Readers Write: EHR Vendor Priorities for Successful Innovation and Marketplace Development

EHR Vendor Priorities for Successful Innovation and Marketplace Development
By Seth Joseph

Seth Joseph, MBA is founder and managing director of Summit Health of Lincoln, RI.

With the release of the final interoperability and information blocking rules, one of the goals of the Office of the National Coordinator for Health IT is to establish an ecosystem of innovation. They mandate that electronic health records (EHR) vendors open up their APIs and effectively serve as the foundation — the platform — for marketplace development. 

But when it comes developing an EHR-based marketplace for innovation, there are a host of challenges under the ONC’s latest guidance,  from the short timeframe in which they are being asked to develop these marketplaces to a lack of experience in network development (i.e., growing sustainable, platform-based businesses). 

With these challenges in mind, what can EHR vendors be doing now to ensure they are in the best position to develop a successful marketplace for innovation?

Establish sound (neutral) governance structures and processes

EHR vendors must carefully think through and give plenty of consideration to developing governance rules, standardizing the rules of engagement for platform development and the governance processes first, then creating documentation around it. Accounting for these fundamentals at the beginning will ensure that there’s a repeatable, scalable process when onboarding new developers to the platform. 

For example, which developers are allowed on the EHR vendor’s platform and marketplace? How do they become certified? How can EHRs ensure that developers abide by all state and federal regulations regarding health data exchange and privacy and security, such as HIPAA?

There are also issues such as those that Amazon is facing in having to determine exactly if/what proprietary data can be used to compete with third-party app developers for the platform. What is allowed and how should the rules and regulations be managed?

The importance of having a strong governance process and operating guidelines becomes clear when considering the issue Apple faced in 2019 related to its app store search results. According to a New York Times analysis of six years of App Store user searches, Apple’s own apps ranked first in the results for at least 700 search terms in the store. That isn’t exactly a vote of confidence for third-party IOS app developers, or the kind of attention Apple wants on its marketplace.

While all of this due diligence will require legal, technical, and business development work, it’s a necessity, as marketplaces will not scale and networks cannot grow effectively without it.

Invest in support resources

Third-party developers will vary in their technical, business, and organizational maturity. From implementation support and technical resources to data management and standardization support, EHR vendors should invest in the necessary resources to ensure that marketplace vendors clearly understand the rules of the road and also are set up to do as well as possible. 

Third-party developer success leads to marketplace success. While EHR vendors may not believe that marketplace success is important to their success in the short term, they would be wise to consider why Airbnb is among the most highly valued lodging businesses. It’s not because it runs a better hotel than Hilton or Marriott (it doesn’t), but because it allows hosts and renters to connect and transact on its platform.

Expectations and investment

Turning a software business into a platform business can be exciting and promising, but it’s important to temper expectations. For instance, while 2018 revenue from Salesforce.com’s third-party developer platform was the business’s highest growth area (41% annual growth rate), that only represents 20% of the organization’s revenue overall. That took over a decade to reach since Salesforce.com’s developer marketplace has been in existence since 2007.

It’s especially important for executives who are managing the marketplace to set realistic expectations internally regarding likely marketplace growth over the next 3-5-year period, then determine how much and what kinds of investments will be required to support that. 

Bring in an unbiased, experienced marketplace manager

There are many reasons why EHR vendors are not in a great position to be managing platform-based marketplaces on their own, but all map back to their inexperience in network development.

For example, under the new rules, EHR vendors will have to respond to developer requests for access within 10 business days. How will those companies manage this process in appropriately screening for privacy, security, and technical concerns while also determining how to address developers who might compete with new functionality that the company itself is planning? How will the EHR vendor think about quality management, in terms of the impact of varying levels of developer and application quality and what that means to the EHR’s brand with its customers? 

Growing a marketplace also requires redundant instances of technology and managing multiple integrations and different types of partner relationships at once. EHR vendors are inexperienced in and ill-equipped in these areas.

Given these challenges, EHR vendors should strongly consider outsourcing the management of their EHR marketplace to an entity that has the right experience and knowledge of standing up and supporting third-party developer marketplaces.

In fact, an effective marketplace manager that works with multiple EHR vendors should be able to deliver increasing value to each one of them by standardizing processes, refining implementation approaches, and managing multiple developer relationships. This is similar to the value they deliver to third-party developers by allowing them to connect once and gain access to multiple EHRs.

For EHR vendors, the innovation train is pulling up to their platform. While conditions might not be ideal since time is scarce and marketplace development in healthcare is still in its infancy, now is the time for EHR vendors to prepare and ensure that when that train reaches its destination, there is a solid foundation from which to grow as a marketplace innovator.

Readers Write: Prognostication Is A Fool’s Errand

Prognostication Is A Fool’s Errand
By Jeremy Harper

Jeremy Harper, MBI is chief research information officer of Regenstrief Institute of Indianapolis, IN. The views and opinions expressed in this article are his personally and are not necessarily representative of current or former employers.

Regardless of how COVID-19 progresses, we have scenarios ranging from (a) everyone is going to die as the stock market goes to zero, to (b) we will be back and running at full steam in a matter of months. I’m optimistic that we will go back to work and keep moving, but less optimistic that we will successfully lower the curve enough to make a significant difference.

However, there will be permanent repercussions of the choices we’ve made so far, things we as employers haven’t had time to adapt to.

Employers need to prepare for the social impact of employees who have suddenly been moved to remote work arrangements en masse. Many employers have had people working remotely for a week and a half at this stage, and states are rolling out more stringent quarantines.

Below I attempt to predict the impact of remote work arrangements for our organizations.

One-Month Quarantine

People

If we have remote work for a month, I anticipate that most will re-integrate into their work routines with relish. Having children out of school also helps. It’s hard to be a full-time caregiver and a full-time employee. Even with dedicated efforts at sharing, it’s hard to balance the workload. People may enjoy the time off, but much like a vacation, they will return to the office and be glad for the peace of a single job.

Prepare your remote work policy, though, because people will be pointing to the last month to explain that if can be done for every one of their jobs.

Organization

Workflows haven’t changed. They might be re-envisioned online, but they have been optimized for in-person, office setups.

If you don’t see an end in sight, start preparing your IT to support wikis, group teleconferences, Slack etc. Optimization of the remote work arrangement is worth the expense.

In general, the organization just needs to grudgingly get through this time period.

Two-Month Quarantine

People

Employers must prepare for a mass outpouring of employees who point to their productivity over the past two months as justification for them to be remote for significant portions of their schedule. “What happens if I am only in the office Tuesday and Wednesday every week, or Thursday and Friday?” will be a common refrain. We still like the in-person interaction, just not every day.

Organization

We will start to see workflows shift and adapt towards an assumption of remote work and effort.

Some people will take vacations while maintaining their digital presence to avoid using vacation time. Vacation could look like visiting family and friends who they never have time to see in person. It might be the dream trip to Hawaii, although during a global quarantine, it probably won’t be to other countries.

Three-Month or More Quarantine

People

Employees will have adapted to a remote work arrangement, they are searching for alternative employment, or the government stipends will be sufficient for them to stay home. Not everyone can handle remote work arrangements. People will start moving to their dream locations, as in,  “I’ve always wanted to live in another state.”

Organization

We as employers have started to change our office policies to meet the need of this new normal. This is no longer waiving policies, it is rewriting them.

We will start to see employees migrating. They won’t all be in a single time zone. We will no longer have the ability to call them in person. They will want to have accommodations for their new time zone and their working later or earlier.

New collaboration tools that were mentioned in Month 1 become a necessity. You might have new opportunities to bring in global talent since if everyone is remote, you no longer need everyone to be based locally. Alternative arrangements for office buildings that are sitting closed will be considered and leases will be dropped.

Upcoming Societal Changes We Need to Discuss as a Community

The requirement for strong telemedicine arrangements outside COVID.

The obesity epidemic is not likely to be helped by quarantine.

Regulatory barriers.

Data analytics, collaboration, and productivity.

Readers Write: COVID-19: You Aren’t Ready

COVID-19: You Aren’t Ready
By Jeremy Harper

Jeremy Harper, MBI is chief research information officer of Regenstrief Institute of Indianapolis, IN. The views and opinions expressed in this article are his personally and are not necessarily representative of current or former employers.

Chief research information officer means that I design systems to connect clinicians, research, and IT for a living. I’m paid to think outside the box. 

I’ve been tracking coronavirus since mid-January. I want to acknowledge as I write this that as of March 19, 2020 we have about 10,000 individuals in the US who have been identified with this disease. We are not at a crises today, but we might be in a week. About 3,000 new cases were identified yesterday.

Our health systems are built upon a tower of electronic assumptions for patient care, triage, and scheduling. If you review the CDC pandemic preparation documentation, we are focused on minimization of the event in lowering the curve. I’m calling on the IT and informatics Industry to look beyond minimization to what happens if we fail. We are not ready.

A crises of this magnitude brings us back to a simpler time, one that requires a massive streamlining. We’re seeing vendors begin to release capabilities for streamlined remote visits, but we need to be prepared internally for our health system operations.

We can’t just focus on how our back office connects remotely, because if the worst happens, our health administration will be ignored in favor of saving lives. We’re going to be rushing to convert swaths of our hospital beds to ICU beds like Italy has done, or creating new hospitals like China did. We are going to see all those beautiful individual rooms that have been built at hospitals over the past 30 years doubled up. 

This will be a new health system in a matter of days, and we have not designed our systems to deal with this. As an executive consultant, I’ve participated in pandemic preparedness and emergency drills in numerous health systems. We are suddenly faced with a situation that has the potential to dwarf the worst-case scenarios we have envisioned.

Almost every report that you have spent years building will suddenly become useless. They will be repurposed for decisions they weren’t intended to support. AI/ML won’t solve this one for you, because this is something new, something that will break every model we have worked to build.

Think about your automated systems to alert clinicians to close charts. If people are dying in the hallways, it doesn’t matter. Closing charts, filling in discrete fields (this one kills me as a researcher — we need discrete data desperately to identify best practices), and most clinical decision support suddenly go out the window.

I’ll take a personal example of what we’re about to face on the clinical and administrative front. My father had an esophagectomy about five months ago. They caught the cancer early. He was asymptomatic, aside from a cancer that was going to kill him. His 10-hour “elective” surgery might not be taking place or might be delayed right now as health systems gear up for COVID-19. He has had strictures (throat closing off) since the surgery. He has already been informed that they might cancel his next appointment (where they put him under and stretch his throat) depending on patient load due to COVID-19.

If we see mass cancellations of these an other “elective” process items, then we’re going to need better reports that prioritize patient rescheduling that is based on acuity rather than who gets on the phone and connects first, or who knows how to manipulate the scheduling system the best. This isn’t Ebola, where simple screening questions and changing our triage process will cut it.

What you can do now:

• Start building reports to support your providers in triage to get the right people to the front of the line.
• Identify how we’re going to support a world where we might ask the public to donate CPAP/BIPAPs to keep people breathing through the disease.
• Stop assuming that you are dealing with a “business as usual, just remote” situation, and use this time to prepare for a world where the EMR is low on the priority list.
• Work with researchers to identify the data we need to get treatment recommendations out to the world quickly.
• Use your time and expertise to help groups in need.
• Figure out your best practices and start telling people about the changes you are making.

I have a full-time job. I do executive consulting on the side. I have a beautiful three-year-old and a wife I love. I know how hard it is to find more time during an “all hands on deck” situation. We are all in this together. Let’s be ready.

Readers Write: Walmart Health Centers Are Here — Here’s How to Respond

Walmart Health Centers Are Here — Here’s How to Respond
By Derek Baird

Derek Baird, MBA is SVP of Avia of Chicago, IL.

I recently wrote about Amazon’s looming threat to health systems and physician practices. I closed with a comment that Walmart poses an even greater threat. Many (actually, most) of you disagreed. Since we all have unexpected free time this week, I hope you’ll hear me out.

Walmart Health is back in the news, thanks to the opening of their second Health Center and a not-so-subtle statement from former Apple CEO John Sculley, “Walmart Health will cause a consumer revolution.” Those are bold words from a smart man (and healthcare investor). Note: John’s been wrong at least once. He drove Steve Jobs out of Apple.

Walmart has run pharmacies since the 1970s and a small number of retail clinics for many years. Last September they opened the first Walmart Health Center. It’s not your 1990s-style retail clinic crammed in a closet next to the pharmacy. The 10,000 square foot clinic sits next to a Walmart Supercenter in suburban Georgia. It provides services ranging from physical exams to dental visits to x-rays. Notably, it is staffed by physicians.

The second clinic opened in another Georgia suburb in January with a similar footprint and services. Mark Wahlberg was at the opening. Makes sense since he’s a model of men’s fitness. On the other hand, he owns a burger chain delivering saturated fat to the masses. Speaking of brand dissonance, purists like me grumble about Walmart providing healthcare services in the building next door to its lucrative tobacco counter. I doubt their shoppers share my scruples.

Not only does Walmart offer a super-convenient one-stop shopping option, the digital experience is great. It features all the stuff we admire in solutions from cooler companies like Amazon, Carbon, and 98point6: clean website UI, extended hours, online scheduling, transparent pricing, text reminders, etc.

One hundred fifty million Americans visit a Walmart every week, though most healthcare executives aren’t part of that cohort. We spend lot more time discussing Amazon and other technology offerings even though 90% of us live within 10 miles of a Walmart store. Many Walmart shoppers are commercially insured  — with $1,600 average deductibles — and are likely tempted by the sound of $40 for an office visit and $25 for a teeth cleaning. I know I am.

Out of the gate, Walmart’s model is differentiated, difficult to replicate, and a savvy marriage of physical and virtual assets. Like Amazon’s not-yet-launched offering, Walmart designed its services to address glaring flaws in traditional offerings. But unlike Amazon and other direct-to-consumer telehealth offerings, it’s not reliant on virtual care. In most markets, virtual care is still hampered by stubbornly low awareness, understanding, and adoption. It will be a lot easier for Walmart to launch virtual care than it will be for Amazon to replicate Walmart’s foot traffic. Let’s keep an eye on Whole Foods.

If you’re more likely to visit Sam’s Club than Walmart, then the Walton family has you covered, too. They launched a set of innovative healthcare packages—including family bundles—for members last year. The bundles include free generic medications, a Humana-supported provider network, and $1 virtual visits through, yes, 98point6.

Here’s the kicker. Unlike Walgreens or CVS, Walmart doesn’t appear interested in partnering with local health systems. These Health Centers are launching to make up for health system shortcomings. They will gladly displace primary care physicians sitting behind ineffective call centers, packed schedules, opaque pricing, and myChart logins.

Just like small town Main Street retailers, health systems will have to compete.

Here’s how to get started. First, aim to match Walmart on digital convenience. Your digital front door must make it just as easy to access care as it is to grab an appointment at the Health Center. Put your price list online. Offer virtual visits for those who don’t want to leave the couch. Offer virtual queuing (“save my spot”) for urgent care centers. Your goal here is to approach competitive parity. This will require an intentional, multi-year focus on convenient access and virtual care. If you don’t have your key executives focused on this effort, it’s time to pull together a task force and allocate substantial capital.

Next, leverage your incumbent advantages so you don’t have to match on price. You have brand equity, data, and locations that can be assets rather than liabilities. If you can marry your clinical expertise with personalized communications to patients, they will value that continuity and credibility.

Some good news: Walmart is not going to scale as quickly as Optum or CVS. They have two, soon to be three, locations. You have a little time to prepare. Unless you’re in Georgia.

Readers Write: Is Healthcare Ready for a New Era of Transparency?

Is Healthcare Ready for a New Era of Transparency?
By Miriam Paramore

Miriam Paramore is president and chief strategy officer of OptimizeRx of Rochester, MI.

It’s not only patients who are demanding greater transparency around healthcare costs. It’s physicians and state and federal government officials. In just one year – January 2021 – a new federal rule will go into effect that requires all hospitals to post standard charge information, including discounted cash prices, payer-specific negotiated charges, and charges for at least 300 “shoppable” services, such as imaging, lab tests, and outpatient visits.

The rule, and associated rules for insurance companies, point to a new era of transparency driven by deepening healthcare consumerism. Increasingly, patients will be armed with data that allows them to guide their healthcare decisions in coordination with their healthcare providers, ultimately leading to more patient-centered care.

But this transparency also changes the patient-provider relationship. It’s never been more important to give both patients and doctors tools to navigate care options efficiently, allowing them to work together to make the best healthcare decisions, personalized to each patient.

The hard truth is that out-of-pocket healthcare costs for consumers continue to soar, creating notable financial burdens for patients and negatively impacting medication adherence and clinical outcomes. Amid continued growth of high-deductible health plans, deductibles alone rose 26% in 2019 from 2008, and expenditures are expected to continue to rise in 2020. Consequently, patients increasingly look to their providers for financial guidance and assistance.

Consider the impact of treatment cost on the day-to-day interactions between physicians and their patients. In May 2019, dermatologist Jack Resneck Jr., MD, chair of the AMA Board of Trustees, testified before Congress in a hearing on high drug prices about the experience of one of his patients. He noted that the wholesale price of the patient’s medications had quadrupled in price over the past 15 years. Faced with a pre-deductible PPO copay of 40%, the patient made the choice to stop his treatment. It’s stories like this one that contribute to rising healthcare costs.

Non-optimized medication therapy, including non-adherence, is linked to $528 billion in potentially avoidable healthcare cost. Notably, the vast majority of patients discuss healthcare costs with their doctors, according to a recent survey of 642 physicians across a variety of specialties. Doctors want patients to take medication that works for their health and their pocketbooks, and they know that one is often dependent on the other.

In the same survey, doctors indicated an overwhelming willingness to engage in these cost conversations with patients. Eighty-six percent of physicians surveyed indicated that they are comfortable discussing health care costs with patients, and over 90% believe they have a role to play in discussing healthcare costs with patients.

So how does the healthcare industry make these conversations part of standard practice? New platforms that build on healthcare providers’ existing electronic health records to streamline the reams of data – pharmaceutical options and costs, drug compatibility and patient adherence – are an important piece of the puzzle. Physicians need access to the data the pharmaceutical industry maintains, such as pricing and saving opportunities, while in the examining room with patients. Digital communication pathways that provide these resources to physicians will facilitate informed discussions that will ultimately drive a patient’s decision to follow through on recommended treatment.

Greater transparency is better not only for patients, who will have the opportunity to work in concert with providers to get the healthcare they can afford, but also for doctors, who will have access to the drug cost information their patients are requesting and to increase the likelihood of their patients following through on recommended care. Doctors already know that discussing drug cost is essential: 73% of physicians in the survey indicated that they feel the patient’s responsibility for cost is important when making a prescribing decision.

Digital tools are poised to facilitate this new era of transparency and improve healthcare outcomes and patient and physician success rates. Let’s make sure we encourage their implementation in time to move seamlessly into a patient-centered healthcare future.

Readers Write: Value-Based Care Can Work When High-Touch, Personalized Care is the Strategy

Value-Based Care Can Work When High-Touch, Personalized Care is the Strategy
By Adam Sabloff

Adam Sabloff is founder and CEO of VirtualHealth of New York, NY.

Humana recently released some noteworthy figures related to the company’s value-based care programs. An annual review of the health plan’s efforts reported 27% fewer hospital admissions and 14.6% fewer emergency rooms visits compared with traditional approaches.

That’s good news for the healthcare industry in terms of the sizable investment it has made into evolving pay-for-performance models over the past decade, especially in light of early studies that suggested lackluster returns. In fact, one 2016 study published in the British Medical Journal found minimal evidence to support the theory that value-based care models impacted mortality rates.

The question now becomes: What is driving Humana’s results?

Simply put, the payer’s model is much more targeted than early, broad-stroke approaches to value-based care. They have implemented infrastructures and workflows that identify and address not only the clinical needs of patients, but also social determinants of health that may be keeping members from following through with care plans. This strategy is enabling Humana to achieve higher-touch, more personalized care.

It’s an imperative differentiator that healthcare stakeholders need to embrace heading into the next decade. At a high level, the industry acknowledges that it is on an unsustainable financial course. Yet, alarm bells should be ringing loudly amid concerning statistics related to the silver tsunami, the rapidly-growing aging population that is characterized by a high percentage of complex, chronic conditions.

Consider the following figures:

• The US Census Bureau projects that by 2030, one in every five residents will be of retirement age.
• 85% of older adults have at least one chronic health condition and 60% have at least two, according to the National Institute on Aging.

Demand for long-term services and supports (LTSS)—an area of high-touch care that currently supports more than 12 million elderly and those living with disabilities —will increase in tandem with the aging population. Consequently, providers and payers must embrace the concept of whole-person care models that consider not only broad clinical strategies that promote wellness, but all the socioeconomic needs of each patient. For instance, Humana attributes much of its success to its ability to identify challenges stemming from social determinants of health—such as food insecurity or social isolation—and help patients access services and make better health choices.

Having insights into social determinants of health (SDoH)— the non-clinical factors that make up 80% of overall health—will continue to characterize success with value-based care, which is crucial for healthcare stakeholders to know. Broad-based approaches to improving population health that may promote regular wellness checks and follow-ups only go so far. In the case of LTSS, many elderly patients who live alone and are no longer able to drive will have difficulties picking up prescriptions or getting to doctor’s appointments. Addressing their lack of transportation can have a significant impact on readmission rates and emergency department visits.

In addition to whole-person care, providers and payers need to address the 5% of patients who require critical, complex, and chronic care, who account for approximately 50% of total spend. After recognizing the shortcomings of traditional care management models implemented alongside legacy technology, some stakeholders are turning to a “wedge” strategy that addresses the needs of complex care populations. The approach carves out the subsets of their member population that have complex care needs and places them on an auxiliary tech tool that surrounds them with a comprehensive care ecosystem capable of effectively addressing their needs.

The healthcare industry has made enormous strides over the past decade to usher in better approaches to care, and there have been many lessons learned. One important lesson is that optimal care considers the whole person, and care managers must have insights into facets impacting outcomes—clinical, behavioral, and social—to impact performance in a meaningful way.

As providers and payers turn the corner into a new decade, it’s important that all reflect on successes, failures, and new opportunities, acknowledging and embracing the promise of high-touch, personalized care for complex patient populations.

Readers Write: Fixing What Ails Healthcare

Fixing What Ails Healthcare: A Checklist for Building a Modern Primary Care System
By Ray Costantini

Ray Constantini, MD, MBA is founder and CEO of Bright.md of Portland, OR.

For years, the industry has been struggling to find solutions to help fix what’s broken in primary care. There’s been an influx of urgent care centers, retail health clinics, and video telehealth services to address the growing patient load, offer more convenient access to care, and help stem physician burnout. While these alternatives are now commonplace, the state of primary care has actually gotten worse instead of better. 

The healthcare sector is plagued by a shortage of primary care physicians. Existing providers are retiring or leaving practice because of burnout, and there are not enough interested medical students to take their place. Between 1996 and 2007, the number of medical students going into general medicine declined as much as 61%.

Making matters worse is that there are even greater demands on primary care providers’ time. The Affordable Care Act added millions of more insured patients into the mix just as the aging population needed more care. Add to that the burden of exponentially more administrative tasks, which take providers’ time away from seeing patients. 

With primary care resources on the decline and waits for appointments sometimes exceeding 50 days, urgent care centers and retail clinics saw opportunities to jump in to offer supplementary services. The number of urgent care centers exploded during the last decade, reaching more than 8,000 nationwide by 2018, and the number of retail clinics doubled. But even these vast amounts of new options have been unable to ease primary care burdens.

Others have turned to video visits to streamline provision of care and eliminate the need to travel to doctors’ offices. But in reality, video telehealth is equally problematic for providers and patients. In fact, video technology often adds another layer to delivering care. To prepare for a 20-minute “visit,” a provider must go to a location where the patient’s privacy won’t be compromised and then set up the equipment. Plus providers still have the same administrative tasks that accompany an in-person visit. On the flip side, video may not be a viable alternative for patients who lack broadband services or who may not be tech savvy.

Even though they value the convenience of these walk-in clinics and video, a recent survey found that patients still overwhelmingly prefer to receive care from their own provider or any healthcare provider rather than from tech companies or retail centers. 

So what can primary care providers do to ensure their practice is on the right track to deliver 21st century care? Here’s a checklist that will help health systems meet the needs of modern patients, while also reducing their administrative burdens:

• Survey resources. Which resources are being underutilized? Which are overburdened? Where can shifts be made to increase productivity?
• Embrace a care team approach. Staffing each step of the care pathway appropriately allows everyone to practice at top of license. Introducing virtual care team members multiplies that positive impact.
• Use technology where it makes sense and for what it does well. Automate the repetitive tasks to let machines do what they do best and free up humans to practice the art of medicine. With an assist from useful technology, high-quality care can be delivered in less than two minutes for conditions that account for about 60% of primary care visit volume.
• Be open to change. Just because it worked 100 years ago doesn’t mean it works today or that people still want to operate that way. Not everyone is resistant to change. Many are likely clamoring for it.
• Link bricks with clicks. Integrate online offerings with in-person ones. Whether a patient gets care virtually, in a clinic, or in the emergency department, every provider should benefit from access to the most up-to-date and accurate health record.
• Find a partner that can help solve challenges today and in the future. Innovation matters, but the technology must be human-centered and configured to address each practice’s unique issues.

Modern primary care must be on-demand, which means not just when patients want it, but from wherever they are — home, school, work, or even the bus. Technology, such as asynchronous virtual care, already exists to make this possible. Practices now must embrace change and evaluate how they can evolve to be true game-changers in primary care.

Readers Write: Alert and Alarm Fatigue: It’s Not Just For Clinicians Any More

Alert and Alarm Fatigue: It’s Not Just For Clinicians Any More
By Drex DeFord

Drex DeFord, MSHI, MPA is a healthcare strategy consultant and adviser to CI Security of Bremerton, WA. 

I’d like to say that we are lucky now that we have all adopted EHRs and used them to drive better, faster, cheaper, safer, easier-to-access care for patients and families. But based on my post-Meaningful Use experience, “luck” is one of the last words used by doctors, nurses, and other frontline caregivers.

The EHR came with a lot of noise. Distracting, aggravating, and even dangerous noise. There was some good stuff, too, and we thought we were doing the right thing. We had good intentions. But along with the good, EHRs have generated a bunch of unintended consequences.

One of those is alert fatigue, which contributes to physician burnout. In fact, most providers suffer from some level of alert and alarm fatigue. One of the most referenced articles from the past year was Atul Gawande’s New Yorker piece describing how doctors hate their computers. EHRs are a work in progress, and the challenge is enormous.

Just like the patient-facing folks, the cybersecurity team has its own seriously debilitating case of alert fatigue. It comes from the beeping and buzzing that is emanated by the multitude of security systems that we have purchased and installed.

They get alerts for things big and small. A staff member plugs a new device into the network. Someone logs in from another country. A user types their password incorrectly three times. 

Somewhere in these alerts is an actual intruder and a real problem. Or even worse, it’s an intruder who is already in the network, biding their time in an effort to quietly find the organization’s data crown jewels, snag them, then quietly exit the electronic premises.

If you have a CISO and a dedicated cybersecurity team, then good for you. In many hospitals and most clinics, the responsibility for maintaining and managing cybersecurity tools is distributed across a small group of information technology professionals who have other, full-time day jobs, such as managing the network, storage systems, or applications.

Watching for cybersecurity alarms generated by this plethora of systems and then reacting to them – figuring out which ones are real versus false – has become a major burden. It is another unanticipated consequence of adding more technology, with the best intentions, to solve complicated problems. 

Based on the number of breaches in healthcare, one can imagine that those tasked with watching cybersecurity alerts are feeling overwhelmed, a lot like their patient-facing teammates. What may be just as bad is that cybersecurity alarm distraction increases the likelihood that IT operators will make mistakes or have an accident – miss a patch or misconfigure a server – and cause the organization to suffer a self-inflicted breach.

Cybersecurity work is massively stressful. For the delivery of modern healthcare, these cybersecurity professionals are critical. One missed alert and entire hospitals can shut down. Physician practices have had to close their doors entirely.

Being a first responder (that’s what cyber-security professionals really are) is one of the most difficult jobs in the world. It takes unique skills, courage, and grit. And there aren’t enough cyber professionals to go around. Unfortunately, all the stress also takes a toll on the professionals themselves, especially when they are spread too thin across too many responsibilities.

When it comes to cybersecurity, there are better ways to manage both organizational and individual risk. For example, managed detection and response services can shift the burden of answering and investigating all those alarms to cybersecurity professionals who do this for a living, all day, every day. They are experts at figuring out what’s real and what’s not. Some can even integrate products that specifically target the Internet of Medical Things, doing both discovery and security analysis. They can do it all incredibly quickly using a combination of well-tuned technology and human review.

By pushing more of this responsibility to managed service organizations, a health system’s IT team can reclaim control of their time. They can shift attention back to the major IT initiatives that can help their organization grow and succeed. Maybe they will even have more time to work on projects to reduce healthcare burnout and alarm fatigue for everyone else in the organization.

Readers Write: ONC Regulations: Why Epic is Wrong and Judy is Right

ONC Regulations: Why Epic is Wrong and Judy is Right
By Chinmay Singh

Chinmay Singh, MSE, MBA is co-founder and president of Asparia of Saratoga, CA.

In August 2018, a highly satisfied medical practice customer of a company I co-founded decided to join a large, multi-state group. As part of this deal, they were required to switch to Athenahealth’s EHR, which was used by the large group. My company was an Athenahealth More Disruption Please partner, so I thought we would get an opportunity to go live across thousands of practices.

My jaw dropped when I got the email below from the medical group’s vice-president of clinical informatics, indicating that the group had decided not to integrate our solution:

This is not the only case where my startup suffered due to information blocking. As any other health IT startup founder can attest, my mailbox is Exhibit A for proving that information blocking is rampant. Thousands of patients can also attest that such blocking impacts their wellbeing.

Despite of all of this, I ended up siding with Epic CEO Judy Faulkner last week.

As many of you know, Judy (my mom in India would be aghast if she knew I was addressing a 75-year-old woman by her first name) asked customers to oppose ONC’s proposed interoperability regulations, which are expected to be announced as soon as next month. CNBC published a series of articles that singled out Judy and hijacked the issue. The tone of the articles and associated tweets was similar to the partisan rhetoric that we regularly see on some national TV channels.

The article ignored Judy’s concerns about patient privacy. The Twitter world competed to paint the most successful health IT entrepreneur — a woman who has not taken a penny from VCs or from the stock market — as the villain.

Epic has done the right things by opening up App Orchard and enabling over 600 APIs. But is that enough? The answer is no.

App Orchard requires a company to pay a hefty membership fee and then a per-API call fee. There is no justification for the fee model. As an entrepreneur, I think the fee is arbitrary and excessive. The hefty membership fee does not make any meaningful contribution to Epic’s revenue (did someone at CNBC say $3 billion?) The only thing it does is to give ammunition to Epic’s opponents.

Similarly, Epic wants hospitals to use its software as the single source of truth. Unfortunately, by charging for each API call, Epic is encouraging the developer community (defined as “API Users” by ONC) to minimize use of such APIs, leading to the creation of new data silos. Why in the world you would develop 600+ APIs and not want them to be used is beyond my comprehension.

Epic’s flat-footed response does not end here. A few months back, the company decided to revoke developer access to all the APIs. Epic wants developers to contact Epic TS with their use case, who in turn will expose APIs on a case-by-case basis. You guessed it right — Epic will charge for this consultation.

Information blocking has hurt me and my company financially. Despite media portrayal of entrepreneurship, it is not fun to drive a rear-ended, 11-year-old Kia in Silicon Valley.

So why do I side with Judy? (sorry mom!) Because she is right to express privacy concerns.

I think everyone agrees that health information data is valuable. Mined at scale, it has the potential to help discover new treatments and reduce costs. At an individual level, interoperability can provide significant relief to patients as they seek treatment from a team of clinicians for conditions such as cancer. I have no doubt that the proposed ONC regulations will allow this. But patient privacy will suffer, and in the end, we will get overpriced and lower quality care.

The proposed regulations mention “API user” 40 times. As far as I can see, the regulations do not ask the API user to sign a business associate agreement or anything equivalent. Not once.

Not only this, the regulation requires “health IT developers” (aka Epic or Athenahealth) to approve the API user rather than their use case. Moreover, the regulation requires that such approval should not take more than five business days.

Who else, other than entrepreneurs like me, will get access to your health data?

Let’s start with law firms. Would malpractice premium jump because law firms will be mining such data at scale to find that one instance where a physician slipped? If that happens, will we continue to attract the best possible talent for medical schools?

Now imagine a cancer survivor who exchanges their health information for a free ride after chemo. Will they be discriminated against in job interviews because of publicly available information? Will politicians pit them against ALS patients in seeking votes?

What if this free ride was given to a teenaged incest victim from an underserved community who went for an abortion? Would the shaming ever end for her?

That is why Judy is right. But I do understand that she may not have said this as eloquently as a fellow Blue Devil from The Fuqua School of Business – “privacy is not an afterthought.”

Readers Write: Amazon is Coming, Here are the First Steps to Prepare

Amazon is Coming, Here are the First Steps to Prepare
By Derek Baird

Derek Baird, MBA is SVP of Avia of Chicago, IL.

Amazon made another high-profile hire last week, further raising the anxiety level of traditional healthcare providers. Dr. Gupta (no, not that Dr. Gupta) has impressive credentials and joins a cast of other smart hires. Though, despite Business Insider’s clickbait headline, I’m not ready to agree with the media experts (?) who quickly posited that this hire means Amazon Care will be available to the public any day now. However. whether it’s tomorrow or in 2022, most predict that the services Amazon is testing with employees will make their way to Prime customers.

Quick refresh: In September, Amazon announced a virtual medical clinic called Amazon Care for use by employees. The services include nurse chat, video visits, and house calls. One month later, they announced the acquisition of Health Navigator, a tool that provides online symptom checking and triage tools to route patients to the appropriate care setting. It’s no secret that Amazon is planning to provide convenient, technology-enabled options for consumers to find and receive physical or virtual care.

Amazon Care services will someday show up next to my book recommendations. Health system executives need to be planning as if that’s going to happen sooner rather than later. That plan must include an aggressive roadmap (and sizable accompanying investments) to develop and scale a digital front door.

ICYMI, digital front door became a buzzworthy phrase in provider-side healthcare in 2019. The digital front door includes consumer-facing capabilities, not hidden behind a friction-filled portal login, to support easy access to information or care. Core components include physician search, online scheduling, video visits, and virtual triage. 

A key reason to develop a digital front door is to attract the increasingly large group of consumers who don’t care about their parents’ advice, physician credentials, or US News awards. They don’t have a PCP, and above all, they value convenience. Many of our health system clients believe three points of commercial market share are at risk, depending on whether they delight or disappoint consumers with the convenience of their front door offerings. CFOs can quickly do the math, where that 3% may be the difference between being in the red or black.

Back to Amazon. A health system’s competition no longer just includes the neighboring health system and the upstart urgent care operator in town. The list is long and growing: Optum, CVS, Walmart, virtual solutions like 98point6, and (soon) Amazon. These tech-enabled competitors will change the expectations and requirements of consumers. If a traditional provider organization falls too far behind, consumers will make choices based on convenience and develop habits that take them elsewhere. Now is the time to become known as the friendly, convenient, transparent place to seek care.

This doesn’t mean another year of dabbling. Many health systems have rolled out a physician finder, video visits, or online scheduling. The results have been underwhelming, in large part because the pieces and parts don’t fit together in a way that supports a seamless consumer journey.

The digital front door is a complicated creative assembly project that requires multi-year focus and investment from many departments: IT, marketing, strategy, innovation, patient experience, and more. If a health system leadership team doesn’t have a robust plan and roadmap, now’s the time to rally colleagues, allocate funding, and get to work.

If health systems don’t get ahead of the digital convenience curve, the impact isn’t just losing flu visit volume. One downstream effect will be further fracturing an already broken continuity of care. It will be much harder to deliver effective population health management when patients are increasingly “seeing other people” who don’t aren’t aware of, or don’t care about, the patient’s chronic condition. 

Many health systems are already taking action to make sure this doesn’t happen. Others need to get organized and mobilized ASAP to build their own front doors, plus develop plans to work well with the other doors that consumers will use, e.g. Google, Amazon, and Yelp.

Note: I believe Walmart is a more formidable competitor than Amazon, but we will save that for another day.

Readers Write: The Case for Compassion in Healthcare

The Case for Compassion in Healthcare
By Frank Myeroff

Frank Myeroff is managing partner of Direct Recruiters, Inc. of Solon, OH.

Working in the healthcare space my whole career, over 30 years, and having always been on the IT side, I always felt I was in healthcare. During my days, I have written code, supported systems, implemented all kinds of applications, managed IT teams, and run large implementations. My view changed when I moved to the staffing space to get off the road for my family. I felt it was a great opportunity to view the healthcare space from another perspective, and it was.

Then that view changed again as the result of a three-minute phone call that truly immersed me and allowed me to see what healthcare really means.

The ultrasound technician told me as I walked out after my test, “The doctor will be calling you today.” That three-minute phone call conveyed a diagnosis and led to immediate surgery and an ongoing treatment plan.

As professionals in healthcare — doctors, nurses, healthcare staffing, healthcare operations, healthcare IT professionals, etc. — we are largely in tune with the processes that go into the healthcare system. As a patient, the experiences are far different, and far more emotional, as I quickly found out.

Being thrust into the patient side unexpectedly has been invaluable in my career. What I realized from all of this is that while IT really impacts patients, we in IT need to work with our clinicians and teams to understand the impact of what we do and the compassion and sensitivity that is needed to pair with innovative technologies for successful patient outcomes.

The roles of healthcare IT professionals go beyond implementing applications and systems. They are responsible for developing and driving technology in the healthcare setting, but also for giving clinicians the tools they need to provide individualized care plans and to ultimately achieve efficient and improved quality of care. The final piece of that puzzle requires compassion and communication from healthcare professionals to patients.

Data and technology are essential. However, if clinicians only focus on the data and ignore the communication and explanation of that data to patients, we are missing something huge. According to a Harris Poll in the Wall Street Journal, and cited in “Compassionomics” by Stephen Trzeciak and Anthony Mazzarelli, three times the number of patients value human connection and caring from their physician versus valuing the prestige of the institution where the physician was trained. Another study showed that 85% of patients report that compassion is important to them when making a healthcare decision. Compassion and empathy are important in healthcare, which is clear to me from both the studies my own experience.

Whatever side of healthcare you’re on, keep in mind the factors that play into quality patient care. The experiences I have had as a patient not only make me proud of what we in IT to help people, they also help me to understand the true usage that in return helps provide better solutions. Healthcare IT professionals influence patient care and have a great impact on all who serve in the hospital.

We should all be proud of what we do and the tremendous impact we have on patients, providing quality care, compassion, and better outcomes. Isn’t that what really matters?

Readers Write: Connected Communities and Social Care in the US

Connected Communities and Social Care in the US
By Jaffer Traish

Jaffer Traish is VP of partnerships at Aunt Bertha of Austin, TX.

I’ve been on the road for more than 100 days this year. I’ve been visiting with payers, healthcare systems, colleges, housing organizations, nonprofits, students, patients, and seniors. I’ve also visited EHR companies, population health vendors, and data scientists. The discussion has been focused on learning how to strengthen communities and reduce poverty through connections to social care programs, leveraging collaborative investment and integrated technology.

There is significant alignment among the broad stakeholders in the principles to govern solutions.

People

• We describe all people in need as seekers. The entry point where we express needs may be in healthcare, at college, after corrections release, or when we’ve become widowed. The seeker is always at the center — not the referring hospital, payer, or other business interests.
• Seekers may receive help, though they deserve and desire the dignity of self-navigation. Make it possible to self-refer, and never hide available resources in the long tail of programs nationwide.
• Seekers own their social care data. This is a tough one, though we have the chance to get it right in social care. Seekers should control how their self-referrals are shared among the network.

Community Organizations

• Community organizations are able to maintain an unbiased ability to serve people. Do not subject them to industry specific contracts, forced services, or quid pro quo funding.
• Community organizations should have tools that facilitate relevant intake data and processes respecting privacy rules, whether FERPA, HIPAA, HUD, or others.
• Community organizations should be more easily able to align with philanthropy in demonstrating service success.
• Each community is unique. Conversations about solutions should take place in the community, with the community.

Helpers

1. Helpers or navigators, the folks who facilitate referrals, go beyond industry (or clinical) staff. Librarians, guidance counselors, and family members are all part of the helper community. This reach of helpers serves the seekers best.
2. Helpers should be able to act as the legal proxy, with permission.
3. Helper information should be protected in the referral process. It’s not always appropriate to share the referrer’s name to the seeker.

With this perspective, creative developers can better build integrated, interoperable technology to serve seekers.

For those of us who have spent time in healthcare, we remember when electronic orders brought ambulatory EHRs to life in the mid-1990s. Similarly, eligibility-driven social care connections will bring a nationwide network to life. While we absolutely need policy changes to support equity and opportunity, there is much we can do today.

Executives ask for a multi-year framework to be successful with social care connections and referrals. An example is below.

• Stage 1: Electronic resource library with breadth and depth available to helpers and seekers.
• Stage 2: Helper organization promotes self-navigation through their portal.
• Stage 3: Helpers share program resources with seekers electronically.
• Stage 4: Helpers share program resource referrals with seekers and CBOs electronically.
• Stage 5: Helper organization integrates staff workflow within the system of record (EHR, care platform, housing platform, corrections) including data acquisition for business intelligence reporting.
• Stage 6: Helper organization builds partnerships with CBOs to affect supply of help available.
• Stage 7: Helper organization funds CBOs, and helpers directly order solutions for social needs.
• Stage 8: Helper organization participates in interoperability of social care data.
• Stage 9: Helper organization leverages predictive methods for identifying and helping seekers.
• Stage 10: Helper organization completes real-time self-navigation risk intervention.

Organizations like the Winn Corporation in housing, Atrium in healthcare, Red Cross and AARP as networks, Cigna as a payer, State of Colorado in government are all exploring these frameworks to build connected communities.

Community organizations also ask for frameworks, such as the one below.

• Stage 1: Respond to or track assistance.
• Stage 2: Leverage network tools to participate in data sharing.
• Stage 3: Leverage reporting for funders.
• Stage 4: Integrate tracking into preferred case tools
• Stage 5: Leverage funding donations from helper organizations and broader philanthropy.

I am excited to thoughtfully continue to grow the social care network keeping the seeker at the center, bringing dignity and ease to the process of finding help.

Readers Write: It’s More than the EHR That Is Causing Physician Burnout

It’s More than the EHR That Is Causing Physician Burnout
By Julie Mann

Julie Mann is chief commercial officer of Holon Solutions of Alpharetta, GA.

The cause of physician burnout is a frequent topic on this site and many healthcare sites. The culprit in these posts and articles – as well as those written in major publications such as the New Yorker and Fortune – is inevitably the EHR.

The story is familiar by now. Doctors hate EHRs, doctors spend too much time on them, they interfere with patient care, they take away from the coveted doctor-patient relationship, etc.

What many of these articles don’t discuss, however, is that it’s not just the EHR – or even EHRs from many different providers – that are causing inefficiency, frustration, and burnout.

The broader problem is the non-EHR-stored data in payer portals, analytics platforms, HIEs, and elsewhere. Physicians have to log-in and log-out of all these different places for almost every patient, 30 or more times a day, and then search and scan through irrelevant screens of data to find the specific information they want to know. If the important, contextual data were available in their workflow immediately at the point of care, then it would drastically speed up their workflows.

The current federal proposal (now closed for public comment) to solve the interoperability problem may make data easier to share across EHR platforms, but it doesn’t solve the context or workflow problem. What the proposal amounts to is not much different than the early days of HIE and sharing CCDs, which no physician has the time or interest to read because they’re too long and filled with information a physician at the point of care already knows, doesn’t care about at that moment, or doesn’t care about at all.

While the quantity of information shared between different parties may improve if the current interoperability proposal moves forward, it’s unlikely the quality or relevance of the data will change at all. That is because this proposal doesn’t seem to consider workflow or context, which means physicians will spend more time searching and scanning through pages of digital data, resulting in greater frustration levels and experience even more administrative burden.

New or augmented automated workflows can be triggered at the point of care, in concert with patient-relevant context, to make the overall healthcare delivery more meaningful, efficient, and robust to reduce physician frustration.

Patented sensor-based software technology in use at health systems and practices delivers actionable patient data to providers within any EHR system, and from any third-party source, without the need for interfaces. These aren’t APIs that just pass blobs of data back and forth without regard for context or what the physician actually wants to know. Rather the sensors recognize when a provider is in a patient’s chart and automatically surface relevant care gaps and other information within the provider’s workflow immediately when they open the chart.

The information is visually integrated into the workflow (think of it as right next to the chart on the screen), allowing the physician to quickly review information he or she actually cares about instead of logging in , searching, and scanning only to find nothing.

Instead of searching, providers have all the care and coding gap information curated from analytics platforms and other physicians’ charts, but also from population health management companies, a laboratory or radiology testing company, or a SMART on FHIR-enabled application hosted by a third-party system.

The sensors, however, aren’t mind readers. The health system would define which data from which EHRs, applications, portals, and elsewhere their physicians would want to know. Because the sensor technology and supporting application are independent of any EHR or other HIT companies, third-party vendors do not need to get involved. That saves months of waiting and untold dollars for the health system because no vendor needs to create or implement an expensive point-to-point interface.

The final interoperability rule may look exactly like the proposal, but it may not. Instead of waiting to see whatever solution comes from the legislation, if any, health systems can reduce their physicians’ burnout through simple, effective, plug-and-play solutions now.

Healthcare data is expected to grow by more than 36% from last year to 2025, which is the largest trajectory of any of the industries studied. Physicians are already buried in data. More data will only add to health systems’ physician burnout problem if they don’t get a handle on this tsunami of information.

Putting contextual insights in front of physicians immediately in their workflow won’t solve all burnout issues, but it is an important step forward in a crucial patient care quality and financial issue for health systems. Liberating the data will liberate the care.

Readers Write: Physicians: The Ultimate Victims of Unusable EHRs

Physicians: The Ultimate Victims of Unusable EHRs
By David Lareau

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

It’s been a decade and a half since President George W. Bush announced his vision for making EHRs accessible for all Americans by 2014. Since President Bush first shared his plan, overall EHR adoption has skyrocketed. As of 2017, 86% of office-based physicians and 96% of all non-federal acute care hospitals had adopted some sort of EHR system, according to the ONC.

But what has this digital transformation really cost us?

I’m not referring to the billions of dollars that the government has paid providers for their meaningful use of EHR technology. The costs that concern me are the ones incurred by the frontline users of EHRs: the clinicians who have been forced to use inefficient systems that cripple their productivity and are fueling unprecedented levels of physician burnout.

In our rush to digitize medical records, we have failed to design and deploy solutions that work for physicians and enhance clinical decision-making. Instead of creating systems that deliver efficient clinical workflows, EHR vendors have been forced to prioritize R&D projects to satisfy regulatory and reporting requirements. Meanwhile, the regulations mandated by the government and payers have largely failed to include standards that enhance EHR usability.

By failing to adequately address usability, physicians have become the ultimate EHR victims.

EHR usability is a major source of frustration and stress that is contributing to physician burnout. According to a recent Medscape survey, 44% of physicians admit feeling burned out and point to EHR use as one of their leading stressors.

Despite their great promise, EHRs are a source of continued physician frustration because usability has remained an afterthought for developers and regulators. The lack of EHR usability hurts physicians, nurses, and even patients.

We could wait for the government to mandate additional usability standards. Alternatively, health IT stakeholders could commit to making EHR usability a top priority and begin taking immediate steps toward much-needed changes.

A few key areas that could make a big impact on EHR usability include:

• Support for flexible EHR workflows. Physicians have varying workflow needs, especially across specialties. Rather than forcing clinicians to adapt their workflows to satisfy the requirements of an EHR, EHR vendors must support flexible designs that allow users to filter information in ways that support the individual thought processes of each physician.
• Better point-of-care information. By making it easier for users to access the specific information they need, when they need it, for the patient in front of them, clinicians can drive better outcomes and increase their productivity.
• Promoting interoperability. Physicians need access to a patient’s complete medical record to optimize clinical decision-making and ensure patient safety. However, many providers and EHR vendors resist opening systems to share patient data out of fear of losing market share. By putting an end to data-blocking, physicians will feel more confident that they are equipped to deliver the highest quality patient care.
• Involving physicians. Both EHR vendors and health system leaders have largely failed to incorporate input from clinicians. If we want physicians to embrace EHRs, rather than viewing them as an additional burden, we must involve clinicians in the design process and seek their guidance to modify workflows to enhance patient care and increase productivity.
• Adopting app-based solutions. Healthcare providers have spent millions over the last decade implementing new EHRs. Few organizations can afford the financial and manpower disruption of starting a new EHR implement from scratch, regardless of how inefficient their legacy system might be. App-based solutions can address some usability issues without the need to rip and replace current EHR systems.

The digitalization of health records has been a painful journey for most physicians because the needs of clinicians have largely been ignored. Instead of being a tool for physicians, EHRs have become a task. By committing to fix EHR usability, we have the opportunity to diminish physician frustrations and give them the chance to stay focused on the delivery of quality patient care.

Readers Write: The One About Moon Landings and AI in Healthcare

The One About Moon Landings and AI in Healthcare
By Vikas Chowdhry

Vikas Chowdhry is chief analytics and information officer at Parkland Center for Clinical Innovations of Dallas, TX. The views expressed in this article are my personal views and not the official views of my employer.

Saturday, July 20, 2019 was the 50th anniversary of the Apollo 11 moon landing. Hopefully, like me, some of you were able to watch the amazing Apollo 11 movie created from archival footage (a lot of it previously unreleased) and directed by Todd Douglas Miller. I saw it in IMAX a few months ago and was astonished by the combination of teamwork, sense of purpose, relentless commitment, hustle, and technology that allowed the Apollo mission team to make this a success within a decade of their being asked to execute on this vision by President John F. Kennedy.

This weekend, I also saw a lot of tweets related to Apollo 11 fly by my Twitter feed, but the one that really caught my eye and brought together a lot of themes that I have been thinking about was this one by the NYU economist Bill Easterly.

I am a healthcare strategist and a technologist. What Bill said validated for me the concerns I have around the hype regarding how technology (and specially AI/ML-related technology) will magically solve healthcare’s problems.

It is naive and misleading for some of the proponents of AI/ML to say that just because we have made incredible progress in being able to better fit functions to data (when you take away all the hype, that’s really what deep learning is), all of a sudden this will make healthcare more empathetic, create a patient-centric environment, solve access problems and reduce physician burnout.

More sophisticated computing did not magically enable us to land human beings on Mars or allow us to create colonies on the moon since Apollo 11. As Peter Thiel so eloquently stated several years ago,  “We wanted flying cars, instead we got 140 characters.”

The reason for that was not lack of technology, but a lack of purpose, mission, and sense of urgency. Nobody after JFK really made the next step a national priority, and after the Cold War, nobody really felt that sense of urgency in the absence of paranoia (the good kind) of Soviets breathing down America’s collective necks.

Similarly, without a realignment of incentives (and not just experimental or proof-of-concept value-based programs with minimal downward risk), without a national urgency to focus on health instead of medical care, and without scalable patient person-centered reforms, no technology will make a meaningful impact, especially in a hybrid public goods area like health.

I am not making the contention that AI/ML holds no promise for healthcare. Far from it. In fact, AI/ML has the potential to fundamentally transform healthcare across the spectrum. From finding ways to proactively detect signs of deterioration to being able to detect drug effectiveness and causality from observational data in areas where randomized controlled trials are not always practical (pediatric care) or too expensive (across various demographics and social conditions), there’s immense promise.

However, none of those promises can be realized without the right incentives. This has been known for a long time by health economists and health policy geeks, but is not stated enough by others in the position of influence. That is why it is important for those of us who sit at the intersection of technology and healthcare to repeat this fact often so that we don’t end up in a situation of only being able to create the equivalent of cat videos for healthcare when we know that we are capable of moon landings.

Readers Write: ASCs Have a Chance to Get Ahead of Physician Burnout

ASCs Have a Chance to Get Ahead of Physician Burnout
By David Howerton

David Howerton is CEO of Simplify ASC of Brentwood, TN.

Not long ago, two retired physicians gathered to reflect on their careers (an OB/GYN and an internist) from roughly 1965 to 2010. Both were in private practices they owned and later sold for a healthy profit. Their careers saw all the benefits of new, lifesaving drugs and medical procedures. The largely hierarchical workplaces they inhabited supported the “buck stops here” identity of the physician as having the final say in patient care. Paperwork was practically nonexistent. A prescription pad, a few notes in a patient’s file, and they were on their way to the next patient.

Both doctors agreed their retirement came at just the right time. While this golden era had its flaws — most notably high rates of medical error and social and racial disparities — the physician felt valued and supported. Today, the healthcare landscape is dramatically different. The headlines proclaim it, from trade media to news magazines, and from research university to family medical clinic: physician burnout is a thing. Harvard’s School of Public Health calls it a public health crisis.

According to Medscape’s 2018 report on “Physician Burnout and Depression,” more than half of the report’s 15,543 respondents, or 56%, cited “too many bureaucratic tasks (e.g. charting, paperwork)” as contributing to physician burnout.

The Annals of Family Medicine found that physicians spent more time working in the EMR than they did spending face-to-face time with patients. An emergency room doctor notes the average ER physician will make 4,000 mouse clicks in the course of a single shift.

To cope with all these stresses, half will exercise, 46% will talk with family members or close friends, and 42% will try to get some sleep, according to the Medscape survey. The Harvard School of Public Health report recognized the positive impacts of these wellness-driven solutions, as well as recommending improved physician access to mental health treatment. Others advocate for the appointment of a chief wellness officer to focus C-suite attention on the remedy.

But the research clearly points to the elephant in the room. Charting and other bureaucratic tasks remain the biggest driver of physician burnout.

Adding to the tension: over 30% of physicians are older than 60 years and began practicing medicine well before computers elbowed their way into healthcare. The story is the same for perioperative nurses: 66% are over 50 years old and 20% of that group are over 60. These digital immigrants, while conversant in digital “language,” aren’t always fluent, and the transition raises stress levels.

While no one is advocating a return to a paper-based system, current technology needs a serious overhaul. Rather than conform to way they practice medicine, clunky, off-the-shelf software leaves physicians at the mercy of the way the software wants them to treat patients.

While ASCs have, for now, been spared from the same burdensome EMR certification requirements as hospitals and health systems, they haven’t been spared from digital tools that leave the average user wishing for something more relevant to their ASC experience in the OR, supply closet or at the front desk.

Now is the time to develop digital tools that respect the time and talents of every clinician and work the way they do. As ASC volumes increase and compliance standards climb, those who work to help ASCs navigate technology transformation have a chance to get it right. But they should be mindful of the words from self-described tech humanist Kate O’Neill: “The meaningful design of experiences in physical space now regularly overlaps with the meaningful design of experiences in digital space.”

Readers Write: Five Emerging Imaging AI Workflows

Five Emerging Imaging AI Workflows
By Stephen Fiehler

Stephen Fiehler is founder and CEO of Interfierce of San Francisco, CA. 

Medical imaging is one area of medicine that could significantly benefit from the implementation of artificial intelligence (AI). Applications that interpret chest x-rays, detect stroke, and identify lung cancer are already available. Many AI solutions have garnered FDA approval for commercial or clinical use.

However, few if any have mastered a “best practice” workflow that seamlessly integrates the application’s output with the hospital’s other clinical applications (i.e. PACS, EHR, dictation system). How should the application’s output be delivered? Who should see it first? The answers to these questions are dependent on the nature of the algorithm (i.e. stroke detection, chest x-ray, pediatric bone age), but five workflows are emerging for imaging AI applications.

Advanced Visualization

Many imaging AI applications are delivering their output to an interpreting radiologist within a separate application. The radiologist is commonly working out of PACS, the dictation system, and the EHR. The Advanced Visualization (or post-processing) workflow introduces an additional application to the radiologist’s workflow. Sending the study to the AI application, launching it, and running the images through the algorithm can add significant time to the interpretation process. The Advanced Visualization workflow sets a high bar for the value of the AI application’s output. If the application does not save the radiologist ample time or provide substantial value, the Advanced Visualization workflow is not viable.

Dictation System Integration

Some imaging AI applications are opting to integrate with the radiologist’s dictation system (i.e. Nuance PowerScribe 360). If an AI application has a discrete output that is independent of the images, it can send that value to the dictation system via Digital Imaging and Communications in Medicine (DICOM) structured reporting (SR). DICOM is the standard way of exchanging images and image related data in healthcare, and DICOM SR is discrete data associated with the imaging (i.e. left ventricle dimension in centimeters).

An example use case is an AI application that analyzes pediatric hand x-rays to determine the patient’s skeletal age can leverage DICOM SR to send its output to the radiologist’s report. The patient’s “Z-score” is conveniently embedded in the radiologist’s report as soon as she opens the study. She can then confirm the value or edit it before finalizing the result. Dictation system integration adds no time to the radiologist’s interpretation process.

PACS Integration

Computer aided detection (CAD) applications have been integrating with PACS for over a decade. CAD applications are designed to annotate images to improve the detection of disease, like breast cancer, and reduce false negative rates. These applications commonly integrate with PACS via DICOM secondary capture (SC), which adds additional annotated images to the study in PACS. Some AI applications use this same type of integration to send annotated images back to PACS to assist with the radiologist’s interpretation. DICOM SC requires the radiologist to navigate to the annotated images within the study, which can be cumbersome depending on the size of the study.

Worklist Prioritization

A popular type of AI integration is worklist prioritization. Many AI applications integrate with a reading worklist to prioritize studies that present signs of time-critical conditions, like stroke, spinal fractures, or pulmonary embolism. Rather than producing a complicated output like annotated imaging or DICOM SR, worklist prioritization simply elevates the priority of the study or flags it as a particular abnormality. This can help radiologists identify time critical studies more quickly in an effort to expedite patient care.

EHR Integration

To my knowledge, no imaging AI applications are sending results directly to the EHR. Yet direct-to-EHR may become the best practice workflow in the future for mature imaging AI applications.

Sending the output of the AI application directly to the patient’s chart in the EHR has many advantages and risks. The information would be immediately visible by other care team members who have the security to view preliminary results. Therefore, the report should adequately warn the viewing user that “THIS IS A PRELMINARY RESULT” and it has not yet been reviewed by a radiologist.

Careful consideration and planning should take place before implementing direct-to-EHR integration, but as AI applications mature in competency, it will become more common. Many hospitals opt to send an EKG machine’s automated interpretation directly to the EHR today. The result is clearly labeled “preliminary” and the inpatient or emergency room providers know it has not been confirmed by a cardiologist. However, the immediate availability of an imperfect result is valuable. I believe many imaging AI applications will eventually send their output directly to the EHR.