refills 0, 30, 90 day refills, narcotics. Labs: A1c in three months, A1c in six months, etc. Imaging: CXR – chest pain, CXR – pneumonia.
• Use portions of the name of the order. Google might say, “Did you mean?” when your search isn’t perfect, but the EHR won’t. However, you can use shorthand to look up med, lab, or imaging orders. For example, here’s an Epic trick that’s been around for at least 10 years that many don’t know. When searching for an order or diagnosis, try typing small pieces of the word (in any order), i.e. “CT Abd Con” will return a short list of “CT of Abdomen and Pelvis with Contrast.” Just remember, when it comes to searching for orders in the EHR, less is more! Check with your training team for more tips.

4. Documenting the Encounter

Physicians likely spend the most time here, inputting all of their notes into the EHR. Documentation takes a lot of time, whether it’s documenting visits, sending thank-you notes for referrals, or fielding follow-up questions in the patient portal. If you have to type, then create templates for things you say over and over. There’s no predictive text a la Gmail yet, but we can emulate it until we’re there.

• Leverage SmartText and SmartPhrase templates. These are Epic system-specific names for their tools, but all EHRs I’ve used have the same type of documentation tool. Again, it’s all about making the EHR work for YOU.
• Speak now. In the age of Siri and Alexa, it’s simply bewildering how many physicians don’t leverage speech recognition software like Nuance Dragon or MModal. Add in voice navigation macros and you can rattle off your notes to your computer with incredible speed and accuracy. For example, “Show me last CBC,” or “order amoxicillin 500.” etc. And be concise! Despite what we learned in med school, verbosity doesn’t mean better care.
• Create SmartLinks. One of my favorite tricks to teach is how to pull data into your note for review, then delete (Ctrl+Z is undo). Don’t type values—learn tricks to pull into your note when appropriate (without pulling in too much in creating note bloat). As you look at others‘ notes, you’ll notice that they are pulling these labs, etc. into their note. Just find out from them how they are doing it, get the link, then you do the same yet with no need to leave it in the note. This is faster than search or filters.

Those four areas of the EHR compose about 80 percent of “pajama time.” Anything that you can do in one of those areas that can shave off a little time, you’ll see time come back in the long run—it adds up over many patient visits. Until the EHR vendors incorporate the functionality from consumer technology noted in the above examples, you must do these things to survive and stay optimistic.

By targeting these areas with these tried and true tips and tricks, I guarantee you’ll feel like you have more control over something that once felt like it was uncontrollable. Keep these fire extinguishers handy and you’ll douse some of the flames of burnout and take back your time.

Readers Write: HIMSS, Innovation, and the Infomercial

HIMSS, Innovation, and the Infomercial
By David Lareau

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

Nothing compares to the annual HIMSS conference in terms of providing educational and networking opportunities for health IT professionals. The recent event in Orlando included 300+ educational sessions, dozens of receptions and parties, and multiple days for scheduled and impromptu meet-ups with other attendees.

And then there is the Exhibit Hall. Perhaps I am jaded from my many years in the industry, but I can’t help but feel that the exhibition portion of HIMSS is a bit like a three day-long infomercial, with vendors pitching solutions to problems that many don’t realize they have (the Wearable Towel, anyone?), or for products that sound too good to be true (can you really say goodbye to flab with the ThighMaster?)

Interestingly, many of the “solutions” I saw at HIMSS were designed to fix problems that were created by other “solutions.”

Case in point: EHRs. The inefficiencies and deficiencies of EHRs are well documented. We’ve all seen the surveys about how frustrated doctors are with EHRs, which add to administrative burdens and contribute to physician burnout. Of course, EHRs have long been touted to be time-saving tools that improve patient care and allow physicians to go home earlier. The reality, however, is that few EHR implementations have lived up to all the hype.

But wait, there’s more

Full disclosure: my company was one of the 1,300 exhibitors at HIMSS this year serving up our own brand of infomercial, though I’d like to think we fall more in the Roomba category (innovative and useful) than Chia Pet (just why, people?)

We conducted a non-scientific survey in our booth to better understand providers’ biggest EHR challenges. When asked “Which health IT challenge are you most surprised is still an issue for the industry?” our 361 participants (all of whom were given a chance to win a prize) indicated the following:

• Lack of interoperability between EHRs and between providers: 36.1 percent
• Clinician dissatisfaction with EHRs: 27.7 percent
• Difficulties using data to improve clinical and financial outcomes: 22.6 percent
• Lack of innovation compared to other industry sectors: 13.5 percent

What these results tell me is that despite years of hype, EHRs still need fixing on multiple fronts in order to meet the needs of users and advance clinical and financial incomes.

Money-back guarantee

Providers have spent billions over the last couple of decades implementing EHRs that have failed to adequately deliver the efficiencies that clinicians require. Even if health systems and physicians could take advantage of money-back guarantees, few could afford the time, disruption, and additional investment required to rip out legacy systems and implement new solutions.

What are frustrated providers to do?

Not available in stores (but perhaps as seen on the HIMSS exhibit floor)

Despite the industry’s failure to realize the promise of EHRs, at HIMSS this year I saw increased interest from providers looking to improve the usability of their existing EHRs. More vendors are offering app-based solutions that extend the value of EHRs without the disruption of implementing a brand, new platform.

Some of these technologies are designed to fix inefficient workflows that diminish physician productivity. Others focus on organizing existing data so that clinicians can easily access the right data at the right time for the right patient – even if that data is coming from an outside system. Additional offerings enable more complete and accurate documentation to facilitate quality care, correct reporting, and better clinical and financial outcomes.

You can do it

I am encouraged that despite the plethora of pitchmen hawking products almost as seemingly frivolous as the Snuggie, I saw more signs of innovation at HIMSS19, especially for solutions that consider the needs and desires of clinicians and support better outcomes for patients.

The HIMSS Exhibit Hall may indeed be reminiscent of a marathon infomercial, but consider this: without infomercials, millions might never have enriched their lives with George Foreman Grills, P90X workouts, or the ShamWow.

Readers Write: EMR Direction Changes in the Post-Growth Era

EMR Direction Changes in the Post-Growth Era
By John Kelly

John Kelly is principal business advisor for Edifecs of Bellevue, WA.

Healthcare acquisitions and mergers tend to give the industry an indication of where investors will go in pursuit of new revenue streams to secure growth in future business. The $5.7 billion sale of Athenahealth is no different. This EMR vendor consolidation represents a significant milestone in what might be a segue toward an end state for the major electronic medical record (EMR) vendor market.

What does this mean for the rest of the EMR market? At the highest level, we may anticipate EMR technology to evolve as a commodity, while the services revenue enabled by the technology will emerge as the primary source of long-term sustainability for EMR vendors. The Athenahealth and Veritas Capital move is an indication that venture investors are thinking just that. This will have long-lasting implications for healthcare technology vendors industry-wide.

The Athenahealth acquisition specifically highlights the fact that the path for growth in software sales in the EMR market continues to narrow, as the vast majority of providers with meaningful spending power have already made the transition to electronic records. The rip-and-replace phase by providers dissatisfied by their first-generation EMRs will continue steadily, but will not compensate for the major decline in new sales opportunities for the industry at large.

With the GE / Athenahealth consolidation of assets, the growth outlook for the five major EMR vendors left in the space (Epic, Allscripts, Athenahealth, Meditech, and Cerner) looks a little different.

Though Athenahealth’s high profile as an EMR vendor provides the primary brand recognition, the revenues associated with its revenue cycle management (RCM) line of business still represents the major portion of its value. The future for EMR vendors will mirror other industries, wherein technology is provided at a small margin in order to capture the high value and healthy profits generated by the information and business processing services tied to the use of that technology.

Early evidence of an emerging trend was seen in the $2.7 billion 2016 acquisition of MedAssets by Pamplona Capital Management. There we witnessed how strategic investors are keenly aware that administrative inefficiencies in healthcare still present big opportunities for gain-sharing on significant cost elimination initiatives. Veritas Capital has doubled down on this opportunity by recognizing the value in merging the RCM book of business at Athenahealth with the clinical software footprint from its GE assets acquisition. Further signaling this industry shift to garner new revenue by the top EHR vendors are the recent announcements by Meditech and Allscripts of their intention to implement consolidated managed services across their EMR and practice management software and services stacks.

The fact is, providers are paying billions of dollars to third-party vendors in outsourcing their RCM activities. Bill-and-chase is costing the providers between 6 percent and 13 percent of receivables (varies by practice setting and size). If the industry can bring those costs closer to the 2-3 percent spread, seen in industries like retail, both vendors and providers would be extremely happy. Outside investors see substantial opportunity here. As a result, EMR vendors left scrambling from the sharp decline in new system sales are beginning to consider a very different view of the future.

While there are many business decisions and regulatory changes that will impact revenue streams for payers, providers, and technology vendors alike, success and growth for EMR vendors in particular will be limited if they don’t embrace creative consolidation. The combination of Athenahealth’s medical records and revenue cycle technology with the existing Virence Health assets is not just a venture firm buying a major revenue cycle company with a great brand, but rather an intentional strategic move to change the nature of the EMR market, one that fosters continued growth and furthers technology stability across the industry.

Readers Write: Measuring to Drive Continuous Improvement in Digital Health Management

Measuring to Drive Continuous Improvement in Digital Health Management
By Mohammad Jouni

Mohammad Jouni, MS is is vice-president of engineering for Wellframe of Boston, MA.

As health plans implement digital health management solutions to support the comprehensive needs of people outside the four walls, measurement is an increasing priority in order to quantify every aspect of the business and demonstrate tangible value. But measurement can also enable organizations to continuously identify areas for improvement, implement changes, and measure the effect.

The following examples are tangible ways data-driven improvements can take place from the individual patient level up to the executive board room.

Real-time interventions. A care manager noticed one patient’s falling medication adherence and reached out to ask about the issue. The patient explained she didn’t take her pills when she traveled on the weekends. The care manager mailed a new pill box, and her patient’s medication adherence rebounded to normal.

Daily improvements. Population reports indicated low comprehension of safe acetaminophen dosage. This finding, combined with the risk of misunderstanding medications, prompted a change in health education delivered directly after discharge to focus on safe dosing, resulting in an increase in patient-reported level of understanding.

Weekly staffing optimizations. Supervisors reduced the number of care managers focused solely on outreach for gaps in care when they noticed low patient satisfaction compared to a population in which care managers worked with patients more holistically, closed gaps more effectively, and saw higher satisfaction.

Monthly outreach adjustments. Claims and patient self-reports revealed falling attendance at PCP appointments. Care managers addressed this issue by switching to mobile channels to contact members before appointments and increase the frequency of reminders. Attendance rebounded to a higher rate than the baseline.

Quarterly care team reassignments. With newly-implemented technology, supervisors recognized tech-savvy staff early on and embedded them among less adept peers to share their tactics, bringing the whole group up to speed faster and with more camaraderie.

Yearly reinvestment in health management. After showing thousands of dollars in cost savings per member, executives increased the budget for health management to support increased recruitment efforts and extend health management services to more members in order to double down on those results across a broader population.

When your organization measures rigorously to demonstrate effectiveness and to continuously improve, executives will pay attention. Leadership will be able to not only justify increased investment to grow digital health management programs even further, but also apply the same data models to effectively predict the return on additional funding.

Ultimately, measurement allows health plans to make data-driven decisions that elevate the stature of care management from baseline requirement to strategic value center. In doing so, health plans will be able to amplify the effect of their programs and extend services to more members, doing incrementally and continuously better by each member.

Achieving these goals creates new opportunities to focus on member support by strengthening provider partnerships, differentiating to employers on service and outcomes, and driving retention and new sales. Through rigorous measurement and continuous improvement towards these goals, health plans are poised to quantify impact and capture significant value from the powerful data of digital health management.

Readers Write: Why Integrated Behavioral Healthcare is More Important than Ever

Why Integrated Behavioral Healthcare is More Important than Ever
By Christopher Molaro

Christopher Molaro, MBA is co-founder and CEO of NeuroFlow of Philadelphia, PA.

The pieces are starting to fall into place. Mental health is becoming an integral part of the overall conversation around health. Mental health is discussed in sync with physical health.

It makes sense, too. One affects the outcomes of the other dramatically and the extra costs associated with mental health co-occurrences is staggering.

The question remains: how do we effectively integrate appropriate behavioral healthcare for individual patients when they need it and do so in a cost-effective and time-efficient manner? In other words, how can we align the interests of patients, providers, and payers?

The market is indicating that now is the time to integrate mental and behavioral health into the patient journey. Physical health and mental health are merged into just “health,” patients get the holistic care they need and deserve, and providers are empowered with the tools to improve outcomes and payers save in costs. The triple win is attainable.

Multiple leading commercial payers are reimbursing for certain collaborative care CPT codes released in 2017 and 2018, highlighting the growing awareness around the importance of mental health. As we shift towards a value-based care system, a focus on patient engagement, satisfaction, and outcomes will add visibility to the benefits – and cost savings – of integrated behavioral health.

Also, considering the enormous behavioral health expenses of employees — mental illness costs the US $193.2 billion in lost earnings every year, according the American Journal of Psychiatry — employers are equally willing to find new ways to provide their employees access to tools to address mental health.

The awareness efforts of non-profits, advocacy groups, and healthcare organizations to normalize the conversation around mental health have been invaluable. At the same time, leading athletes and entertainers opening up about their mental health conditions is eroding the historical stigma surrounding those who struggle with behavioral health. Heightened awareness begets healthier, more frequent discussions around treatments and solutions for the one in five Americans experiencing mental illness.

Aetna’s recent “Health Ambitions” study highlights that healthcare consumers recognize the importance of mental health. Over one-third of respondents say digital messaging would make them more likely to communicate with their doctors, and the majority of people ages 18-50 say they would be likely to use a confidential website or app to track health information.

This new narrative around mental health is getting louder, and it will only help to bridge the gap between mental and physical health and the solutions patients need. But numerous studies indicate that we still have a long way to go when it comes to providing digital health technologies that meet the expectations of the modern healthcare consumer.

The digital doctor’s office is no longer a future vision, but a present-day reality. While adoption of these innovative tools can be slow, healthcare providers are rapidly warming up to technologies that can improve patient outcomes while absorbing it into their workflow and existing EMRs.

With behavioral health integration, we’ve arrived at an alignment of incentives and mechanisms among payers, providers, and patients that is rare in the modern healthcare landscape. This is an exciting opportunity for the future of mental health and one that we as a community can’t afford to pass up. The data supports the opportunity as well. Decades of research highlight the effectiveness of collaborative care in psychiatry, and when patients stay engaged with behavioral health treatment, outcomes are improved drastically.

Eighty percent of people with a behavioral health disorder will visit a primary care provider at least once a year, yet we know that treatment and access are still major issues, as nearly 60 percent of adults with a mental illness didn’t receive mental health services in the previous year, according to the National Institute on Mental Illness.

While there is much work ahead, we are encouraged by the progress we’re seeing in hundreds of clinics around the country from pediatric / school settings to geriatric and Medicare populations. Mental health knows no bounds — it can affect anyone. As a health system, our effort in addressing mental health access and engagement should also show no bounds.

Readers Write: Expanding the Horizon of Clinical Surveillance

Expanding the Horizon of Clinical Surveillance
By Janet Dillione

Janet Dillione is CEO of Bernoulli Health of Milford, CT.

Pay-for-performance programs, like the Centers for Medicare & Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP), determine provider reimbursement based on a hospital’s ability to meet key patient safety and performance measures. To reap the financial incentives—and avoid the penalties—of HACRP, more hospitals are “investing in clinical surveillance solutions that utilize real-time patient data to reveal deteriorating patient conditions at an early stage,” according to a report released in November by AGC Partners, a multi-vertical research and investment firm.

Continuous surveillance traditionally has been the near-exclusive domain of hospital departments that care for high-acuity patients with the greatest risks for deterioration, such as the ICU. However, the persistence of preventable catastrophic events, such as post-surgical opioid-induced respiratory depression (OIRD) — which accounts for more than half of medication-related deaths in care settings — suggests that the ability to monitor patients continuously and communicate insights to clinical teams in real-time must extend beyond the ICU.

According to a new KLAS report on the subject, “clinical surveillance tools hold the promise of giving caregivers clinically actionable insights that decrease mortality, reduce readmissions, and improve overall patient outcomes, and clinicians expect these alerts to be embedded directly within their workflow.”

However, successfully broadening the utilization of this technology can be complex and disruptive and can bring new uncertainties to the entire organization.

How Scalable is Continuous Surveillance?

For many health systems, continuous surveillance can be broadly used with existing technology infrastructure, especially organizations with critical care units or ICUs. Optimizing that infrastructure’s capabilities and incorporating it into existing clinical workflows is the real heavy lift, but advances in monitoring technology, use of real-time physiological data and smart alarms, and sophisticated analytics and the ability to route that information to remote clinicians show promise for scaling continuous surveillance to a number of patient care departments, including telemetry, maternity, med-surg, and even beyond the walls of the hospital.

Additionally, health systems exploring the viability of continuous surveillance are using their EHRs as a natural starting point. Multivariate, real-time data from medical devices aggregated with retrospective data from EHRs, provides a holistic and complete source of objective information on a patient that can be used for prediction and clinical decision making.

Does It Save Lives—and Costs?

Hospital investments in clinical surveillance and analytics solutions are driven by organizations that are migrating toward value-based care models and are trying to achieve the objectives of value-based care, including improving care quality and outcomes, reducing clinical variation, and reducing healthcare costs.

Similarly, patient safety in the era of value-based care is increasingly defined as preventing adverse events before emergency interventions or costly escalations are required. However, most common monitoring practices are reactive, not proactive –interventions are often applied only after a patient has deteriorated.

A number of hospital-acquired illnesses (HAI) could be prevented by continuous clinical surveillance. Sepsis and respiratory compromise are among the most costly in terms of resources and morbidity and mortality.

• Industry costs. Respiratory failure that requires emergency mechanical ventilation occurs in 44,000 patients per year in the United States. The cost to US hospitals for opioid-induced respiratory depression (OIRD) interventions is estimated at nearly $2 billion per year.
• Hospitalization costs. Respiratory compromise ($22,300), ranks in the top five of 20 conditions that have the highest aggregate costs per stay due to the high frequency of hospitalization.
• Length of stay. Ventilator-associated complications (VAC) can lead to longer stays in the ICU and greater rates of readmission. VAC complications add approximately $40,000 in costs to each case, $1.2 billion in total costs annually.

Will Clinicians Adopt It?

Technology implemented without proper consideration of impacts on workflow and user ability to fulfill their core responsibilities can have deleterious effects on its overall efficacy.

Involving direct-care staff is critical to the success of any new technology. How will this new technology impact how nurses deliver patient care? What adjustments in workflow and practice need to be made, at go-live and beyond? Starting with these questions fosters buy-in from the staff who will be utilizing this equipment. If end users are not involved in the selection, adoption, and implementation of a technology, then the likelihood that they will become owners of that product is significantly lower.

According to a clinical surveillance report released this year by Spyglass Consulting Group, “hospitals recognize the importance of real-time capabilities to enhance patient safety and improve care quality.”

Ultimately, the ability to safely manage patient populations across the enterprise, reduce the cost of care, and align with reimbursement and regulatory incentives are driving and accelerating adoption. Clinical surveillance has arrived in healthcare and the future looks bright.

Readers Write: Once Retro, Now Current Again: Why Print is Essential to Your Health Education Program

Once Retro, Now Current Again: Why Print is Essential to Your Health Education Program
By P.J. Bell

P.J. Bell is co-chief content officer at StayWell of Yardley, PA.

Smartphones, tablets, computers. You might think the best way to educate patients about their healthcare is electronically. That’s a fair assumption, considering the average American spends nearly 24 hours a week online. With more than 84 percent of folks accessing the Internet from mobile devices (that’s according to a report from the USC Annenberg Center for the Digital Future), you have good reason to think digital is the way to go. But if your practice is considering going all digital, pause for a moment to rethink that strategy.

While digital experiences are critical for engaging today’s savvy healthcare consumer, printed educational materials remain an important part of the care continuum. People still like to receive printed information at an office visit or during discharge from a hospital stay. Both patients and healthcare providers report that printed brochures or handouts are the most effective means of communication. In fact, more than half of patients say that printed educational material about their diseases or the drugs they’ve been prescribed are more useful than other tools available to them. A similar number of providers also indicate that they rely primarily on print collateral when talking to their patients.

Surprisingly, this majority isn’t just older patients. Even Millennials prefer printed materials. Various surveys have shown that more than three-quarters – and in some cases, 90 percent or more – of Millennials said they preferred reading print materials. In fact, if cost was the same for a print or digital book, they’d pick the paper version.

Paper Rules

Healthcare practices and hospitals are faced with the great challenge of ensuring that their patients fully understand their medical conditions and treatment plans. And just as vital, a patient needs to know what to do after leaving the doctor’s office or being discharged from the hospital. More than $73 billion is spent each year on unnecessary healthcare expenses because patients don’t fully comprehend what their medical providers say to them, according to the Institute for Healthcare Advancement.

The fact is, patients face a number of barriers when trying to follow medical guidance. They can be confused by medical jargon or simply overwhelmed by the amount of information—good or bad—that they can access. Some may be embarrassed to seek additional information or hesitant to ask questions. This alone results in about half of all patients leaving their doctor’s office without a solid understanding of what they were told or what they should do going forward.

However, when printed materials are used as a resource, medical staff can go over the information with patients in the office or at the hospital and get a sense of their understanding. This allows staff to determine any additional resources that could benefit the patient. Just as important, when patients are faced with an unexpected diagnosis or new medicine to take, having something in-hand to take home and re-read later enables them to think more clearly about next steps. That way, they can develop questions they may want to ask of their provider via email, phone, or at a follow-up appointment.

In many cases, given the vast quantity of medical information on the Internet—potentially from questionable sources—patients often believe print materials are more official and trustworthy than electronic documents.

The Prescription for a Well-Rounded Patient Education Plan

If your practice is planning to go all digital, let the evidence showing the importance of printed materials give you pause. Going digital can help you deliver advanced offerings. But ultimately, you need to know your audience and communicate in ways that resonate best with them. This may require a multimedia approach.

To develop a patient education program that will deliver greater value to patients and improve outcomes, consider these tips:

• Don’t re-create the wheel. Your organization probably has a lot of educational content in its archives, whether it is pre-printed brochures or an electronic library from which you can print on demand. Leverage these existing resources to provide customized education that meets individual needs. Give your patients a takeaway that they, as well as family members and caregivers, can refer to later at home.
• Use technology where appropriate. Every patient has a different learning style, so offer educational content in a variety of formats to help enable comprehension. Also, keep in mind that a large part of health literacy is ensuring your patients have repeated access to information. For some, printed material that they can read and keep as a reference is ideal. Others may respond better to watching a video made available online or as a DVD they can borrow from the office. Some patients may be tech savvy and prefer to access their information from a patient portal, while a few others may lack internet access or be uncomfortable using a computer. Also, consider the primary language of your patient base. Do you need to provide educational content in languages other than English?
• Review materials with patient and family members. Sometimes just a few extra minutes can make all the difference. When possible, carve out time to talk through the educational material you’re providing, and use common language that most people will understand. Take cues from your patient. If he or she is impacted by fatigue or the shock of a diagnosis, it can be harder to absorb what you’re saying. It’s also important to consider whether patients have physical, mental, or emotional impairments that may affect their ability to learn. Some may need specialized resources if they are vision- or hearing-impaired. Whenever possible, include family members in the education process, since they often play a critical role in your patient’s healthcare management.

Education is key to ensuring that patients understand what they need to do to address chronic conditions, recover from injury or surgery, or improve their overall health. Digital technologies shouldn’t override your practice’s ability to share healthcare information in a way that enhances patient understanding. As you explore new ways of delivering patient education, don’t miss out on the successful communication available when print materials are part of the process. A winning patient education program is flexible enough to deliver content in the format that works best for each patient.

Readers Write: What’s Good for the Dentist is Good for the Medical Doctor as Well

What’s Good for the Dentist is Good for the Medical Doctor as Well
By Robert Patrick

Robert Patrick is president of dental at Vyne of Dunwoody, GA.

Medical professionals might be tired of the endless requirements of mailing x-rays or other documentation to the insurance company every time they file a claim. Some of them might simply want the ability to add their supporting documentation to claims electronically for easier adjudication.

While medical professionals continue to wait for developments and guidance related to the use of electronic attachment solutions and technologies, their dental colleague counterparts have no such obstacles. Even though there’s no formalized standardization from an organization like the Center for Medicare and Medicaid Services (CMS) for dental, there is a range of solutions that have permeated the sector and enjoy robust use by many thousands of dental practices. Why the disparity?

The simplest reason is that the solutions are readily available in the dental sector, Their use has been embraced despite there being little formal regulation or guidance related to submitting electronic attachments. For example, as long as the solutions are compliant with HIPAA, their use is fair game. Per recent reporting, some on the medical side of healthcare are waiting for a push toward standardization in the way electronic attachments are sent before moving forward with similar solutions.

According to reporting by MedPage Today, Robert Tennant, director of health information technology policy at the Medical Group Management Association — a trade group that represents medical practices — said that HIPAA includes a directive for the federal government to develop standards for electronic attachments. But the HIPAA provision still is not seeing traction or light of day. Even when the Affordable Care Act (ACA) was passed in 2010, it included a provision requiring the federal government to issue a final rule on standardizing electronic attachments, and a deadline of January 1, 2014, for doing so, but nothing yet.

The delay, Tennant speculates, might relate to how CMS can address “solicited” versus “unsolicited” attachments. Maybe the use of a secure attachment protocol or portal for data submission could eliminate this concern. For example, with dental electronic attachment solutions, providers can simply upload their supporting documentation via HIPAA-compliant software services. The respective payer is then notified that attachments are available for claim processing. No muss, no fuss. 

While there’s no requirement or mandate for dental providers to submit attachments, just like there is not one for medical doctors, dental providers are leading the way having embraced the move to electronic attachments years ago, unlike their medical colleagues. Any care professional can (?) make use of the technology, and there is a market on the medical side of the fence, so why the delay in adoption?

One potential issue is that some believe submitting attachments to be “a fairly complex transaction” for health plans to implement. “Since CMS also controls Medicare and Medicaid, they would be required by law to implement this standard, and maybe there is some pushback in terms of the cost to implement this transaction,” said Tennant in the report.

Is regulation on electronic attachments forthcoming for medical providers? The federal electronic attachment conversation continues and was included in the federal government’s unified agenda — a plan of action issued by the Office of Management and Budget — that might not be considered until later this year.

According to regulatory guidance, the electronic attachments rule must contain data formats to be used for the attachments. In 2016, the National Committee for Vital and Health Statistics, a public group that advises the Health and Human Services (HHS) secretary on health data issues, laid out its recommendations for electronic attachments, including suggested formats, in a letter to then-HHS Secretary Sylvia Burwell:

• For the request for attachments, the group recommended using the ASC X12 format
• For the response with a submission of attachment, the HL7 format is recommended
• For the acknowledgement of the response, the ASC X12 format is recommended

For reference, the Accredited Standards Committee X12 (ASC X12) provides standards that can be used for nearly all facets of business-to-business operations conducted electronically. The committee aims to:

• Develop high-quality e-commerce standards that are responsive to the needs of the standards user
• Collaborate with other existing standards to make the standards developed more interoperable
• Avoid any conflict, confusion, and duplication of effort
• Publish and promote the standards along with their education
• Drive the implementation and adoption of the standards developed by the committee

Health Level 7, or HL7, refers to a set of international standards for transfer of clinical and administrative data between software applications used by various healthcare providers. These standards focus on the application layer, which is “layer 7” in the OSI model.

The group also recommended that HHS define attachments as the “supplemental documentation needed about a patient(s) to support a specific healthcare-related event (such as a claim, prior authorization, referrals, and others) using a standardized format.”

One thought is that with such guidance and with the backing of CMS, there might be a reduced “provider burden.”

What about the payers? Why not a push by payers for standardized operations? Why don’t payers and providers just decide on standards and implement them without any government help? This hasn’t happened because payers argue that it will cost too much money to implement; no one is going to bother if vendors don’t create products for the providers. Some vendors, of course, are not willing to produce a solution for such without payer’s backing.

In medical care, it seems that everybody’s waiting for somebody else, and no one will do it until the government issues the standard. Perhaps these arguments are valid for physicians, but for dentists, this foundation already is laid. Perhaps infrastructure is the real problem for medical providers. Nevertheless, the technological capabilities exist and have for many years.

If electronic attachments were implemented in medical care, the result could be savings for both health plans and providers, according to the Council for Affordable Quality Healthcare (CAQH), a non-profit alliance of health plans and other organizations whose goal is to streamline healthcare administration. The 2017 CAQH Index report found that only six percent of medical attachments were submitted electronically that year, but the report also found that providers could it save 51 cents per claim – 30 percent of their current cost — if electronic submission were employed, while health plans could save $1.64 per claim, a 94 percent savings.

CAQH launched a project under its Committee on Operating Rules for Information Exchange (CORE) division — a group of about 130 organizations developing operating rules for healthcare administration — to scan and discover where the healthcare industry stands in relation to electronic attachments, including use of a standard format. The organization is examining the varying types of use cases for documentation and the products available in the marketplace to support an automated approach to move the industry forward.

While the number of electronic attachments exchanged is quite small in volume, at least for medical providers, there is a clear path in place that can be executed with or without the support of an organization like CMS or others, as we have seen on the dental side of the house. While doctors may have been waiting for some guidance since HIPAA’s creation in 1996, dentists have been successfully using electronic attachment solutions since at least 1997, and with great results.

Thus, if more than 60 percent of the dentists in America who need to send supporting documentation to payers to get paid for their service are doing so electronically, why can’t the medical professionals of America do the same? America’s dental payers have agreed to participate in electronic attachments while America’s medical payers seem to be waiting for a mandate.

Readers Write: Our Experience with Epic’s App Orchard

Our Experience with Epic’s App Orchard
By Chinmay Singh

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

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

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

1. Epic is the most customer-focused EHR vendor

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

2. The App Orchard team knows the customer

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

3. Epic listens to App Orchard members

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

4. App Orchard documentation is lacking

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

5. No Hyperspace

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

Readers Write: Hurricanes Michael and Florence Remind Us Why We Need a Data Backup Plan

Hurricanes Michael and Florence Remind Us Why We Need a Data Backup Plan
By Marty Puranik

Marty Puranik is president and CEO of Atlantic.Net of Orlando, FL.

The immense flooding of Hurricanes Michael and Florence across the Florida Panhandle and southeastern areas of the Carolinas, respectively, is yet another business reminder of the omnipotent power of natural disasters. The devastating chaos and aftermath of the massive storms bring into sharper focus a humbling affirmation of the critical need to safeguard health data.

The data backup plan is a mandatory stage of HIPAA compliance requiring healthcare organizations to create, implement, and maintain a set of rules and procedures to follow when managing the backup and restore requirements of electronic protected health information (ePHI).

The data backup plan encompasses wider contingency planning processes that include your chosen business associate (BA) or managed service provider (MSP). The company engaged to remotely or on-site manage your plan must demonstrate a compliant backup service capable of backing up and restoring exact copies of ePHI. 

In choosing a backup service for business continuity and HIPAA compliance, it is critically important to understand the HIPAA Security Rule requirements. This rule demands a backup solution that adheres to the following criteria:

• Use of data encryption. Backup data is expected to be encrypted at rest and in transmission. This encryption is achievable by using a storage hardware or operating system-level encryption techniques.
• User authentication safeguards. Applying unique multi-factor password protection is accomplished using Active Directory and a token-based security key such as PKI.
• Role-based access rules. Users are restricted access on a need-to-know basis following a least-privileged design. These measures help prevent access to backup data by unauthorized personnel.
• Offsite storage capabilities. Backups must be stored in a separate location to production services.
• Secure data center facilities. This measure applies to the facility security processes such as SSAE 16 SOC1 and SOC2 standards.
• Detailed monitoring and reporting functions. Backups must be reported upon and alerts generated in the event of failure.

Moreover, leaving any best-laid plan involving patient data to chance opens to the door to security risks. Proactively test your data backup plan to ensure the MSP’s systems work harmoniously in any unexpected situation. Testing procedures can include:

• File-level restore. A file-level restore involves one or several files restored to the file system. This can be set up on the original server or to a different location.
• VM-level restore. If the MSP deploys virtualization technology, a full virtual machine restore can be performed. The server then can be tested for functionality.
• Application-level restore. A common application restore is a database from inside a Microsoft SQL server instance or a mailbox from Microsoft Exchange. This test guarantees data integrity and verifies that correct permissions and security configuration are recovered.

I often recommend to providers to delegate the backup and restore responsibilities to a compliant cloud or backup-as-a-service (BaaS) offering. The MSP determines the type of backup media to use, which is usually disk-based storage. Once successful backups are achieved, the next step is the restore process for testing to validate the data’s integrity. The testing also assures the backup engineer’s ability to restore data in tandem with the precise speed of timing to complete the process.

Integration within a wider contingency plan is also essential as a failsafe for the data protection. Most MSPs offer disaster recovery technology capable of failing over data and services to a secondary location almost instantaneously. However, be aware that backups are often considered the last line of defense in the event of a catastrophic system failure. The contingency plan authorizes instant data restoration capability in the worst possible case scenarios.

To meet HIPAA security rule requirements, the BaaS platform incorporates offsite backup technology that will offload entirely the ePHI healthcare infrastructure to an external location. The offloading is most frequently performed through site-to-site replication technology or even by shipping backup tape media to a compliant external location. Since backup data is transferred externally over a network, determining the network security being provided by the MSP is imperative to prevent breaches.

Hurricanes Michael and Florence clearly bring into focus the need for emergency preparedness to protect the security of patient data. Indisputably, losing data has huge consequences for healthcare providers who routinely handle sensitive and private ePHI. For example, if access to a critical pharmacy, lab or EHR system is severed, a medical practice struggles to recover and continue its business operations. Reputations are damaged. More importantly, patient lives are put at risk.

Like insurance plans, a data backup plan is there when you most need it as an integral part of your overall business strategy. Before the next natural disaster strikes, what is your backup plan?

Readers Write: The Compliance Difficulties of Medical Device Connectivity

The Compliance Difficulties of Medical Device Connectivity
By Abbas Dhilawala

Abbas Dhilawala, MS is CTO of Galen Data of Houston, TX.

There are numerous challenges facing the global healthcare ecosystem today, including aging populations that require more healthcare products and services; rising costs across the industry (shared among consumers, insurance carriers, healthcare providers, and taxpayers); growing wait times for medical services; and a growing demand for convenient and personalized care.

To address these challenges, medical device companies are beginning to produce medical devices with cloud connective capabilities that promote the digitization of healthcare and promote better physician-patient engagement while driving down costs. The global market for connected medical devices is expected to increase from $21 billion in 2018 to $63 billion by 2023, an annual growth rate in excess of 25 percent, according to one report.

Still, the path forward for medical device companies that want to design the connected medical devices of the future and get them to market isn’t always clear and direct. Medical device manufacturers are subject to extensive regulations and compliance requirements for the medical devices that they produce. A recent survey of 237 medical technology employees by Deloitte found something important: 67 percent believe that the current regulatory framework will not catch up with what we can do with medical device technology today for another five years.

Medical device companies today face a fractured compliance landscape that can stifle innovation and lead to heavy expenditures in compliance activities at the expense of research and development. Medical device companies that wish to sell their devices in the United States must comply with the quality regulations set forth by the United States Food and Drug Administration (FDA) in Chapter 21 of the Federal Code of Regulations, Part 820. The regulations include guidelines for ensuring the safety and effectiveness of medical devices, including the establishment of detailed design control documentation, the creation and maintenance of processes for corrective and preventive actions when non-conforming products are discovered, and requirements for document control and approval.

Quality system regulations exist around the world in different forms. Canada uses the Canadian Medical Devices Regulations (CMDR), while medical devices sold in Europe must obtain a CE Marking through compliance with ISO 13485, the international standard for medical device quality. Each time a medical device company enters a new market, it must demonstrate compliance with the corresponding local quality system regulations. Sometimes this means conducting a gap analysis and addressing compliance issues internally, but it could also mean hiring a Notified Body to conduct an expensive and time-consuming third-party compliance audit.

To help ease the path to compliance for medical device companies and reduce the cost burden of compliance activities, regulators worldwide are working towards a Medical Device Single Audit Program (MDSAP) that can establish medical device compliance for global markets based on a single audit. While this measure should reduce compliance costs for medical device companies, it remains to be seen how connected medical devices will be regulated under a new system.

As healthcare innovators continue to develop connected medical devices, privacy is a growing concern for regulators and industry professionals. Imagine a future where in-home care is increasingly common and where patients use wearable and implantable medical devices that deliver patient data electronically in real time to a central repository of electronic medical records.

Such a future might not be far off. The EHR mandate already requires hospitals and medical clinics across the United States to use electronic medical records to track patient data, and connected devices with data transmission capabilities already exist. What doesn’t exist yet is a common framework that promotes interoperability between connected devices and patient databases or any kind of privacy and security regulations that would safeguard such a system against malicious attacks that could compromise patient data.

The final compliance issue faced by manufacturers of connected medical devices has to do with changing payment models throughout the healthcare industry. As the industry shifts towards a model that compensates healthcare providers based on the effectiveness of treatments and patient care outcomes, government regulators and payers are increasingly asking for objective evidence that medical devices are positively impacting patient outcomes. Manufacturers of connected medical devices may face additional compliance obstacles when required to demonstrate that their devices actually improve patient engagement, satisfaction, and outcomes.

Despite the compliance difficulties faced by the industry, medical device manufacturers are meeting the challenge head on by innovating new ways of doing business, including funding models that offer data as a service, the adoption of value-based pricing, and the use of real-world patient data to drive business decisions. The medical device companies of today are ready to advance healthcare into the future. Now it’s up to healthcare providers and regulators to keep up.

Readers Write: Recapturing the Best Part of Best-of-Breed

Recapturing the Best Part of Best-of-Breed
By Meg Aranow

Meg Aranow is CEO of Edaris Health of Boston, MA.

Early on in HIT, departmental systems were the only computer-based clinical and business solutions we had. Often built and sold by teams that came directly out of the operational areas and bringing experiential credibility, these solutions spoke the language of the department leaders who were making the purchasing selections. The more relatable they were, the more significant their market share.

Later, with reputations solidified, these vendors began to capitalize by broadening their horizons into related areas, offering suites of applications to handle adjacent functions, such as all labs sections, not just blood labs, or all finance departments, not just AP/AR.

Then came the perfect storm that really engaged us all in the allure of the enterprise systems. First, computerization became the expected standard and big-budget centralized IT departments took root. Second, the market responded with R&D money and new investment capital. Third, healthcare costs and patient safety became everyday news and the idea of health consumerism grew. As timely, accurate shared data seemed the holy grail for both quality and expense control, the lure of single fully integrated systems became irresistible.

The decisions seemed easier 10 years ago. That was when the primary definition of an enterprise was its physical boundaries. There wasn’t much talk about IDNs and integrating freestanding surgery centers, urgent cares, or SNFs.

Now, even as we seek to integrate the data that ensures quality, safety, and expense control within the walls of our institution, we are simultaneously pushing care outside the walls to be handled in places that have less overhead and are easier for patients to navigate. There’s a tightrope to walk. We can’t trample on the very workflows that have created those higher margins and faster throughput at the lower-cost locations. If we make them behave as the rest of the enterprise does, we may lose the very things that made them attractive business assets and popular care destinations for patients in the first place.

As interoperability standards have become de rigor, there are options of where to draw the perimeter of the enterprise system and where to allow – or even encourage – deep support of site-specific workflows without compromise. That is, workflow support as once delivered by narrowly-focused departmental systems.

Customized workflow support is the new best-of-breed. With mature interoperability standards in place, we do not have to sacrifice tailored, intuitive workflow support for the sake of integrated data, decision support, and analytics. There is no reason not to have it all.

Readers Write: The Key to Population Health Management: The Convergence of Data, Technology, and Social Determinants of Health

The Key to Population Health Management: The Convergence of Data, Technology, and Social Determinants of Health
By Matt Miller, PhD

Matt Miller, PhD is vice president of behavior science at StayWell of Yardley, PA.

Advances in technology are having a significant impact on the healthcare individuals receive. Patient DNA is used to personalize treatments with precision medicine. Artificial intelligence (AI) and machine learning are speeding diagnosis and helping providers determine the best courses of action. The Internet of Things (IoT) is enabling a wide range of remote clinical applications, from medication adherence to monitoring vital functions including glucose, heart rate, and blood pressure to configuring and gathering real-time data from medical devices such as pacemakers and defibrillators.

While these technologies are powerful on their own, the combination of these various patient-specific data streams can produce an exponential impact on improving patient outcomes when merged with behavioral and environmental insights. Integration of this diverse data, through electronic health records (EHRs) and other critical healthcare systems, will play an important role in creating an ecosystem that enables providers and patients to get the information they need, when they need it. In turn, this integration of data will support the larger goals of improving population health.

Modern healthcare is well positioned to reap the rewards of recent advances in technology. Silicon and graphene at the chip level and microelectromechanical systems (MEMS) in semiconductors are in devices used every day for diagnoses and treatment, such as CT scanners, X-ray machines, magnetic imaging, ultrasound, and for monitoring blood pressure, glucose levels, and other vital statistics. These components play critical roles in sensing, data processing, and controlling machines used to monitor and treat patients. Add data science – AI and machine learning – to the mix and the industry can begin to explore new frontiers in healthcare by expanding our ability to detect and interpret patterns.

We are beginning to see this convergence of new technologies emerge in targeted use cases. Computer vision and convolutional neural networks are helping radiologists identify malignant tumors, minimizing the pain, inconvenience, and cost of biopsies. Pharmacogenomics and precision medicine are enabling researchers to identify first-line medications for patients based on their genomes and develop therapeutics based on the unique characteristics of the individual and his or her disease.

These applications are just the beginning of innovations that will redefine healthcare in the 21st century. But there may be a simpler example of how today’s data capture technology can make an equally significant impact in improving population health. This approach involves integrating behavioral, environmental, and social data directly into physician’s workflows, so healthcare professionals can have a more robust understanding of a patient’s risk factors and take proactive steps to help patients remain, or become more, healthy.

Social determinants of health (SDOH) are macro-level factors responsible for influencing health risks and health outcomes. SDOH include economic stability, neighborhood and physical environment, level of education, access to healthy food and quality healthcare, available support systems, and stress. These factors contribute to an individual’s life expectancy, mortality, healthcare expenditures, health status, and functional limitations, according to the Henry J. Kaiser Family Foundation.

Research demonstrates the enormous influence of behavior and SDOH on patient outcomes. Clinical interventions impact only 10 to 20 percent of a person’s health outcomes, while socioeconomic and environmental factors determine 80 to 90 percent, according to The National Academy of Medicine.

Consider the possibilities if a physician had access to social and behavioral information alongside lab tests, imaging results, and other background information about the patient. Not only could the doctor see that his 50-year old female patient’s glucose is high and creatinine and hemoglobin are slightly off, he could also evaluate the impact of her adherence to taking prescription medicine, stress level, and the fact that she lives in an urban food desert and doesn’t have access to regular care.

These types of solutions are already coming to fruition, in a variety of forms and functionality. Consider the offering developed by Proteus Digital Health, which combines ingestible sensors, a small wearable sensor patch, and mobile application to monitor patient health patterns and medication adherence behaviors. The objective information collected by the Proteus system enables doctors to initiate, adjust and measure treatment effectiveness, saving patients and payers money while optimizing care and amplifying outcomes.

Johns Hopkins University School of Medicine was also recently awarded a grant to continue research of the Emocha mHealth app, which tracks medication details and care management for individuals with tuberculosis, a diagnosis where strict medication adherence is essential for positive outcomes. The app connects patients and providers for Directly Observed Therapy (DOT), in which patients record themselves taking prescribed medication. The video is uploaded to a telehealth portal, where providers can confirm the medication was taken correctly and collaborate with patients on care management. Early results show that Emocha app boosted medication adherence rates by 94 percent and saved almost $1,400 per patient in treatment costs.

Using multiple data points to triangulate a patient’s condition enables physicians to deliver healthcare with a more holistic perspective. Understanding the gravitational force SDOH has on health outcomes, physicians not only can address the symptoms of disease, but can also respond to variables known to cause and/or exacerbate illness. With these types of insights, they can make more informed decisions around diagnosis, treatment and the continuum of care.

It can be a challenge for physicians to get insights into social and behavioral factors. But the move to EHRs, plus greater integration and effective data exchange through standardization efforts like Fast Healthcare Interoperability Resources (FHIR), are beginning to make these promises a reality. By capturing more data points through EHRs and having access to complete records regardless of where healthcare services are delivered, physicians will have a more comprehensive picture of patients’ background and health, empowering them to provide the care and resources to meet the unique needs of each patient.

Several device manufacturers are already offering remote monitoring tools capable of capturing patient health data at home and uploading it to an EHR for physicians to track.

For example, Boston Scientific’s Latitude Home Monitoring System enables physicians to monitor implanted devices to manage heart conditions. A five-year study of the system showed that there was a 50 percent relative risk reduction of death as compared to patients who only went to the clinic for device checks. Honeywell’s Genesis Touch collects biometric information, such as oxygen saturation, blood pressure, and weight and shares them with physicians. The related mobile app also enables video visits between patients and physicians and offers an interactive teaching tool to demonstrate techniques to manage various conditions and ensure the patient understands the treatment protocols.

Now take this integration a few steps further. Imagine,that through the power of AI and machine learning, a physician could be proactively alerted to key data points about a patient, in real time, outside of a hospital or office visit. Machine learning would identify certain thresholds that trigger the need for the physician to send a message containing educational materials to the patient, change a prescription based on data trends, or even alert emergency services.

Lessons learned from these types of just-in-time, adaptive interventions can be extrapolated to improve population health services by empowering physicians to offer data-driven recommendations to their patients.

For example, many practices may offer a universal stress reduction program to their patients. However, stress can manifest itself in a myriad of ways for different people at different times in their lives. By using the full scope of data available to understand the stressors – physical, social, and behavioral – and other factors impacting each patient, providers can do more than simply and generically “manage stress.” They can develop an intervention that helps specifically manage that patient’s unique stressors.

The future of each individual patient’s outcome is brighter when you combine the nuance and tailoring of personalized medicine with the reach of population health. Advances in science, technology, and use of SDOH brings this future within reach.

Readers Write: Projects and Costs Out of Control? Take a Low-Dose Aspirin

Readers Write: Projects and Costs Out of Control? Take a Low-Dose Aspirin
By Frank Poggio

Frank Poggio is president and CEO of The Kelzon Group.

A recent announcement in the news about the lack of effectiveness and risk of taking daily low-dose aspirin triggered my re-thinking about the age old question of, “Why is healthcare IT so far behind commercial industry?” or, “Why is healthcare delivery so costly and inefficient?”

“Experts” always say we can improve costs and quality if we practice evidence-based medicine. OK, I can buy that, but what if the evidence keeps changing every few years? I am willing to bet that in about five years some researcher will say that new data shows daily aspirin is good for you, so hope you didn’t stop taking it. How many times have we seen that with other foods like coffee, red wine, etc.?

And what about classic annual diagnostic procedures like Pap smears, mammography, and PSA tests? Or therapies like angioplasty, tonsillectomy, bloodletting, or frontal lobotomy? The list goes on. All deemed good one day in the past, but not so good or maybe deadly soon after.

This obsession with comparing medicine and healthcare to other industries falls apart if you look at a simple example. Say you are washed up and stranded on a large island. As it turns, out there is an abandoned cabin on the island with a motorized boat left at the dock. You also find a set of mechanic’s tools in a storage area, and lucky you, you happen to possess a little mechanical talent from your high school shop class. What you do not have is any documentation covering the boat or engine, but with your cursory experience with cars, you figure out how to start the engine. But alas, it will run only for a few minutes.

You tinker with it for days, but without any owner’s or repair manuals or other specs, everything you do is hit or miss. Of course you take an evidence-based approach, using trial and error and a little creativity. As you fail to make headway and start experiencing severe hunger pains, you take the engine apart to try to get a better understanding of its engineering and how it should function. Put it back together, try again, no luck, apart again, try again, and on and on.

Wouldn’t it easier if you had some documentation, like maybe a troubleshooting guide? Every boat engine that comes off an assembly line has one. If only the original owner had kept it, you could avoid all the time-wasting reverse engineering. And thank heavens the engine isn’t amorphous or biological, which brings us back to the human condition.

When you were born, didn’t the doctor give your mother your owner’s manual, troubleshooting guide, design specs, and of course a warranty? What, you say, you can’t find them, and the frustration is giving you a severe headache? Too bad, maybe try this aromatherapy — it worked for me.