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.

Readers Write: Why the Interoperability and Patient Access Proposed Rules Matter for the Future of Healthcare

Why the Interoperability and Patient Access Proposed Rules Matter for the Future of Healthcare
By Russ Thomas

Russ Thomas is CEO of Availity of Jacksonville, FL.

The Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) have proposed new rules designed to give patients greater control over their own data and advance interoperability across the healthcare industry. Should the rule be finalized in its current form, millions of patients will have unprecedented access to and control over their own health information by 2020.

With some limited exceptions, including several related to privacy and security, the Interoperability and Patient Access Proposed Rule would make patient data exponentially more accessible and portable through open data-sharing technology and patient-facing apps.

Ideally, this would not only provide patients greater ownership of information related to their diagnoses, procedures, and tests, but also would mandate the seamless transfer of information from one healthcare organization to another as patients transition from physician to physician – enabling the promise of coordinated care within a complex healthcare system.

HL7 FHIR will be required as the standard for supporting all APIs under the proposal. Nearly 90% of hospitals and 70% of MIPS-eligible clinicians are using FHIR-enabled EHRs, according to ONC.

On paper, the rules are a logical extension of the Triple Aim—delivering better quality, better population health, and lower costs. Our industry has long advocated for the migration of patients to the center of the healthcare ecosystem.

However, empowering patients as consumers is only as effective as the tools they have to make more informed choices about their care. In this regard, healthcare is woefully behind the curve. Consumers can easily and securely access banking transactions and retail purchases over their smartphones, but not, say, their own clinical information, which is often tangled in a web of data silos, privacy rules, and vendor competition. Implementing and standardizing these rules will not be an easy lift.

In the real world of healthcare, the free flow of data and determining how, where, and when it is routed to the appropriate person is a daunting task with the highest of stakes. Although applying the proposed rules industry-wide will be time-consuming and resource-intensive, I believe the effort is both worth it and long overdue.

These proposed rules are a critical tap on the shoulder, a reminder that achieving healthcare’s future is impossible without first solving the foundational problems rooted in our present moment.

Healthcare technology companies should be at the forefront of supporting industry standards that drive efficiencies and interoperability and reduce costs and administrative burdens for their customers. Tools like FHIR enable healthcare organizations to efficiently exchange well-defined information.

I believe that this standardization is essential to the shift to value-based models of care, where payers and providers are seeking secure ways to better communicate and exchange information.

Standards, however, are only one part of the solution. Creating a more solid foundation for healthcare’s building blocks requires several key ingredients: widespread adoption of automation; more efficient channels for sharing and maintaining healthcare information; and modernization of laws governing healthcare data access and sharing, like HIPAA. It also requires evolution of business models to reward transparency and information sharing and penalize data duplicity.

On the payer side, many health plans still store provider data on legacy systems in multiple disconnected databases. As business requirements have evolved, insurance organizations have implemented incremental stopgap measures to address data limitations, but these don’t address the core challenge, the lack of a single source of truth.

It’s important to hear from all concerned stakeholders in order to get these rules right. However, I believe that at the core of these rules lies an essential truth. Unlocking and harnessing the power of data and providing patients the ability to access it is the truest course to a more sustainable and patient-centric healthcare system.

We have been presented an opportunity to fundamentally transform the American healthcare system for the better. It would be a mistake to miss it.

Readers Write: Three Reasons to Look Beyond the SNF Five-Star Rating When Assessing Potential Hospital Partners

Three Reasons to Look Beyond the SNF Five-Star Rating When Assessing Potential Hospital Partners
By Tom Martin

Tom Martin is director of post-acute analytics for CarePort Health of Boston, MA.

Last month, the SNF Five-Star Rating program underwent major changes in all three domains. As a result, many SNFs saw their ratings drop on Nursing Home Compare, and many hospitals and health systems questioned whether these facilities could continue to meet their high standards for quality.

A close look at the program’s methodology revealed that CMS’s changes in measurement were the root cause of the decline in ratings, as opposed to a true dip in quality. As tempting as it is to use the star ratings as the primary criteria for adding or keeping SNFs in a preferred post-acute network, there are a few compelling reasons for hospitals to look beyond these general statistics and consider alternative strategies.

The first reason is that the quality domain carries the least weight though it includes some of the most important measures.  The survey domain is the most heavily weighted in the calculation of a facility’s overall star rating.

While surveys are certainly an important indicator of quality, they’re not the most relevant or timely markers for hospitals that are assessing SNFs as potential partners. The results are subjective, standard surveys only happen once a year, and the forced distribution of ratings in this domain makes it difficult to know if a provider is truly improving or if other SNFs in their state are just getting worse.

In contrast, CMS is constantly adding new measures to the quality domain, some of which are highly relevant to hospitals. In fact, for a few key measures such as 30-day readmissions, ER visits, and successful discharge to the community that really matter to hospitals, the period of time that patients are followed has been extended beyond discharge from the SNF. These longer measurement windows are especially helpful to hospitals that are part of an ACO or involved in other value-based programming that holds them accountable for patient outcomes across the entire care continuum.

Unfortunately, with a total of 17 quality measures currently included in the quality domain, a SNF’s performance on these critical measures has a limited impact on its quality star rating and minimal impact on its overall star rating.

The second reason to look beyond the star ratings is that the claims-based quality measures are limited to the Medicare fee-for-service population. Even if a hospital or other acute entity such as an ACO focuses on the measures that are most relevant to them, as mentioned above, and ignores the composite star ratings, the data on these measures are confined to a facility’s Medicare fee-for-service population, which may or may not make up a significant portion of its current population. And looking ahead, the percentage of Medicare beneficiaries choosing to receive their benefits under a Medicare Advantage plan will only continue to rise, making these fee-for-service claims-based measures even less representative of the quality of care provided at a SNF—ironic given that they would otherwise have the potential to provide the most valuable information in the program.

The third reason to look beyond the star rating system is that changes in measurements, such as those made this April, have occurred many times over the 10 years the program has been in place and will likely continue to occur. But as we saw in April, they skew the data and can mask true trends in quality, making it hard for hospitals to get a complete and accurate picture of the performance of participating SNFs. What hospitals really need are objective means of measuring performance, and that’s not a given with the Five-Star Rating program. For example, in April CMS changed the cut points for the various star levels in the staffing domain, so even though a provider may have actually increased staffing levels in April, that provider may still have received a lower rating due to these new higher thresholds.

Selecting a few measures from the Five-Star Rating program to focus on when assessing potential SNF partners is a reasonable strategy, but one that doesn’t quite go far enough in the era of value-based care. In today’s climate, where hospitals and health systems are being held responsible for patients long after their inpatient stays are over, these acute entities need to be much more closely connected to their downstream partners. They need access to real-time patient data from SNFs, and not just on their Medicare FFS patients, but on their entire population.

All stakeholders—acutes, post-acutes, and most importantly, patients—benefit when providers break down data siloes and exchange healthcare information freely. Simple alerts stemming from ADT (admissions, discharge, and transfer) data can go a long way toward helping providers stay on top of what’s going on with their patients. The star ratings have their place, but to truly understand the quality of care that is being provided by their post-acute partners and ensure patients are receiving high-quality care at every point in the continuum, hospitals need to get proactive and start collecting their own data.

Readers Write: The Big Fib

The Big Fib
By Weary Healthcare Traveler

On Tuesday, May 7, Don Rucker appeared before the Senate to garner support for ONC’s new rule relating to 21st Century Cures. Although he used complex language and invoked incantations of magic like JASON, Restful Services, APIs, AI, ML, and OAuth2 to US Senators who all just nodded and went back to their scripted questions, this is my summary of what he was really championing in that hearing.

The Baseless Promise that Apps and APIs will revolutionize health and healthcare records. There is no evidence to suggest this at all after almost a decade of patients having the ability to download their own medical records, billions of dollars of venture capital spent on startups, and a wide range of APIs available across all the major healthcare vendors. This includes both standard FHIR and proprietary APIs available through agreements with third parties.

The Big Stick of severe penalties for the new vague crime of data blocking of patients and venture capitalists seeking data perpetrated by doctors, health systems, or technology developers who submit to ONC in support of their ever more ridiculous programs which continue to torture doctors in the name of CMS quality management and payment programs.

Of course, given the lack of any traditional enforcement for such a nebulous crime, ONC’s plan is to invoke False Claims Act laws to create a Sword of Damocles over any vendor or steward of patient data who does not submit fully to the Baseless Promise and the new rule.

The False Flag of claiming patient data rights as the primary rationale for their new rules, as ONC has fully submitted to the venture capitalists of Silicon Valley and other special interests who wish to exploit patient data on a massive scale. The Big Stick is big, but of course specifically designed by ONC to not be big enough to reach the new bread of app developers mentioned in The Baseless Promise who would abuse patient data through complex and intentionally deceitful terms and conditions (they are not covered by HIPAA or ONC Certification.

Rucker misleads the Senate by claiming that OAuth 2, a beautiful standard that works in other industries, will provide protections for patients when in fact he simply means that the patient would retype their passwords and afterwards the same rules that apply to Facebook, Google, Cambridge Analytica and the like would magically protect our most sensitive and personal data. It won’t.

The Big Hero as ONC tries to claim the high ground defending all that is right and just. And,but for the evil forces of vendors, health systems, and wicked data blockers would be able to fix up healthcare in a matter of months if everyone just got behind their new rule. Per Rucker previously, to wait even a month for additional input would have dire consequences to patients.

The Big Villains are said to be EHR vendors, who through their mandated support of ONC, CMS, and other payer requirements, try to help doctors and health systems cope with a fundamentally polluted reimbursement and regulatory system and are cited as the cause of burnout as thanks for their efforts. These vendors will inevitably stand accused under these new regulations for not fully supporting the data broker industry and be subjected to The Big Stick.

And, oh, gag me – this notion that EHR vendors have gag clauses is ridiculous. Asking customers not to publish trade secret intellectual property is not a gag clause. Health systems and provider contracts almost always tip the other way, restricting vendors from sharing any confidential information they may have. That would include basics like fee schedules, business expansion, and acquisition plans, but also observable medical errors that providers and pharmacists make on a routine basis even after overriding a warning to stop and reconsider. That’s where the real gag clauses exist.

If EHR vendors actually had gag clauses, I doubt you’d have the level of ONC- and AMA-sponsored EHR bashing you have today. Let EHR vendors protect their intellectual property and use well-established methods through Patient Safety Organizations for any real EHR safety problems.

The Evil Empire is healthcare providers and systems who themselves hoard data with a fearful eye toward outsiders who seek to exploit it. Fearful because HIPAA will crush them if they make even an innocent mistake in their stewardship of patient data. And now fearful that patients won’t understand how their data, their family history, and their genetic information was permanently released to the Internet and sold many times over when the terms and conditions of an app seemed to assure patients it wouldn’t do so when the patient connected the app to their doctor’s EHR.

All this in spite of health systems now offering online portals and apps that rival any travel, banking, or self-serve app found in any other industry. Going back to the Baseless Promise, only about 35% of patients even sign up to use their apps and portals at the urging of their doctors and health systems which, like airlines, also benefit from patient self service.

So, finally, The Big Fib. Through this new rule and under the flags of innovation and healthcare reform, our government (this administration as well as the previous) is on a path to sell out American patients to a data broker industry that has spent over a decade and countless millions of dollars lobbying for unwitting and uninformed patients to allow their data to be used in ways they can’t even imagine. This False Flag above is in large part sponsored by the a data broker industry worth hundreds of billions of dollars seeking hundreds of more billions.

What should we be focused on instead of ONC’s “Game of Thrones” heroes and villains narrative?

The healthcare industry is largely built on a model of cost shifting from patients without coverage or covered by government-subsidized programs to patients with employer-sponsored commercially insurance. That worked out in a world with more commercial than government subsidized patients. With the Medicaid expansion, there are now more people on subsidized plans and fewer on commercial plans, and thus we have run out of the ability to shift costs. Prices and deductibles are rising fast because neither insurance companies nor healthcare providers want to take a hit to revenue or their bottom lines.

There is not a quick solution here because it is more beneficial for politicians to campaign on the issue of healthcare coverage than to come together to create a bipartisan solution. We need more than a Baseless Promise to fix healthcare. We need to press Washington to unwind this hairball of a reimbursement system.

Healthcare providers seek to enhance and protect their relationships with patients and often do so by using data and services in beneficial ways, leveraging their unique relationship with the patient and their stewardship for the patient data under HIPAA. This can be used for good and as well for evil. Rethinking regulations to protect patients by enforcing rational HIPAA-protected interoperability including both doctor to doctor exchange, but also patient to their chosen apps with full awareness, audit abilities, and responsibilities similar or under HIPAA for those app providers. Force apps to protect patient data in a reasonable and accountable manner similar to health providers.

Get over the fixation on EHR vendors as villains. They have done more to dramatically enhance patient outcomes, reduce medical mistakes, and improve convenience, consistency, and compliance in healthcare over the last decade than any other technical innovation. Spend a moment contemplating this array of regulatory and payer requirements and the explosion of medical knowledge unaided by automation. If enough providers hate their EHR when EHRs are being built to deal with the rules providers choose to submit to, then maybe they’ll stop buying certified EHRs and take the penalties as CMS dictates.

If ONC and DOJ continue to abuse vendors who work in good faith to support these complex and ambiguous programs on ridiculous timeframes, maybe those vendors should simply decide to no longer offer certified EHRs. What would happen in this industry if ECW, Greenway, Allscripts, Epic, and Cerner walked away from the ONC certification program?

Maybe most important of all, stop using exaggerated anecdotes and innuendo to “make your case.” As leaders of ONC, CMS, Congress, and industry, it’s time to put some science and integrity to work in crafting a better-functioning health system for Americans. Many billions of API transactions and hundreds of millions of patient records are being transported across health systems and with apps, also made available directly to patients every year. To hear senators read from their scripts that “we still don’t have interoperability” is embarrassing.

Will it be better 10 years from today than it was 10 years ago? Of course it will, but not if we continue to exaggerate and fool ourselves to the benefit of those who continue to seek to exploit patients and their data. This willful campaign of misinformation will likely lead to a backlash by patients when they realize their government has sold them out to data brokers.

Readers Write: AI and Machine Learning Only Work if You Do

AI and Machine Learning Only Work if You Do
By Brian Robertson

Brian Robertson is CEO of VisiQuate of Santa Rosa, CA.

Do AI and ML represent a game-changing opportunity for revenue cycle management? Absolutely. An annual research report by EMC and IDC indicates that the digital universe will contain 44 trillion gigabytes of data next year, with nearly a third of that data collected and stored by the healthcare industry, according to a Ponemon Institute study.

Within this vast ocean of data, AI and machine learning are well equipped to act as the precision sonar to detect and solve business problems using advanced data-driven methods. Indeed, AI and ML are part of today’s buzzwords du jour, but few now question that it will play a role. We must now advance the conversation: how to get going and laser in on value.

Let’s rewind to a time not long ago when we couldn’t blink without seeing a plethora of white papers on big data. They seemed to all contain the same message: “Big data has the potential to be a game-changer.” As the CEO of a company in the data analytics arena, we sometimes struggled with how to best communicate the power of big data to our clients. Our ultimate answer was to focus less on the intelligentsia and more on “get stuff done” (GSD) thinking.

Using AI and ML as an accelerator

First on deck? Don’t get too caught up in the hype cycle. From a pure technology standpoint, it’s just not that hard. One of the benefits of back-office operations, as opposed to clinical departments, is easy access and availability of structured data.

The harder part? Prioritizing business problems where a return on analytics (ROA) could deliver big value. Back to the ocean. Don’t boil it! Invest more time with your team thinking through what you’re trying to accomplish and what can deliver ROA/ROI.

Let’s take something like denial management. AI and ML can help speed up the discovery of problems that are both acute and systemic.

First, resolve what’s in front of you. Then go upstream where the real potential is. If you’re fixing the same problems repeatedly, solve that problem at its core.

Consider a physician dictation issue where some dictate with great attention to detail the complete services and care provided during a complex surgical case. Coders love that because they rely on substantive information to correctly code. That’s in contrast to physicians with less attention to detail, where denials and/or lost revenue is impacted a la the old adage, “If it wasn’t documented, it wasn’t done.”

Automating variability by physician can help you better solve problems upstream. Maybe it’s a system glitch where a bill editor is not set up correctly. Inaccurate or incomplete payer edits often repeat month after month. Deeper trending insights can automate the illustration of consistent anomalies.

This is where AI and ML become a competitive advantage, particularly when you stay focused on business value vs. the glitter of new tech. Start narrow and allow the algorithms do some of the heavy lifting.

1. Purely repetitive process automation. Take a binary process and drive automation via robotic process automation (RPA) tools and methods.
2. Enhance user or consumer experience. Chatbots can deliver an exceptional user experience. Why not leverage voice automation and have your chatbot send you the daily cash report for your commute home? Or a report showing slow-paying payers? Or the bad debt forecast?
3. Deep data mining. Use anomaly detection on historical claim data to empower upstream decision-making. Leverage ML to see what’s going on with the patterns. Let the decision-making power get smarter every day.

Done right, AI and ML will improve yield, increase velocity, and optimize FTE impact.

Final tips to those looking at AI and ML for back-end optimization

• Fail fast so you don’t lose precious time over-analyzing.
• Avoid the technology hype and focus more on business problems the technology can help enhance or catalyze.
• Train your staff. FTEs in repetitive roles will become obsolete — it’s just the reality of our future. We as leaders have a moral responsibility to train our talent. As Gartner often advocates, create learning pathways to enable your staff to become capable citizen data scientists. Give them a meaningful shot at surviving in the long-term.
• Lastly, pick three business problems. Go narrow and deep. but as deep as you possibly can. Then it’s time to grab a shovel and get after it.

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

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

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

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

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

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

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

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

Why holistic patient engagement matters

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

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

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

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

Recommended best practices

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

Technology

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

Analytics

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

Convenient Care

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

Right Care Setting

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

Personalized Care

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

Provider Organization

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Encrypt all files

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

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

Assign unique IDs to all staff

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

Implement multi-factor authentication

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

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

Implement auto-logoff

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

Ensure that all software is HIPAA-compliant

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

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

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

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

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

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

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

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

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

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

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

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

1. Searching for Clinical Data

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

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

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

2. Managing the Inbox

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

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

3. Entering Orders

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

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

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

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

4. Documenting the Encounter

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

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

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

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