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

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

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

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

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

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

You will need to gather from your system:

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

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

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

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

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

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

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

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

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

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

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

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

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

This is why healthcare interoperability singlehandedly enables the fax industry.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Readers Write: Have You Lost Your Job?

Have You Lost Your Job?
By Jim Gibson

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Happy hunting.

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

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

Terry Zysk is CEO of LiveProcess of Chelmsford, MA.

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

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

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

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

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

All of these changes require intense coordination and collaboration.

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

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

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

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

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

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

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

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

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

Rob Dreussi is CIO of HCTec of Brentwood, TN.

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

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

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

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

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

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

Keeping up with all the change has been really hard.

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

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

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

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

Readers Write: Blowing the Whistle on Technology Fraud in the Healthcare Industry

Blowing the Whistle on Technology Fraud in the Healthcare Industry
By Joseph Gentile, Esq.

Joseph Gentile, JD, Esq. is a partner with Sarraf Gentile LLP of Great Neck, NY.

The healthcare industry has always been an area susceptible to fraud. In fact, government investigators estimate that in 2016, about $95 billion was improperly paid out by Medicare and Medicaid. That’s only a single year’s amount of fraud in just two of the government’s many healthcare programs.

With an aging population, increased healthcare spending, the passage of the CARES Act, and the government’s multi-trillion dollar effort to mitigate the health and economic effects of the COVID-19 pandemic, fraud in the healthcare industry will only increase. With social distancing become the new normal, the use of technology to deliver healthcare services will also increase. Fraud in this area will, therefore, likely increase.

As a result, the need for insiders to blow the whistle on technology fraud in the healthcare industry is more important than ever. Whistleblowers help ensure that these precious government dollars go towards stopping the harmful effects of the virus and shoring up our economy—and not to line the pockets of opportunists.

The best tool for combating this scourge is the False Claims Act (FCA), a Civil War-era law that was passed to address the fraudulent sale of decrepit horses, ill mules, and faulty rifles to the Union Army (which not only stole tax dollars, but endangered soldier’s lives). The FCA has since been expanded to cover most government dollars, including healthcare spending such as Medicare, Medicaid, and Tricare.

The FCA has been regularly used to fight technology fraud in the healthcare industry. Just last year, the Department of Justice announced a $57.25 million settlement against Greenway Health LLC (Greenway), a Tampa, Florida-based developer of electronic health records (EHR) software for causing its users to submit false claims to the government by misrepresenting the capabilities of its EHR product Prime Suite and providing unlawful remuneration to users to induce them to recommend Prime Suite. 

The US Attorneys whose offices prosecuted the fraud said it best. According to Christina E. Nolan of the District of Vermont, “These cases are important, not only to prevent theft of taxpayer dollars, but to ensure that the promise of health technology is realized in the form of improved patient safety and efficient healthcare information flow.” According to Byung J. “BJay” Pak of the Northern District of Georgia, “Medical professionals and patients depend on the security and competency of electronic health records as a means to improving both the quality and coordination of health care services… Vendors who falsify the viability of their products erode the integrity of public health systems and will be held accountable for their misrepresentations.” 

Cases like Greenway are just the tip of the healthcare fraud iceberg. Indeed, the FCA has been used to recover billions in healthcare fraud and was most recently used in the government’s historic $1.4 billion recovery from Reckitt Benckiser Group involving the marketing of Reckitt’s opioid addiction treatment drug Suboxone. Whistleblowers were awarded over $100 million.

While blowing the whistle may not be easy, the FCA encourages it by offering anti-retaliation protections for those who out the fraud as well as lucrative financial rewards. Where the government obtains a recovery as a result of fraud, the whistleblowers are generally awarded between 15% and 30% of the recovery. Because many FCA healthcare cases are large by nature, the FCA’s financial rewards to whistleblowers have been historically large as well.

Our healthcare industry is being tested like never before, and the people in it — especially those who are working to use technology to improve its delivery and accuracy — play a critical part in ensuring its effectiveness, now more than ever. Those same people can help ensure that the billions of dollars being spent on healthcare aren’t being wasted by fraud. Every dollar counts. Pplicing that is not only a civic responsibility, but legally protected conduct that can result in significant economic awards.

Readers Write: Strained but Secure

Strained But Secure
By Troy Young

Troy Young is chief technology officer of AdvancedMD of South Jordan, UT.

Healthcare providers are pressed to the max, working to deliver ample care to the increasing volume of patients infected with COVID-19. Employees rise to the challenge and learn to get the job done in vastly different circumstances, be it on the front lines, in the back office, or remotely.

While we all try to navigate the new realities this pandemic presents, computer hackers are exploiting them: “Don’t let a crisis go to waste” is their mantra. Indeed, the novel coronavirus crisis has led to a rise in cyber scams and other security breaches as healthcare providers move quickly to redistribute workloads and manage care overflow.

Hackers are using tactics that capitalize on emotions of fear and anxiety and behaviors of internet users looking to stay on top of the situation during these uncertain times. They entice healthcare workers to open malicious files and links by:

• Creating a sense of urgency.
• Implying or stating that the e-mail comes from a person of authority.
• Offering a resolution to a difficult problem (the current virus, shortage of medical supplies, people in need, and similar) in exchange for sensitive information.

These tactics are especially effective during a time of crisis, when urgent communications from employers, friends, family, and government agencies are filling inboxes. These e-mails may include fake virus tracker maps, hand hygiene instructional sheets, or online marketplaces for high-demand items. Hackers have impersonated the World Health Organization (WHO), for example, in recent phishing emails.

As is the case with security at any other time, employees are the first line of defense against cyberattacks that are predicated by false communication. Providers should review policies with staff—whether employees are on site or working from home—and adhere to standard security plans and general workflow processes during the pandemic. Some scams are so well concealed that employees get fooled. These are best practices to keep top of mind:

• Always be suspicious of unexpected emails. Check the sender’s email address.
• Always look closely at any URLs, even those that are supposedly from people within the organization. Check the link by typing it into the browser.
• Never open a file attached to an email that was unexpected, or one that looks suspicious in any way. Take a pause to think through the purpose of the email. Don’t feel rushed or pressured to take any action.
• Never provide personal information like usernames / passwords or financial information after clicking through an e-mail link.

Even if someone falls prey to a phishing attack, organizations can mitigate risk by following these precautions:

• Require multi-factor authentication (MFA, or two-factor authentication) on as many accounts as allow them, especially banking and e-mail accounts.
• Enable automatic software and operating system updates on computers and mobile devices.
• Download anti-virus and anti-malware software on the network and personal computers as well as mobile devices. Windows and MacOS include these by default; just confirm they’re enabled and up to date.
• Back up all data.

The current crisis has highlighted organizational weaknesses in healthcare security and privacy protocols amid the urgent need to respond to government lockdown mandates, patient emergencies, and employee shortages due to illness. Employers have been rushed to establish telecommuting capabilities for staff who don’t typically work from home: when the need to expand capacity outstrips the organization’s ability to apply the security and privacy measures, risk increases exponentially. Also, as telecommuting employees increasingly use virtual meetings to communicate with each other, the National Institute of Standards and Technology (NIST) has recently published guidance on protecting virtual meetings from eavesdroppers.

VPNs are commonly used by healthcare organizations with telecommuting staff to provide secure access to technology resources. Microsoft recently warned that hackers are attacking vulnerable networks and VPNs, having particular success with a ransomware campaign known as REvil (or Sodinokibi). Organizations that use VPNs should refer to guidance from the Department of Homeland Security to secure their VPN and network infrastructures.

The COVID-19 crisis has also dramatically increased the use of telemedicine, which has emerged as an essential tool for providing contactless patient care. Regarding penalties, HHS recently notified providers that OCR has relaxed enforcement of HIPAA privacy rules during the crisis. This is great news for clinicians and patients, but providers should still be deliberate about using technology that is HIPAA-compliant and be sure to have BAAs in place with their vendor of choice.

The uncertainties of this global pandemic has many of us feeling vulnerable right now. Let’s control what we can. That includes built-in cybersecurity protocols that keep patients, employees, and organizations secure.

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

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

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

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

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

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

Establish sound (neutral) governance structures and processes

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

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

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

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

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

Invest in support resources

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

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

Expectations and investment

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

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

Bring in an unbiased, experienced marketplace manager

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

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

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

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

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

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

Readers Write: Prognostication Is A Fool’s Errand

Prognostication Is A Fool’s Errand
By Jeremy Harper

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

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

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

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

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

One-Month Quarantine

People

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

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

Organization

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

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

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

Two-Month Quarantine

People

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

Organization

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

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

Three-Month or More Quarantine

People

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

Organization

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

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

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

Upcoming Societal Changes We Need to Discuss as a Community

The requirement for strong telemedicine arrangements outside COVID.

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

Regulatory barriers.

Data analytics, collaboration, and productivity.

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

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

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

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

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

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

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

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

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

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

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

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

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

What you can do now:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Consider the following figures:

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

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

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

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

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

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

Readers Write: Fixing What Ails Healthcare

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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