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Readers Write: Change Your Change Management

June 29, 2016 Readers Write 8 Comments

Change Your Change Management
By Tyler Smith


Does your organization have a solid change management system in place? Hopefully for most, the answer is yes. In large-scale IT projects, it is essential that a well-constructed system of checks and balances for each system-affecting change be in place, as well as a forum for the discussion of each change that has a material effect on other pieces of the project.

However, due to overhyped fears of errant build moves, change management often becomes an organizational behemoth, larger and more threatening than the worst government bureaucracy and capable of effectively killing the desire of any analyst to make any change.

When the change control warps to such a state that analysts dread getting up and going to work because they know that every software improvement they make will cost them an exorbitant amount of time in the approval process, the project runs the risk of losing talented staff (if not in body, then in mind).

Having worked on a variety of EMR projects over the years, I have seen everything from no change control to a change ticket process that required a PhD to navigate the nuances and still left no one feeling fulfilled when the update in question eventually reached the live environment. Many times it isn’t just the process — it’s the outdated change management software that is used at these organizations, which causes the confusion and lengthy timelines. I’m not going to name names but anyone who has worked in these projects knows what I am talking about. These ancient enterprise change management software suites make the worst-performing EMR seem user-friendly.

The real loser in this dreaded combination of micromanagement and crappy software is the loss of productivity and creativity. If an analyst spends more time getting a change through than building it, that is not necessarily bad. Some simple changes require lots of analysis to see the broader system impact.

However, if every change requires a time effort 1.5 times or greater than the time spent to perform the actual configuration, that is a serious issue. You are effectively sacrificing productivity out of a fear of your analyst being incompetent or too short-sighted to see/think through the effect of their change. In effect, your organizational policy is stating, “We trust you to make changes in the system, but no we do not think you have any degree of comprehension of what these changes mean.”

Therefore, as organizations stabilize and try to determine how to get the best work from their full-time teams, I would highly suggest taking a look at your change management process and change management software vendor and see if the process and software really align with the other organizational initiatives you promote within your IT team.

Here are a few suggestions for moving forward:

  • Simplify. Cut down the change management process and software to the most necessary components. For example, do you really need to have seven different fields where a description is entered? Do the technical specifications ever need to be entered more than once? How long do these meetings need to be and do all changes need to be presented in such a forum? How many people need to attend? Trim the digital and process components. Every step whether in the software or in the change meeting/presentation process is like the dreaded extra click for the provider. Eliminate documentation processes that are redundant, in addition to required fields that do not serve a purpose.
  • As you simplify the governing structures, try giving analysts more control and in doing so see how little processes you actually need in place to maintain order. If analysts have the mental capacity to perform build tasks, they can probably handle taking on a degree of higher level organizational thinking regarding the impact of their change.
  • Do not allow the change control process to be constantly updated unless those changes are removing redundancies or irrelevant steps. Adding additional rules and processes often confuses analysts and these updates rarely serve their intended purpose.
  • Eliminate the standalone change control team altogether and make a committee formed from actual team members. It is OK to have a PM if the organization mandates such a structure. However, analysts who solely sit in a change control cube and who are not building in the system can never have a real world view of the software. These team members are essentially reactive (which means that in order to feel they have a purpose, they need to make the jobs of others more difficult, for better or worse). It may be a stretch to say that a change control team is a form of featherbedding, but the roles within it should be looked at with care as to the greater purpose they serve and their need to be full time.
  • Finally, if you can, scrap the medieval change control software and use the most minimally time invasive platform to document and present change and keep a record for the future. An Excel document may be enough. If the change control is linked to the help desk ticketing software this may not be possible without getting a new help desk software, but add this to the analysis.

Reducing change control staff and processes may not be pleasant. However, the long-term gains in efficiency and creativity that you will see in return from your analysts will benefit the end users of the software far more than the negatives of a temporary overhaul.

Tyler Smith is a consultant with TJPS Consulting of Atlanta, GA.

Readers Write: Patient Privacy — A New Way Forward

June 20, 2016 Readers Write No Comments

Patient Privacy — A New Way Forward
By Robert Lord


Health data security and patient privacy are in a state of crisis. Electronic health records (EHRs) are in the process of being ubiquitously rolled out, providing access to as much patient data as possible, to as many users as possible, in as little time as possible. As a consequence, hundreds of millions of patient records have been made easily accessible to millions of health system employees and affiliates, with essentially no oversight of who is viewing what patient data in the EHR and if that access is appropriate.

However, this isn’t because of health system negligence – it’s about a collective lack of accountability among several key stakeholders. Due to the sheer volume and complexity of patient records accessed each day, it is impossible for privacy and security officers to efficiently detect breaches without new and practical solutions and standards.

Something needs to change. Despite promises of role-based access controls, training programs, and security templates, the problem just isn’t being solved, and HIPAA violations continue to affect hospitals on a daily basis. That critical human layer of access is the root of these problems, and that doesn’t have an easy solution.

A new report from the Brookings Institution details that the majority of recent healthcare data breaches are caused by theft or unauthorized access. Research also shows it takes more than 200 days to detect an insider threat, if it is detected at all. And the in-depth report from ProPublica last December helped bring into focus that small-scale violations of medical privacy — like the Walgreens pharmacist who snooped in the prescription records of her boyfriend’s ex — often cause the most harm.

We are now at an inflection point that will decide the future of patient privacy. The actions and decisions of four key stakeholders and their collective will to collaborate through an independent fifth apparatus will significantly advance or stall patient privacy protection and next-generation health data security.

Patient privacy technology vendors need to invest in their teams and products to take advantage of the significant advances made in big data analytics, clinical informatics, and cybersecurity. These advances have changed many other fields, but cybersecurity and compliance solutions built for non-healthcare industries are rarely effective in the complex and idiosyncratic healthcare environment.

Furthermore, the big data environments that define many modern hospitals also require big data solutions that are at the cutting-edge of technological possibility. Critically, vendors need to better listen to their customers to create clinically-aware, healthcare-first solutions that address patient privacy. Health systems cannot purchase what does not exist and rarely have the in-house bandwidth to create production-ready systems.

Hospitals and health systems are working hard to protect patient privacy, but their security and privacy teams are stuck in a reactive mode, having to put out fires with limited resources. It’s clear that CISOs and chief privacy officers need a seat at the boardroom table and their roles need to give them the breathing room to see into the future rather than just to react to challenges as they occur.

Furthermore, compliance and bare-minimum standards are no longer enough. To truly protect patient data, a close relationship between hospital security and privacy groups must be formed. This partnership must be augmented by the technology necessary to detect and remediate threats and their collective mission must be aligned with the board. Fundamentally, resources and C-suite support must be allocated to tackle the next generation of privacy and security challenges, as current efforts aren’t on the right trajectory.

The federal government, with privacy protection authorities like the Office of Civil Rights and standard-setting bodies like ONC, want very earnestly to protect vulnerable populations and help hospitals protect patient data, and I have always been impressed by my interactions with them. However, there is no denying that they are under-resourced and limited in the amount of time they can spend looking into better solutions that could serve as next-generation patient privacy platforms. As a result, they are not able to offer much substantive guidance on what hospitals should and shouldn’t do to keep patient data secure. While distance must be maintained between vendors and regulators, greater public-private partnerships, like those in national security, are critical.

All of us as patients are an important but (amazingly) often overlooked constituency when it comes to advancing the protection of health data. Just as we wouldn’t keep our money in a bank that didn’t use passwords for online accounts or locks on their vaults, patients should expect and ask for more details about a hospital’s security posture. When hospitals ask you to sign forms that let them use your data, we should request that our providers detail how they’re protecting our information. A basic set of criteria about data encryption, proactive patient privacy monitoring, dual-factor authentication, network security, and whether or not a CISO/CPO are part of the team can tell you a huge amount about a hospital’s stewardship of patient data. We are all patients and I’m just as guilty of signing a HIPAA release form without thinking as anyone else. But if we’re to drive change, we have to think hard about what’s truly important to us and take a stand.

Ultimately, each of the above stakeholders has its own incentives, and I would contend, its own set of responsibilities and roles with respect to bringing about a new standard of patient privacy. In addition, while industry partnerships and bodies like the NH-ISAC are steps in the right direction in unifying these stakeholders, we need collective accountability and transparency regarding insider threats and HIPAA breaches beyond HHS’s “wall of shame.” Only through creating central, practical, collaborative bodies that bring all of these stakeholders to the table will we be able to move patient privacy forward and set a new standard for protecting our patients’ data.

Robert Lord is co-founder and CEO of Protenus in Baltimore, MD.

Readers Write: Mapping Out a Big-Picture Strategy to Drive Smarter Healthcare Decisions

June 20, 2016 Readers Write 2 Comments

Mapping Out a Big-Picture Strategy to Drive Smarter Healthcare Decisions
By Nancy Ham


Analytics are like a GPS navigation system for healthcare. With a full view of your route, they give you step-by-step directions for exactly where you need to go. By aggregating data from electronic medical records (EMRs), claims, health risk assessments, admission / discharge / transfer (ADT) systems, and other sources, analytics can create 360-degree views of individual patients and entire populations. This holistic approach drives smarter decisions and better outcomes.

When providers can see which patients are not following treatment guidelines, visiting out-of-network specialists, or are at risk for readmission, they can deliver more impactful interventions, close gaps in care, and improve quality. In a recent survey, 82 percent of healthcare decision makers say analytics have helped to improve patient care at their hospital or health system and 63 percent say analytics helped to reduce readmission rates.

With the right technology and strategies in place, health systems can drive change and shift value-based care initiatives into high gear.

Strategy #1: Keep patients in-network

When patient care falls outside of a health system’s network, it can lead to gaps in care, administrative referral headaches, and lost revenue opportunities. However, keeping patients in-network is a challenge, especially in today’s competitive healthcare market. Having the right data to even know who is going out of network and why compounds the problem.

Yet studies estimate that only 35-45 percent of adult inpatient care stays in network. For one accountable care organization with 27,000 lives, out-of-network services resulted in lost data, missed care coordination opportunities, and increased costs. Patients seeking treatment for hip/knee replacements saw a:

  • 10 percent increase in radiology services
  • 32 percent increase in emergency and medical visits
  • 25 percent increase in physical therapy sessions

Advanced analytics with drill-down capabilities can help. It allows users to tap into claims and clinical data so they can identify out-of-network drivers by service line and provider. These systems even allow users to see how much they are losing by diagnosis code.

From there, health systems can find ways to close gaps in services and create a strategy to keep patients in-network. For example, health systems may find opportunities to improve retention by expanding their cancer service line or adding a new service such as electrophysiology. As a result, out-of-network referrals are reduced, in-network retention improves, and the health system finds new revenue opportunities.

With this detailed level of insight, it’s also possible for health systems to pinpoint network leakage down to the provider level and use this information to educate providers about their referral patterns. When doctors and other caregivers see the impact of their referral processes on overall network performance, it’s easier to have collaborative conversations and work towards improving retention.

Strategy #2: Coordinate care to reduce readmissions

Patient data resides in a number of different sources across the continuum of care, including ambulatory EMRs, community health records, and hospital information systems. By aggregating and analyzing this data and applying predictive algorithms, it’s possible to create readmission risk scores for admitted patients so they can be proactively flagged for intervention or special consideration upon discharge.

Capabilities like these are critical for improving outcomes, particularly when it comes to managing the five percent of patients who drive more than 40 percent of our healthcare costs. When this type of information is presented as part of the clinical workflow, providers can review discharge data, anticipate potential roadblocks, take action quickly and efficiently, and reduce readmission rates.

Strategy #3: Leverage actionable intelligence and analytics

Data and analytics can help providers to gain a clearer picture of all of the populations they serve. With data from multiple sources in one central location, it’s possible to layer and visualize this information in new ways. Much like how a GPS presents directions differently based on whether you are walking, driving, or taking public transit, these tools offer users flexibility on how to view and analyze data.

By looking at clinical and claims data in a new light, providers can better understand a patient’s complete profile, including lab tests, self-reported data, health conditions, co-morbidities, lifestyle risk factors, and gaps in care. As a result, it’s possible to better stratify risk, match patients to the right interventions, and address high-risk conditions before they lead to costly treatment. Providers can then prioritize the appropriate interventions and determine a complete care plan that includes support, such as personalized patient education and coaching.

Having a comprehensive, 360-degree view of a patient or population—much like the one a GPS navigational system would provide—can ensure your journey is a successful one. With this perspective, you can reach your destination of high-quality, cost-effective care by following these key takeaways:

  • Concentrate on keeping patients in-network to improve quality care, capture vital performance metrics, and retain service revenue
  • Strengthen care coordination to reduce readmissions
  • Visualize data in new and different ways through enhanced analytic capabilities to promote better clinical and financial performance

Providers need a full picture of their patients and populations to deliver high-quality, impactful care. By harnessing a wide range of data and actionable insights, healthcare organizations can make smarter decisions that better engage patients and clinicians, reduce duplicative services, mitigate risk, and improve quality.

Nancy Ham is CEO of Medicity and VP of Healthagen Population Health Solutions, an Aetna company.

Readers Write: A Healthcare Merger, Acquisition, or Consolidation Doesn’t Have to Spell Disaster

June 1, 2016 Readers Write No Comments

A Healthcare Merger, Acquisition, or Consolidation Doesn’t Have to Spell Disaster
By Sandra Lillie


Healthcare organizations are undergoing significant change to survive (and thrive) under new reimbursement models. Mergers, acquisitions, and consolidations of healthcare organizations are rampant. It is not surprising that health IT is under tremendous pressure to advance information strategies in support of their organizations in its ever-changing portfolio of IT systems.

Much has been discussed about the changes in adoption of EHR technology during M&A activities and the amount of due diligence involved. But what about the 80 percent of healthcare data that is unstructured and resides mostly outside the EHR? Nowhere is this scenario more complicated than the unique space known as medical imaging, which makes up the lion’s share of unstructured data and is the most complex to manage.

Today, health IT often oversees multiple PACS solutions in support of radiology and cardiology for their institutions. The variety of systems grows exponentially with organizations that are involved in M&A transactions, leaving very complex support environments for IT departments when there are multiple differing proprietary PACS systems that require unique IT infrastructures.

Evolving this diverse portfolio into an enterprise strategy that can flexibly adapt to change is paramount for both acquiring and divesting organizations. Including a vendor neutral archive (VNA) as part of this strategy can:

Liberate. Healthcare organizations have the opportunity to take back ownership of valuable clinical imaging content from PACS and make that information available in a patient-centered, aggregate manner to providers of care, where and when they need it, to deliver positive outcomes for patients.

Consolidate. In addition to the ability to consolidate and economize for storage, new hospitals and partners can more easily integrate into existing networks and gain access to systems. Fewer systems alleviate IT departmental stress. Additionally, when new hospitals are acquired, core VNA services are simply extended to the newly-acquired locations. New imaging studies from these locations are efficiently redirected to the VNA to aggregate all of the enterprise’s images centrally.

Aggregate. A VNA is intrinsic to the lifecycle management of the breadth of images associated with a patient. This can include radiology, cardiology, dermatology, ophthalmology, wound care, endoscopy, and many more in a patient-centered association. VNAs support the ability to integrate studies directly into the patient’s record in the EHR. This benefits everyone – the radiologist, the referring physician, clinicians, and the patient – because it brings vital and comprehensive patient information to the care team.

Divest. Ownership of these images also provides improved capability to segment images to accompany the divestiture of a facility from the hospital organization.

VNA selection criteria should include not only technology, but also:  

  • Experience. Select a VNA technology with a proven track record of vendor neutrality across a wide range of imaging vendors.
  • Diversity. Be sure the VNA product provides support for all images that exist outside of radiology and cardiology.
  • Visualization. Review enterprise image viewers that enable the seamless visualization of images across care stakeholders and settings.

Adopting VNA as part of an M&A strategy can accelerate the ability to adapt to or lead change.

Sandra Lillie is industry manager of enterprise imaging for Lexmark Healthcare of Lexington, KY.

Readers Write: New State Mandates for Opiates Create the Next Wave of Requirements for EHRs

June 1, 2016 Readers Write No Comments

New State Mandates for Opiates Create the Next Wave of Requirements for EHRs
By Connie Sinclair, RPh


New York’s I-STOP mandates have dominated health information technology news for the last three years. I-STOP requires electronic prescribing  for all prescriptions, which has driven most EHR and e-prescribing vendors to come fully up to speed on e-prescribing for controlled substances (EPCS). Now many of these same vendors are moving on to the huge task of rolling out their EPCS-compliant versions to prescribers in other states.

More states are expected to follow suit with their own legislative mandates, especially now that New York’s deadline has passed without earth-shattering problems. Indeed, Massachusetts and Maine have recently passed sweeping changes to address the opiate crisis, but in true federalist style, each state is addressing the problem in unique ways and are calling upon the EHRs and e-prescribing systems to fall into line in new and different ways.

Very recently, Massachusetts and Maine passed new laws that will limit the quantities of opiate prescriptions prescribed; require the prescribers to view the prescription drug monitoring program (PDMP) under specific circumstances; and require the pharmacy to notify the prescriber via the EHR if lesser amounts of opiates are dispensed than what was prescribed. Most pharmacies do not have the ability to send messages of this type to the prescriber’s EHR, and EHRs are not equipped to receive them.

This notification requirement is similar to the biosimilar substitution notice required by several states and will require a different type of interoperability between pharmacy and EHR than what exists in practice today. Maine’s new law will also require EPCS for opiates and also impacts prescriptions for benzodiazepines. Massachusetts patients will have the ability to complete a non-opiate directive form which indicates that the patient does not want to be prescribed opiates. The prescriber must retain this form and rules have not yet been promulgated to describe how this information can be recorded in the “interoperable electronic health record.”

With all of these legislative mandates, it is clear that states and the federal government are reacting to the national epidemic of drug overdoses. According to the Centers for Disease Control and Prevention, nearly half a million people died from drug overdoses from 2010 to 2014, the vast majority of which were from prescription pain medications and heroin. Put another way, 78 Americans die every day from an opioid overdose. Officials fear the death toll will continue to escalate, which is creating urgency for new laws and programs to address the situation.

One method that seems to be successful in addressing the opiate problem is the popular mandate to require PDMP viewing by prescribers. PDMPs are databases maintained by each state (except Missouri) of prescriptions for controlled substances. This information can help prescribers be more savvy about their patients who may be inappropriately seeking pain medications. This one feature alone goes a long way toward inhibiting the doctor shopping (patients who go from one practitioner to the next requesting new prescriptions).

Some states have the technology and laws to support PDMP data sharing with neighboring states to better address this problem. A few states have enacted laws to require or encourage the integration of state PDMPs into EHR systems and workflows. The federal government also is working to make PDMPs more interoperable with EHRs and each other.

Addressing opioid abuse is one of our nation’s top priorities. States will continue to introduce bills for new mandates to address the opiate crisis. The challenge for EHRs and practitioners is that each state seems to put its own twist on their laws, so that they impact a different subset of drugs or require different quantity limits or PDMP viewing time frames. Vendors will be challenged to keep up with this developing patchwork of regulation and determine how to facilitate workflows that will help their prescriber clients with compliance.

Connie Sinclair, RPh is director of the Regulatory Resource Center of  Point-of-Care Partners of Coral Springs, FL.

Readers Write: Why HIT Leaders Should Consider Mentoring

May 25, 2016 Readers Write No Comments

Why HIT Leaders Should Consider Mentoring
By Frank Myeroff


The most successful leaders in healthcare IT tend to have something in common: they all have had a mentor or multiple mentors. A mentorship program can offer support towards an individual’s career as well as help to build knowledge among mentees which ultimately strengthens the organization.

Through four different types of mentorship programs, HIT leaders can use their experiences and knowledge to share with mentees, but also can benefit their own careers.

  • New hire mentorships. Mentors offer insight and guidance through new employees’ first couple of weeks of work. This helps mentees to become acclimated to the new work culture and environment while learning new things from an experienced HIT employee quicker.
  • Career mentoring. Mentors assist in the development of a mentee in the healthcare IT field. This could be formally organized through a mentorship program or informally take place in an organization where managers accept mentoring requests from employees. Professionals who are one or two positions above mentees can give valuable coaching and help to work through challenging work situations.
  • Networking mentoring. This allows individuals to share ideas and contacts throughout the marketplace. Networking mentoring is often informal and can take place at industry trade shows, healthcare IT conferences, or even social media platforms such as LinkedIn. Jeffrey Pelot, CIO at Denver Health, has used networking mentoring in his career. “I have sought out CIOs in various industries that have been willing to provide mentorship or act as sounding boards when I have been faced with difficult situations.”
  • Untapped potential mentoring. This type of mentoring is targeted towards an average or underperforming employee who has great potential, but has other components preventing them from reaching it. This can help an employee develop and discover how to excel in the field, and provide he or she with knowledge to succeed.

HIT leaders can participate in any of these mentorship programs to offer advice, share past experiences, and help up-and-coming leaders in the field. In fact, HIT leaders should view mentoring as an essential leadership skill. Mony Weschler, chief technology and innovation strategist at Montefiore Medical Center (NY) has had many great mentors who helped propel his career. Now he gives back, and according to Weschler, “What I really enjoy is mentoring others and infecting them with a passion for healthcare IT.”

There’s no doubt that mentoring others can be quite rewarding. By participating and becoming a mentor, you are likely to:

  • Obtain personal satisfaction from making a difference to the career development of another person.
  • Help in shaping future leaders and thereby impact the organization’s succession planning.
  • Increase your professional networks.
  • Enhance your people skills in areas such as leadership, interpersonal skills, and communication.
  • Learn more about areas in the organization where you may not be as knowledgeable.
  • Re-energize your career.

Overall, mentors can provide so much value for mentees and often mentorship programs are what shape future leaders of companies. When asked about mentors, Sue Schade, founding advisor at Next Wave Health Advisors and serving as Interim CIO at University Hospitals in Cleveland, summed it up nicely: “I’ve had mentors along the way, people I have either worked side by side with or as my boss. These have been some really solid people who have been able to give me good advice and who have been supportive and helped me stretch. Knowing how I have been supported in my career is why I have been so willing to do the same for others, to give back now that I have something to offer.”

Frank Myeroff is president of Direct Consulting Associates of Cleveland, OH.

Readers Write: Ten Ways to Avoid Making the List

May 25, 2016 Readers Write 1 Comment

Ten Ways to Avoid Making the List
By Ryan Secan, MD, MPH


In honor of the Year of the Hospitalist, I would like to share some hard-earned wisdom with those just entering our profession.

There are many unique things about hospitalist medicine – the seven on/seven off schedule (don’t get me started on this one – that’s another post), the exclusive inpatient focus, and the unfortunate administrative tasks that always seem to fall on our shoulders. Since we don’t have appointments, our patient assignments are determined early each morning at about 7:00 a.m. And often, ‘making the list’ is a job that falls to one of the hospitalists (despite hospital administrators consistently talking about everyone practicing at the top of their license). This remains a manual process that is time-consuming, painful, and delays everyone’s start to the day.

In my 15+ years of experience as a practicing hospitalist, I’ve never run into anyone who enjoys this process, and in fact have seen lots of creative ways that folks have been able to avoid the job. At one of my prior programs, the first doc who arrived in the morning made the list, so everyone started coming in later and later to avoid it. When you feel like you aren’t up for the task, feel free to borrow from:

The Top Ten Ways to Avoid Making the List

  1. Refuse to shovel your driveway. Even if the hospital sends someone out to get you, the list should be done by then (this will only work in Boston through April).
  2. Delete Waze and just accept that traffic will make you late.
  3. Make the list really badly once. They’ll never ask you again.
  4. Keep handy a picture of your car with a flat tire. Send to your program director in the morning as needed (but remember, you have four tires).
  5. Hide in your car until everyone else has gone in.
  6. Park really far away to get those 10,000 steps.
  7. Schedule 7:00 a.m. family meetings.
  8. Fake an emergency page.
  9. Become a nocturnist.
  10. Talk to IT. Isn’t there an app for that?

Ryan Secan, MD, MPH is chief medical officer of MedAptus of Boston, MA.

Readers Write: Telehealth Can Create a Healthcare Nirvana: More Access, Lower Cost, and Enhanced Experience

May 25, 2016 Readers Write No Comments

Telehealth Can Create a Healthcare Nirvana: More Access, Lower Cost, and Enhanced Experience
By Rohan Kulkarni


Healthcare in the United States generally inspires a sense of foreboding despite the progress that has been made since the 2010 enactment of the Affordable Care Act (ACA). While there continues to be challenges on both the cost of care and patient experience fronts, I believe that the most progress has and can continue to occur with access to care, which can in turn impact cost and experience.

It’s important to recognize the evolving patient population and how that will impact healthcare over the next 5-10 years.


The Millennial generation was recently recognized as the largest generation, overtaking the baby boomers. They make up approximately a third of our total population.

The implications of that are highly consequential. Consider this: Millennials are currently low consumers of healthcare, accounting for less than 10 percent of the total spend. But historically, care consumption begins to steadily rise at a dramatic pace after women turn 25 and after men turn 30. This trend indicates that over the next five years, Millennial consumption of healthcare will significantly increase. Given the size and consumption preferences of that population, we are going to see marked changes in how healthcare is delivered.

One area in which Millennials will drive a seismic shift is the engagement of providers through virtual and mobile channels. It is seismic not only because of the size of the generational population, but their impact on the adjacent generation of Gen X who have had to continuously adapt to the new technologies. Let us consider a few ways in which they will manifest the idea.


  • Alternate channels. In early 2016, Oliver Wyman published a white paper titled “The new front door to healthcare is here” in which they describe non-primary care physician interaction such as pharmacy- based clinics, mobile apps, and telemedicine in an alternate setting as the new front door of healthcare. As consumers find these alternate channels better, easier to access, and possibly less expensive, close to $200 billion in current healthcare spend is poised to flow from traditional venues to one or more of these alternatives. In fact, once you use a retail clinic or telemedicine, you are less likely to use traditional care.
  • Increased conditions supported. Telemedicine used to be for the simple stuff. Not any more. It is able to support more complex situations including strokes, intensive care unit situations, and behavioral health. As the number of conditions expands from the simple to the complex and as the monitoring of chronic conditions such as sugar levels for diabetes, heart rate, blood pressure, etc. becomes more stable, telemedicine will potentially become the channel of choice for healthcare interactions.


  • Impact on cost of care. There is a sense that telemedicine will bend the cost curve. However, it will be a while before the needle begins to move in any meaningful manner. In the short term, providers will need to strategically invest in telemedicine to extend their front offices all the way to patient homes or wherever it is that patients choose to connect from. But this investment will be a fraction of what it would take to build new physical structures. Consequently, there will be near term capital cost benefits with longer term operational savings that will be sustainable and meaningful.
  • Payers are paying. Recognizing the value of telemedicine both in its ability to provide care and optimize costs in the midterm, more payers are willing to reimburse these costs. Today, 29 states require insurers to pay for telemedicine services. Medicare is also beginning to pay for telemedicine-based care, which is a strong signal of the faith in the efficacy of this newer channel.


  • Convenience. Telemedicine offers new levels of convenience: the ability to get healthcare from the comfort of one’s home is very compelling. Paired with the prospect of having the physician send prescriptions to the local pharmacy that can deliver it to the home enhances medication adherence. This heightened level of convenience will influence the use of care in a timely manner. Patients will be able to avoid driving through traffic and decreased productivity at work but still receive the care they need.
  • Streamlined service. There is a very high likelihood that healthcare is about to be digitized end to end like never before, and that has healthy consequences. The telemedicine platform will be connected to the EMR platform, claims, and revenue cycle management, driving new levels of efficiency and enhanced patient experience. Healthcare will be at the tip of your digits.

Telemedicine is coming of age thanks to the large Millennial population that is likely to consume healthcare through this newer channel and payers’ willingness to pay for it. It is improving access at a fraction of the cost of a new ambulatory setup and giving rural constituents a chance for good healthcare. While still very small as a channel for healthcare delivery, it is about to be turned on its head like never before.

Rohan Kulkarni is vice president of strategy and portfolio for Xerox Healthcare Business Group.

Readers Write: Giving Patients Access to Prior Mammograms: For Me, It’s Personal

May 11, 2016 Readers Write 2 Comments

Giving Patients Access to Prior Mammograms: For Me, It’s Personal
By Kathryn Pearson Peyton, MD, Chair of the Women’s Health Advisory Board, LifeImage


I never imagined that I would be a radiologist advocating for patients in the healthcare tech world. The life pursuit of throwing open access to prior mammograms for women wasn’t on my career to-do list when I consulted my high school guidance counselor to narrow my college choices.

In due time, however, the career found me. Here’s my story.

I grew up in Northern California, in an area where breast cancer risk is doubled simply by virtue of being born there. Breast cancer had a strong history in my family. My great-grandmother died of it. In those days they didn’t screen. By the time they found her breast cancer, it was metastatic to the brain.

My grandmother had a mastectomy in her 40s. Her twin daughters had breast cancer, one in her 40s and the other developing three pathologically distinct breast cancers. Another aunt was diagnosed when she was 38 and passed away leaving two-year-old twins. My mom had breast cancer.

Breast cancer ravaged my family emotionally, starting with my grandmother, who was psychologically crippled from her surgery, which in those days was deforming. My aunts were terrified and anxious. By the time I came along, it was painfully obvious there was a genetic predisposition toward breast cancer in my family, and I wouldn’t be far behind.

Breast cancer found me, too

While I was in early medical training at the University of California, San Francisco in my mid-20s, I went through genetic counseling for breast cancer. A counselor looked at my family history and determined I had an 85 percent lifetime risk of developing breast cancer. They advised me not to get tested for the gene since, by law in California, that would assign me a pre-existing condition that would preclude me from qualifying for health insurance.

I followed their advice and did not get tested. What I did, however, was learn everything I possibly could about breast cancer. I became a radiologist, followed by a fellowship in breast imaging with Ed Sickles, MD, one of the fathers of mammography. I monitored myself, starting screening mammography at age 30.

During those years, I practiced high-volume breast imaging in San Francisco and Jacksonville, Florida, for 15 years. Every time I diagnosed a patient’s breast cancer, I thought, “This could be me … this will be me.”

Finally in my mid-40s, it was me. The signs of early bilateral breast cancer appeared on my own MRI screening: 6 cm of abnormal ductal enhancement in one breast and an entire lower inner quadrant in the other. A negative biopsy would not have reassured me, and the uncertain future of my extremely dense breast tissue was a ticking time bomb. The decision was easy. I don’t mind surgery. I do mind chemotherapy.

Without hesitation, I underwent a nipple-sparing bilateral mastectomy, which was unusual at the time – before Angelina Jolie’s raising awareness of the decision process that some women choose for preventive medicine.

That whole experience gave me a wake-up call. I was burning myself out practicing radiology 10 hours a day during the week and three to four weekend days a month. I stopped practicing.

Fixing mammography, one scan at a time

While I had stopped seeing patients, I still had a strong interest in helping women and I certainly knew a lot about medicine and breast cancer in general. It was clear to me this was an area in which we could improve medicine. Research shows that, with increased availability of prior exams, the quality of patient care and outcomes are improved. Breast cancer can be detected earlier, therefore resulting in less-traumatic and less-costly treatments.

In a study at UCSF, the risk of unnecessary additional examinations is increased 260 percent when prior mammograms are not available for comparison. These high recall rates account for the majority of imaging costs related to breast cancer screening.

Because breast tissue is unique to each individual, archived images provide a benchmark for evaluating changes in tissue composition and assist in the early detection of cancer. When there is a perceived abnormality, the patient is called back for additional imaging of a screening finding. In a grand majority of the time, it is not cancer, and therefore a false-positive result is discovered. This average callback rate for mammography screening in the United States is approximately 10 percent, according to peer-reviewed studies that have examined the data.

Yet it is technically difficult to keep patients connected to their prior mammograms. Patients move between locales, health systems, or both. Some hospitals willingly share mammograms with patients. Others are hesitant, for fear of losing them.

I found the lack of accessibility to priors a barrier for patients and launched Mammosphere to help solve this problem. The concept is a mammogram-sharing cloud that provides hospitals, imaging centers, and patients with electronic access to prior mammograms. It is most active in the Jacksonville, Florida where Mammosphere was formed. Now we’ve joined forces with LifeImage, and in the coming months, the reach of the network will open mammogram access to millions more women.

For patients, the health IT interoperability argument is real

Among the bits, bytes, and bottom lines of technological and financial considerations involved with health IT initiatives, we must never lose sight of the patients and their stories. They need to be at the center of all technology initiatives to improve care.

Physicians who are informaticists can lead the way in accomplishing care improvements. They comprehend not only the technology, but its usefulness in care paths, as well as the specific clinical justifications for using technology to overcome challenges that today create financial waste as well as angst, inconvenience, and sometimes pain for patients.

While it would have been impossible for me to foresee this career path, I now find myself in the health IT realm as a patient advocate. Like many others, I’m hoping to positively influence care quality while helping reduce costs for patients, providers, and payers. By using technology as the tool to achieve it, I believe it’s possible, and that breakthroughs on a national scale are right around the corner.

The top federal health IT leaders came to HIMSS16 pushing health data interoperability. It might sound geeky, but it’s not. It is foundational to helping 60 million women who undergo regular mammograms in the United States, 39 million of whom screen annually. They need access to prior mammograms in a central cloud repository, and they need to maintain freedom of choice to see healthcare practitioners best suited to their needs and personal circumstances.

How do I know all of this is true? Because I am that person. A radiologist who sees the potential power of health IT to fix broken care paths and take on breast cancer – which found me through my family tree. I will not rest until we stop this disease.

Kathryn Pearson Peyton, MD is chair of the Women’s Health Advisory Board of LifeImage.

Readers Write: Healthcare Consumerism

April 27, 2016 Readers Write 1 Comment

Healthcare Consumerism
By Helen Figge


Everyone has at least one healthcare catastrophe to share. Mine is simple. My mother died of a mischievous breast cancer that disintegrated her bones, but only after it was missed “buried” in a pile of papers several years before.

One sentence tells all in a scribbled office note: “current testing could not rule out malignancy — suggest follow up.” The problem was that no one ever informed my mother. We only found incidentally upon her demise. The electronic health record with data exchange capabilities could have given a temporary reprieve.

Technology, however, did enter her life before her untimely death. Mobile technology in her final days delivered every hospital amenity into her home, supporting her last wish “to die in the same room I was born in,”which was 64 years earlier. Innovative healthcare technologies do indeed play a role and can satisfy the healthcare consumer, but certainly in this instance, arrived too late to be her savior.

Technologies are gearing more towards self-monitoring, self-direction and consumer empowerment. At least 52 percent of smartphone users directly gather their health-related information along with indications of how poorly or well one is living life. Healthcare technologies are creating an opportunity for the consumer’s total control of his/her own health destiny. But is this proactive or counter-productive? Is it a sustainable model for healthcare awareness?

Companies are offering technologies that provide the consumer access to laboratory results via apps that are private, secure, and fast, able to be viewed 24/7. However, in some instances, inaccurate results create self-doubt to the end user and clinicians. As the next chapters of technology dissemination evolve, vendors need to better understand what the end user is really looking for in order to support and sustain this new wave of healthcare consumerism.

Chronic diseases are often manageable and sometimes even preventable, yet the healthcare delivery system seems to do better at optimizing managing rather than preventing diseases. In order to turn the pendulum around in healthcare delivery and disease prevention and finally make us all healthy, a technology solution set is needed that is all-encompassing and that comes second nature to the end user. The true challenge in healthcare is to implement a practical solution that comes second nature to us in life’s daily workflow.

Several studies in healthcare show that most consumers want to use digital services for healthcare regardless of age, thanks to the success of Facebook and other social media platforms. The demand for mobile healthcare is definitely there and is resonating throughout all age groups. Consumers also state that they do not want bells and whistles, but the simple brick and mortar in the healthcare technologies to service their basic needs (supporting efficiency and accuracy). Reinforcing the phrase, “Going big is not always better.”

Given the leveling off of healthcare technology spending, the industry needs to better listen to the healthcare consumer’s wish and bring us back to the basics. Our society is not short of technology solutions, but the healthcare consumer is realizing that for health sustainability, sometimes the reliability and usability of a product might now be worth the effort to keep it.

Providing solutions that will allow self-diagnosis and self reflection are the first steps in acknowledging illness, thereafter empowering steps of going to a clinician for an unbiased assessment.

Helen Figge, PharmD, MBA is senior vice president of LumiraDx of Waltham, MA.

Readers Write: Why Secure Messaging is Failing Hospitals

April 27, 2016 Readers Write 2 Comments

Why Secure Messaging is Failing Hospitals
By Ben Moore


Healthcare communications are growing up. Where we were once reliant on interruptive, one-way message pushes; device juggling; and kludgy workflows driven by pager use, modern clinicians have a wealth of tools at their disposal to facilitate effective care coordination.

Yet despite a relatively crowded marketplace (some estimates put the number of secure healthcare messaging providers at over 70) and a market that is ripe for disruption (just ask anyone who still uses a pager if they enjoy it), healthcare messaging solutions still face relatively low adoption, with an estimated 85 percent of hospitals still eschewing smartphones in favor of pagers.

Secure messaging and pagers share a common thread. Neither was specifically designed to address the nuances of healthcare communications. They were mass-market solutions that were adopted by healthcare owing to being in the right place place at the right time.

For pagers, adoption was spurred by the need to deliver around-the-clock care while also allowing providers to (occasionally) leave the hospital. For secure messaging solutions, it was a matter of encrypting PHI that clinicians were transmitting from unsecured personal smartphones, mitigating the risk that came with smartphone use in a clinical setting.

As smartphone use grew organically in healthcare workplaces, HIPAA pitfalls abounded:

  • Data remained resident on personal (and often unprotected) devices.
  • There was little control or policy enforcement.
  • There was no guarantee of SMS message receipt.
  • There was no visibility at an organizational level that any communication had occurred at all.
  • Clinicians became accustomed to utilizing shorthand codes or acronyms to communicate, increasing the propensity for error.

The end result of this was an enormous financial risk of HIPAA violation and compromised care delivery and confusion in the healthcare setting. Secure messaging vendors sought to correct these problems by handling data through a single vendor, implementing message self-destruction from personal devices, guaranteeing message delivery, supporting rich media such as images and video, and performing integrated directory lookup.

If security is the only concern (and don’t get me wrong—it should be a very big concern), these solutions fit the bill. But if the 85 percent of hospitals still utilizing pagers are any indication, healthcare providers are looking for much more when it comes to enabling mobile communications.

In application beyond HIPAA compliance, secure messaging is falling short in a big way. According to a survey conducted this year, 56 percent of providers felt a lack of useful integrations with other software was the leading reason current providers fell short; 44 percent felt they lacked structure and policy; and 33 percent felt that low user adoption was the biggest hindrance.

Inclusion and integrations must be addressed by secure texting apps. Messages are data in its rawest form. If this information is siloed from other departments (for example, if nurses and physicians use different mediums) or different systems (such as scheduling, EMR, nurse call, and paging systems), it’s useless.

The Joint Commission ruling on secure texting states that mobile order entry is not permitted because basic secure messaging lacks the ability to verify the identity of the sender and record a copy of the original message against the EMR. Integrations with Active Directory and EMR software (in that order) ensure that mobile orders remain compliant. Ask any physician if they’re looking for another way be awakened at 4 a.m. when they’re not on call and you may begin to understand why they’re not falling over themselves to try something new (see “adoption issues.”) This can be easily mitigated by integrating with the on-call schedule to ensure that messages and notifications are automatically routed to the correct on-call party.

In the age of big data and informed decisions – and, we’re told, interoperability — there is no excuse for messaging applications to not pull and push relevant or necessary information from other systems to provide additional context, value, and insight.

Healthcare communications are, by and large, structure- and policy-based. Providers in a clinical setting are familiar with not only which information needs to be captured, but who that information needs to be relayed to and when. Basic messaging such as SMS or chat does absolutely nothing to address this (just look at a millennial’s messaging history to confirm.)

For a healthcare communications application to succeed, it must be able to ensure that the relevant information is being captured, and then navigate a complex web of individual providers, care teams, departments, and schedules to deliver that information to the appropriate individuals. Further, secure communication solutions must provide an automated escalation policy and user confirmation of receipt of critical labs to ensure those results are delivered in a timely manner, according to JCAHO’s National Patient Safety Goals.

To address this, next-generation healthcare messaging solutions are building fail-safes into the software itself, including continuous multi-channel delivery attempts (by text and phone), automated escalation rules and message routing in the event that a recipient is unavailable, and delivery visibility so that senders can conclusively confirm a message has been received.

Lastly, in the world of healthcare technology, particularly communication applications, a product is only as good as the number of people who use it. It’s no surprise that a number of secure messaging implementations have been scrapped or cancelled in the face of low adoption. Concerns about device number privacy, a lack of time to learn a new product, or even, yes, pager attachment (a digital version of Stockholm Syndrome) can prevent secure messaging solutions from being successfully rolled out enterprise-wide.

To overcome these obstacles, solution providers must support dedicated number provisioning (providing a unique phone number that exclusively works for communications within the app), pager network integration and pager functionality via a smartphone app (for the pager holdouts), and driving messaging through integration points (some hospitals use as many as 10 disparate systems, including call centers, scheduling solutions, and so on) and providing a user experience that is, at minimum, better than native SMS functionality on smartphones. Really, it’s not that difficult to do.

As a whole, secure healthcare messaging has a lot of room for improvement. However, with the willingness to listen to customers and the ambition to look beyond simply providing security as a service, the opportunity to transform how healthcare workers communicate, collaborate, and deliver care is there.

Ben Moore is founder and CEO of TelmedIQ of Seattle, WA.

Readers Write: The Journey from Population Health Management to Precision Medicine

April 20, 2016 Readers Write 1 Comment

The Journey from Population Health Management to Precision Medicine
By David Bennett


Imagine a world where individuals receive custom-tailored healthcare. Patients are at the center of their own care, making key decisions themselves. They are supported by research and education, and their information is shared easily between caregivers and clinicians. Preventive care is more effective than ever, and medical interventions occur in record time.

With precision medicine, this world is not just within reach — it’s already happening.

Precision medicine (also known as personalized medicine) is the next step in population health management, transforming healthcare from being about many, to focusing on one.

Population health serves as the “who” to identify cohorts of patients that are at risk and require attention. Precision medicine is the “what,” providing caregivers with the specific information they need to create effective prevention and treatment plans that are customized for each individual.

Having the largest variety of data sets possible optimizes therapeutic tracking of each patient’s care plan to make and refine diagnoses. This sets the stage to pursue the most personalized therapy possible by detecting patterns in clinical assessments, behavior, and outcomes.

Data is essential, but it’s only useful if you have the ability to make big data small in order to personalize care. Today’s technology platforms can do just that, by capturing vast amounts of health data and applying real-time analytics that provide information and tools that help healthcare professionals and health insurers make more effective, individualized treatment decisions.

Using this information to engage patients and guide care management makes the journey from population health management to precision medicine that much easier, paving the way for an era of truly personalized medicine that prevents the deterioration of health.

The timing couldn’t be better for precision medicine’s heyday, and here’s why: one-size care does not fit all.

Many factors are converging to make the adoption of precision medicine a reality:

  • A growing number of EMRs, EHRs, and HIEs are being connected and cover a significant number of individuals.
  • Patients are more interested in participating in their care, especially when they get access to their own data. There are myriad devices on the market today that are relevant — from wearable devices that measure activity and sleep quality, to wireless scales that integrate with smartphone apps, to medical devices that send alerts (such as pacemakers and insulin level trackers). The data from these devices contribute to a robust longitudinal patient record. The interactive nature of the technology is also an excellent way to engage patients.
  • MHealth advances allow us to easily capture consumer data using cellphone technology and monitoring patients remotely with telehealth and virtual consultations.
  • Ability to see which inherited genetic variation within families contributes both directly and indirectly to disease development. We can now adjust care plans when genetic mutations occur as a reaction to the treatment in place.

If we look at healthcare outcomes in the United States, it’s clear that we need to anticipate patients’ needs with evidence and knowledge-based solutions. Only then will we will be able to identify a patient’s susceptibility to disease, predict how the patient will respond to a particular therapy, and identify the best treatment options for optimal outcomes. Precision medicine will get us there.

Precision medicine is about aggregating all forms of relevant data to enable different types of real-time data explorations. More concretely, specific areas of medicine are expected to make use of new sources of evidence, and the data types they leverage vary based on medical specialty. A good example would be the difference between the data sets used by oncologists versus immunologists.

There are two critical types of data explorations that both need a very large number of data sets to bring results:

  • Medical research with scientific modeling. Precision medicine can be leveraged to advance the ways in which large data sets are collected and analyzed, which will lead to better ways and new approaches to managing disease.
  • Clinical applications. Treatment plans and decisions can be greatly improved by identifying individuals at higher risk of disease, dependent on the prevalence and heritability of the disease. We call this cognitive support at the point of impact. To support this, more control is needed in real time over macro variables: genomics, proteomics, metabolism, medication, exercise, diet, stress, environmental exposure, social, etc. Precision medicine provides a platform that has an extensive number of data sets with the ability to easily create custom data sets to capture these types of variables.

Precision medicine not only means care tailored to the individual, it also brings to the healthcare industry the visibility on variability and the speed necessary to act expediently on findings to prevent the deterioration of health. Not only does this enhance patients’ lives, it saves healthcare dollars and prevents waste.

Tailoring deliverables to the needs of individuals is nothing new, at least in other fields such as banking and retail. Pioneers in these industries have leveraged open-source technology on a solid data foundation to meet their markets’ challenges.

Surely we can do the same in healthcare, where it’s literally a matter of life and death. That’s why so many of us are working on a daily basis to accelerate the science behind precision medicine and to encourage its adoption. Precision medicine is nothing short of revolutionary, and together, we can all make it a reality.

David Bennett is executive vice president of product and strategy at Orion Health of Auckland, New Zealand.

Readers Write: Three Tips for Supporting a Population Health Management Program

April 20, 2016 Readers Write 1 Comment

Three Tips for Supporting a Population Health Management Program
By Brian Drozdowicz


Provider organizations have a lot of options when selecting population health management expertise and system support, including analytics, data aggregation, clinical workflow / care management, and patient engagement solutions. With the market for these solutions expected to reach $4.2 billion by 2018, it is not surprising that new vendors pop up practically daily, or that existing vendors are beefing up their solution portfolios to capitalize on the opportunity.

As providers’ wish lists continue to grow, driven in part by government initiatives and commercial payer programs, system selection starts to take on the overwhelming feel of a second EMR implementation. This is causing providers to hesitate just when they need to act. How can providers find the right path to effective population health management?

No matter what shape a program might take, the right team is a foundational imperative. Assuming risk for populations often means that provider organizations are learning and mastering a new set of skills while simultaneously balancing the demands of “business as usual.”

One frequently deployed tactic is to hire staff from payer environments. They bring the requisite knowledge to the table and can help incorporate proven payer techniques and processes that both build on and complement a provider’s current infrastructure. Team members are needed who “speak data” and are also representative of groups across an organization (e.g., clinicians, program managers, business leads, finance team members, IT staff) to best determine what program goals are, what is possible for the specific organization, and what actions should be taken along what timeframe.

Once  the right team is in place, here are three tips to support the implementation of a population health management program:

  1. Recognize that data quality is more important than data quantity. The foundation of any population health management program is data. However, providers don’t need or want it all because each type of data has to be managed and maintained, often by separate people and according to different rules (e.g., privacy constraints). Focus on obtaining and properly maintaining the right data to drive population analysis, program structure, program management, and ongoing assessment.
  2. Learn to embrace claims data. Provider organizations need the longitudinal view that claims data provides to adequately assess utilization, total cost of care, and provider performance, and in turn to answer complex, multi-faceted questions about risk. Other benefits of claims data include that it is: (a) easier to manage and maintain; (b) more readily available and accepted than ever before; (c) controllable from a systems perspective; and (d) proven to yield accurate insights.
  3. Show physicians the numbers and what drives those numbers. Physician change is required to embrace the concept of value-based care. Comparative performance data can be a huge eye-opener. Physician leadership can help physicians be the champions of program performance assessment by making sure they can dig deep into the data, develop confidence in its findings, and understand what precisely needs to change. Complement performance data with compensation plans that reward participation, improvement, and outcomes. Start by placing the emphasis on participation, and then weight improvement and outcomes more heavily over time.

Provider organizations must know what is essential versus nice to have before they go into the vendor evaluation process. In a new and volatile market, the number of vendors offering potential solutions is huge, and the allure of slick user interfaces that can perform every population health management function, while integrating all types of data, is understandable.

However, little is proven, and most organizations do not have the time to wait until it is. Solutions have a gestation period to build, test, and revise before they become accurate, produce valid results, and deliver actionable business value. Answers are needed now, so organizations should look for a track record of results in a similar setting.

What does an organization need to effectively manage risk and care for populations? Of course, the answer is, “it depends,” but if you build the right team and thoroughly research your options, these tips can help bring order to the chaos.

Brian Drozdowicz is executive vice president of product management at Verisk Health of Waltham, MA.

Readers Write: It’s Time to Get Doctors Out of EHR Data Entry

April 20, 2016 Readers Write 9 Comments

It’s Time to Get Doctors Out of EHR Data Entry 
By Marilyn Trapani


There was a day when medical transcription was neat and clean. A doctor dictated what happened during an exam and a transcriptionist accurately typed each detail into the patient’s record. Each future encounter built on that record, a detailed history meant to ensure quality care. It wasn’t a perfect system, but it worked.

Now doctors sit for hours each week in front of a computer screen entering patient encounter data into electronic health records (EHRs). These complex systems were meant to more efficiently and effectively track health data for hospitals, payers, and physicians alike. EHRs were promised to save physician practices, hospital systems, and other provider organizations millions of dollars in the long run. 

Reality shows something quite different. Placing documentation responsibilities on physicians is resulting in severe problems not only for doctors, but for patients and the hospitals and practices who serve them. Doctors are spending more time – in some cases, 43 percent of their day – entering data into EHRs, which means less time available for patients. This continual influx of data is bloating EHRs with unnecessary, repetitive, unintelligible information. 

Doctors play an integral part in developing and maintaining medical records. But we are asking them to do too much and the entire healthcare system is suffering because of it. Instead of dictating information into the medical record, many physicians are required to type notes into their EHR, which is time-consuming and distracting.

That’s just one challenge they face when required to directly document into an EHR. Upon accessing the system, the doctor enters a patient’s medical number and their record pops up. There are boxes for history, medications, procedures, etc. This “structured data” methodology allows physicians to click radio buttons or check boxes to denote what was done, but too often allows for little or no free text. Physicians are presented options from which to choose, even if those options aren’t applicable. The structured data choices can’t be changed, and the patient’s record is built off what the doctor ultimately chooses as the lesser of evils.  

Most EHRs allow doctors to copy and paste information from one area of the record to another. This creates “note bloat,” a serious issue that’s resulting in junk data and unwieldy, unmanageable records. It’s not uncommon for information copied from one patient’s record to end up in a different person’s file.

Not only does that create note bloat, it also causes mistakes. One hospital was recently sued by a patient who suffered permanent kidney damage from an antibiotic given for an infection. The patient also had a uric kidney stone, which precludes antibiotic use. The EHR file was so convoluted, none of the attending physicians noticed the kidney stone. Printed out, the patient’s record was 3,000 pages. The presiding judge ruled the record inadmissible, in part because a single intravenous drip was repeated on almost every page.

In late January, Jay Vance, president of the Association for Healthcare Documentation Integrity (AHDI), testified to the US Senate Health, Education, Labor and Pensions Committee that EHR documentation burdens on physicians can be reduced by expanding language to a draft bill aimed at improving the functionality and interoperability of EHR systems.

The move to pay providers based on the quality of the care they deliver instead of the volume of cases seen by physicians and specialists is driving much of the federal healthcare discussion. There’s a chance that work can help restore sanity to the interaction between doctor and document. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the bill that ended the onerous Sustainable Growth Rate, authorized the Centers for Medicare and Medicaid to pay physicians via value-based reimbursement. The law also called for a replacement for Meaningful Use.

One component of MACRA is the Merit-Based Incentive Payment System (MIPS) that, among other things, incentivizes providers for using EHR technology. The goal is to achieve better clinical outcomes, increase transparency and efficiency, empower consumers to engage in their care, and provide broader data on health systems. But there is more that can be done. 

This is progress, because at the end of the day, patient focus should always trump data entry by physicians. That’s not to say that physicians shouldn’t have a hand in documentation. According to AHDI, accurate, high-integrity documentation requires collaboration between physicians and the organization’s documentation team – highly skilled, analytical specialists who understand the importance of clinical clarity and care coordination. Certified documentation and transcription specialists can ensure accuracy, identify gaps, errors, and inconsistencies that may compromise patient health and compliance goals.

AHDI’s recommendation: include wording that expands the definition of “non-physician members of the care team” to include certified healthcare documentation specialists and certified medical transcriptionists.”

There’s not a single documentation and transcription scenario to meet every organization’s needs. But there is common ground to be found where all functions – EHR vendors, documentation specialists, transcription experts, physicians, hospital administrators – can create a structure that results in clean, effective, understandable patient medical records. 

Step 1 – reduce doctors’ administrative burdens. A physician’s role in documentation should be focused on dictation, not data entry. EHR voice recognition software allows doctors to directly narrate into the system. Like any other text, narrated notes need to be reviewed for accuracy and then approved. In some cases, doctors are approving their entries without reviewing them. This increases the risk of inaccurate data and mistakes. 

Step 2 – find the balance of structured and unstructured EHR data. There is a place for both structured and unstructured data in the EHR. Structured data can be queried and reported on with much greater ease than free flow text. However, doctors complain there aren’t enough options to share narratives about encounters and what patients had to say about their visit. The goal of an EHR is to provide a complete and accurate view of patients’ conditions, treatments, and outcomes. It makes sense to use structured data for entries such as those required by CMS. Using dictation and expert transcription assistance, unstructured free-text narratives and information also can be a part of the EHR while maintaining accuracy and completeness. 

Step 3 — eliminate interface barriers. EHRs require interfaces to “talk” with other systems. Fees charged for said interfaces prevent providers from using outside documentation and transcription services. Interfaces are necessary, but should be part of the standard development of EHR structured data forms and information collection.

Step 4 – put the responsibility of document editing and transcription in expert hands. I believe there will be resurgence of transcription services in 2016. Streamlining data entry into an EHR will never replace the need for documentation and transcription experts. Providers will continue to need outside assistance in ensuring patient data is accurately and cleanly logged in the EHR. 

EHRs are here to stay. So are documentation and transcription experts. Provider organizations need both of us. When experts on both sides to combine their strengths and expertise, we can put doctors, physicians, and other health care professionals back where they belong: taking care of patients.

Marilyn Trapani is president and CEO of Silent Type of Englewood, NJ. 

Readers Write: Radiology Benefits Managers: An Inelegant Method for Managing the Use of Medical Imaging

April 13, 2016 Readers Write No Comments

Radiology Benefits Managers: An Inelegant Method for Managing the Use of Medical Imaging
By James A. Brink, MD, FACR


Doctors, lawmakers, and regulators are supposed to work together to make healthcare better. So why put a process in place that takes medical decisions out of the hands of doctors and patients, may delay or deny care, and often results in longer wait times to get care?

That is what insurance companies do by requiring preauthorization of advanced medical imaging (such as MRIs or CT scans) ordered for beneficiaries. A better way to ensure appropriate imaging is widely available and already in use.

In most cases, if your doctor thinks an imaging scan can improve your health, he or she has to ask a radiology benefits management company (RBM) whether the scan will be covered or not. This process can take days or even weeks. You may not be able to get the scan at all if the RBM says no, which happens a lot.      

In fact, a Patient Advocate Foundation (PAF) study found that in people who challenged coverage denial for scans, 81 percent were denied by RBMs and 90 percent of reversed denials were in fact covered by the patient’s health plan. The U.S. Department of Health and Human Services (HHS) says there are no independent or peer-reviewed data that prove radiology benefit managers’ effectiveness. HHS also warned against the non-transparent coverage protocols that RBMs use. 

What’s more, ensuring appropriate imaging is already being done in a more modern and efficient way. Clinical decision support (CDS) systems, embedded in electronic health records systems, allow providers to consult appropriate use criteria prior to ordering scans. American College of Radiology (ACR) Appropriateness Criteria, for instance, are transparent, evidence-based guidelines continuously updated by more than 300 doctors from more than 20 radiology and non-radiology specialty societies.

CDS systems — easily incorporated into a doctor’s normal workflow — reduce use of low-value scans, unnecessary radiation exposure, and associated costs. The systems educate ordering healthcare providers in choosing the most appropriate exam and suggesting when no scan is needed at all.

An Institute for Clinical Systems Improvement study across Minnesota found that such ordering systems saved more than $160 million in advanced imaging costs vs. RBMs and other management methods over the course of the study. A major study by Massachusetts General Hospital and the University of Florida showed that these systems significantly reduced advanced imaging use and associated costs. This was done without delaying care or taking decisions out of the hands of patients and doctors.

In fact, the Protecting Access to Medicare Act — passed by Congress with the backing of the ACR and multiple medical specialty societies — will require providers to consult CDS systems prior to ordering advanced imaging scans for Medicare patients starting as soon as next year. This makes image ordering more transparent and evidence-based than any other medical service. The law would require preauthorization only if a provider’s ordering pattern consistently fails to meet appropriate use criteria.

In short, preauthorization is an antiquated approach to utilization management that disconnects doctors and patients from learning systems designed to improve patient care. Patients. together with the providers and legislators who serve them, should be demanding a more modern approach to prior authorization through the delivery of EMR-integrated imaging CDS.

James A. Brink, MD, FACR is vice chair of the American College of Radiology, radiologist-in-chief of Massachusetts General Hospital, and Juan M. Taveras Professor of Radiology at Harvard Medical School.

Readers Write: Why Can’t I Be Both Patient and Customer?

April 13, 2016 Readers Write 7 Comments

Why Can’t I Be Both Patient and Customer?
By Peter Longo


I love the clinicians at my local health system. However, I hate the bills from my local health system.

When the clinic staff helped last month with my knee, they were the best — rock stars. When I got their confusing bill, they were the worst. Is there any other industry where you love the service, but 30 days later, they go out of their way to take away all of your happy thoughts?

Yes, I did something stupid again. Over the holidays, I took some time off to go skiing with the family. Time with the family was not stupid; skiing in the trees was stupid. (note to self; you are not in your 20s any more and need to take it easy). The ensuing tumble, spin, twist, and crash resulted in an injured knee.

I entered the local university health system in search of a cure. In total amazement, I walked into the office and the entire staff greeted me. Just like in the Gap, the entire front staff looked up and said “hello” loudly.

Over the next month, the medical group and hospital went out of their way to make me feel at home … until the bill came. Or should I say “bills” (plural). They should have stamped on the envelopes, “Screw you” in an effort to be more honest.

Most of the bills appeared to be for my knee, based on the dates of service. But for the record, they decided to add some of my wife’s medical charges into the mix on one statement.

Having spent 25 years working in the healthcare tech world plus having two graduate degrees, it still did not give me the skills to make any sense of the bills. I decided to call them at 4:50 one afternoon. The very nice recording said, “The billing office closes at 4 p.m. Monday through Friday.” Seriously? What about people who work and don’t have time to call until after work, or on the weekend? The Gap has greeters, but they are open nights and weekends. Seems my health system copied the Gap only on the greeters.

A few days later, I was able to talk to someone. I started the call by saying, “I want to pay all that I owe, so please provide a summary and explain the charges so I can pay you.” Surprisingly, they did not understand half the statements. They indicated they could not access the “other system that has more information,” so they would need to call me back.

A few days later, someone from the billing office called. Together we figured out where there were some discrepancies and determined the correct amount owed. She indicated she would clean everything up and send me a new statement. Thirty days later, I got the statement and paid right away. As I was writing that check, I had already forgotten about how they “cured” me, as it seemed so long ago.

The cost for the billing staff involved in my bill was probably more that what I owed, so I did feel bad for them. That sympathetic feeling only lasted a short time. Last night I got a call at the house. My 15-year-old handed the phone to me. I owe $25 and they sent it off to their collection agency.

Is it too much to ask that my health system treat me both as a patient and as a customer?

Peter Longo is SVP/chief revenue officer of Sirono of Berkeley, CA.

Readers Write: Three Reasons EHRs Need to Treat Biosimilars Differently from Generics

April 13, 2016 Readers Write No Comments

Three Reasons EHRs Need to Treat Biosimilars Differently from Generics
By Tony Schueth


Biosimilars are being introduced in the United States and are expected to quickly become more mainstream in the near future. In response, stakeholders are beginning to work on how to make them safe and useful within the parameters of today’s healthcare system.

The reason is that biosimilars, like biologics, are made from living organisms, which makes them very different from today’s conventional drugs. These differences will create challenges and opportunities in how they are integrated in electronic health records (EHRs) and user workflows as well as how patient safety may be improved.

Normally, there is a lot of lead time before EHR vendors must address such issues. Things are different with biosimilars. Here are some reasons.

There are powerful drivers

Several drivers will stimulate demand for EHRs to address biosimilars sooner rather than later. This is because of central role EHRs play in value-based care coordination and patient safety.

New biologics will be bursting on the healthcare scene. Although biosimilars have recently been approved for use in the US, they have been in use extensively in Europe and Asia for many years. More than 80 biosimilars are in development worldwide, and the global biosimilars market is expected to reach $3.7 billion. This will stimulate rapid adoption by payers and physicians in the US, which, in turn, will create the need for EHRs to capture and share a variety of information about biologics and biosimilars. It is easy to envision the availability of four biosimilars for 10 reference products in 2020, given projected market expansions.

Next, uptake in the US is expected to take off because biosimilars are lower-cost alternatives that will be used to treat the growing number of patients with such chronic diseases as arthritis, diabetes, and cancer. Rand has estimated savings from using biosimilars at $44.2 billion over 10 years. Money talks and payers will create demand for EHRs to fold biosimilars and biologics into EHR functionalities and workflows.

Payers and regulators also will demand enhanced tracking of biologics and biosimilars because they are key pieces of the move toward value-based reimbursement and are a focus of public and private payers. Identifying, tracking, and reporting adverse events that might be associated with biologics and biosimilars are expected to become key metrics for assessing care quality and pay-for-performance incentives.

Biosimilars are not generics

It would be a mistake to think of biosimilars as being synonymous with generics, which have been around for years and use mature substitution methodology. The reason begins with the fact that biologics and biosimilars are medications that are made from living organisms. Unlike generics, which have simple chemical structures, biosimilars are complex, “large molecule” drugs that are not necessarily identical to their reference products, thus the term “biosimilar,” not “bioequivalent.” In addition, biosimilars made by different manufacturers will differ from the reference product and from each other, making each biosimilar a unique therapeutic option for patients.

Furthermore, biologics and biosimilars have varying locations where they are administered, most commonly infused in physician offices, hospitals, or special ambulatory centers, or by patients at home. Given that administration location and type can vary, such information — along with the particulars of the drug that was administered — must get back to the physician and incorporated into the patient’s EHR record.

Getting this information into the patient’s record in the EHR also is important for improving patient safety. That is because it will help in identifying and distinguishing the source of the adverse drug events and patient outcomes from a biosimilar, its reference biologic, and other biosimilars.

Substitution laws are expanding and evolving

Developers of EHR systems will need to keep abreast of evolving state laws concerning substitution. In fact, many states already are considering substitution legislation or have enacted it. According to the National Conference of State Legislatures, as of early January 2016, bills or resolutions related to biologics and/or biosimilars were filed in 31 states. Keeping pace with these new laws is likely to be a challenge to ensure that EHRs are compliant, especially since requirements are apt to vary considerably from state to state. Given the rapid changes in the regulatory landscape, latency of updates to EHR systems is a problem that needs to be addressed.

Not only that, the drug that is dispensed may be very different than what was prescribed. As a result, it is important for physicians to know whether a substitution has been made and capture information about the drug that was administered in the patient’s EHR record. Because of the differences from conventional medications, different, more granular information such as lot number, will also be required. This is important for treatment and follow-up care as well as in cases where an adverse drug event or patient outcome occurs later on.

All in all, EHRs will face a brave new world when it comes to adapting to biologics and biosimilars.

Tony Schueth is CEO and managing partner of Point-of-Care Partners of Coral Springs, FL.

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