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EPtalk by Dr. Jayne 4/4/19

April 4, 2019 Dr. Jayne 4 Comments

CMS has launched an Artificial Intelligence Health Outcomes Challenge. The three-state competition is planned to “accelerate artificial intelligence solutions to better predict health outcomes such as unplanned hospital and skilled nursing facility admissions and adverse events.” The CMS Innovation Center plans to use the data “in testing innovative payment and service delivery models.” Partnering with the American Academy of Family Physicians and the Laura and John Arnold Foundation, CMS will award up to $1.65 million during the three stages.

CMS has decided to be confusing by naming the three stages “Launch,” “Stage 1,” and “Stage 2” rather than just numbering them. Launch is essentially an application phase, with 20 participants selected to advance to Stage 1, where challengers will design and test their solutions using Medicare claims data. Up to five participants will move to Stage 2 where they can refine their solutions using additional Medicare data sets. The grand prize winner will receive up to $1M with a $250,000 award to the runner up. Launch is already underway and the program will run through April 2020.

If you’re wondering how to further translate the CMS-speak, the goal is to build “explainable artificial intelligence solutions to help front-line clinicians understand and trust artificial intelligence-driven data feedback to target scarce resources and improve the quality of care.” CMS Administrator Seema Verma explained this further: “For artificial intelligence to be successful in healthcare, it must not only enhance the predictive ability of illnesses and diseases, but also enable providers to focus more time with patients. The power of artificial intelligence will truly be unleashed when providers understand and trust the data and predictions.”

I was talking about this with a colleague, particularly the focus on diseases rather than health and prevention. There are so many factors that could immediately impact both individual and population health parameters that don’t require a challenge or competition. We already know what needs to be done, but lack funding to do it. These not-so-sexy solutions involve things like public health education, social workers, and strategies to eliminate food deserts and improve healthy behaviors. AI is a pretty distraction from the difficult work that could (and should) be happening.

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Speaking of the challenges found in trying to improve healthy behaviors, there is much speculation on whether financial incentives make a difference. Many organizations including my own hospital have done this by increasing insurance rates for smokers or offering discounts for non-smokers or those who complete a biometric profile. Discounts for non-smokers seem to make sense because we know smokers have more illnesses thus higher healthcare costs; the benefits of a biometric screening, however, have not been proven. I know that for me personally, going for the biometric screening did nothing to change my behavior, but cost me a half day out of office.

A recent article in the Journal of the American Medical Association looks further at the effect of financial incentives on improving healthy behaviors. In a recent US-based randomized trial, lottery-based incentives tied to medication compliance didn’t lead to a significant reduction in cholesterol levels. Another study found lack of reduction of cardiac events or hospitalization even though patients could earn more than $1,000 for being compliant. Other studies including those looking at smoking cessation in pregnant patients do show some benefit for financial incentives.

The article looks at reasons why studies might not show successful incentive use, including bias created when patients self-select for a study, since those who self-select are more likely to be motivated to change behavior whether there is an incentive involved or not. These motivated patients “rarely represent the population most in need of support, yet they are most often targeted by trials.” There are also issues creating control groups and in timing study enrollment based on patients transitioning through “hot and cold states in which their motivation varies, potentially determining their response to incentives.” Another issue is offering an incentive that is too small for the desired behavior change, which can be a negative motivator when higher incentives may actually drive change.

The authors conclude that when incentive-based interventions are being designed, subtle factors need to be considered, including the size / frequency of the incentive, how it’s positioned, and whether the target population fully understands the incentive and the desired behavior.

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From Midwest Afficionado: “Re: pastry therapy. Here’s some for you, Dr. Jayne, in the form of an edible book festival.” Apparently, this is the third annual edible book festival at Washington University School of Medicine in St. Louis. Although submissions were welcome from any genre, there was a special award category for “Most Edible Medical Book.” Submissions will be eaten promptly at 2:30 p.m. Previous entries included a “Checklist Manifesto” Rice Krispy Treat and a tribute to “Grapes Anatomy.”

Data from a recent Kaiser Family Foundation tracking poll indicates that patients aged 18-29 believe EHR technology has led to increased quality of care and has improved provider communication. The age bracket caught my eye since if you consider the pre-MU era (pre-2009) to be solidly pre-EHR, most of these patients weren’t even adults, so it might be a difficult comparison. General public perception of the benefits of EHR has decreased – in 2009, 67% of patients believed EHR would improve care, but a decade later, only 45% believe it has actually happened.

Still, only 6% of respondents said they felt EHR has worsened quality of care and 7% felt communication has worsened. More than 20% of patients said they or a family member has found an error in their chart. More than half of respondents voiced concerns about unauthorized access to the medical record, although younger adults (that 18-29 year age group) are less likely to be concerned than other age groups. I suspect that group is used to having their data used or mined by third parties, or that perhaps they’re just so used to hearing about data breaches that it is less concerning.

The American Medical Association shares sound advice on the use of wearable health devices in practice. They note four main possible issues that should be considered when adding devices to the care plan. Patients might disengage before the benefit can be realized, either due to convenience or perceived lack of benefits. They might also ignore symptoms and rely too much on devices. Others may obsess over the data, resulting in anxiety. Last, they might try to interpret the data without physician help, leading to false-positives and additional intervention. It was a nice little review of what to think about, and should be helpful for physicians who don’t have a lot of experience with wearables.

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Morning Headlines 4/4/19

April 3, 2019 Headlines No Comments

UMass prize will fund telemedicine initiative

UMass will roll out video-based substance use disorder evaluation software developed by prize-winning physicians within its Memorial Medical Group at three of its EDs over the next three months.

VA’s IT leadership problem has infected modernization efforts

Officials at a House Veterans Affairs Committee Hearing say the VA’s abysmal CIO track record has hampered – and will continue to hamper – the success of its extremely expensive IT modernization efforts.

Quil, The Joint Venture Between Independence Health Group And Comcast, Names Carina Edwards Chief Executive Officer

Digital health company Quil names former Imprivata executive Carina Edwards CEO.

HealthVerity Announces $25 Million in Series C Funding

Patient data retrieval and management company HealthVerity raises $25 million.

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

April 3, 2019 Readers Write No Comments

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

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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

April 3, 2019 Readers Write No Comments

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.

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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.

Morning Headlines 4/3/19

April 2, 2019 Headlines No Comments

Walgreens Boots Alliance Reports Fiscal 2019 Second Quarter Results

Walgreens announces executive changes, store layout redesign, and cost-cutting measures following its announcement of disappointing quarterly results.

U.S. Department of Veterans Affairs Joins DirectTrust’s Accredited Trust Anchor Bundle

The VA joins DirectTrust’s anchor bundle, which will allow its employees to use Direct messaging and information exchange to communicate with 1.8 million providers.

Abernethy tapped as FDA’s CIO

Politico reports that FDA Principal Deputy Commissioner and former Flatiron Health executive Amy Abernethy, MD will become the agency’s CIO, taking over from CISO and interim CIO Craig Taylor.

Theranos Whistleblowers To Launch Tech Ethics Venture

Theranos whistleblowers Erika Cheung and Tyler Shultz will launch the nonprofit Ethics in Entrepreneurship to help connect startups with ethicists, more experienced entrepreneurs, and resources that will help them avoid the fate of the disgraced blood-testing company.

News 4/3/19

April 2, 2019 News 1 Comment

Top News

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Walgreens announces executive changes, store layout redesign, and cost-cutting measures following its announcement of disappointing quarterly results Tuesday.

WBA shares closed down 13 percent Tuesday after the company released results that fell short of expectations for both earnings and revenue. They’re down 12 percent on the year and up just 14 percent over the past five years vs. the Nasdaq’s 96 percent gain.

In yet another example of the “healthcare is big business that takes money from the ill” paradigm, the company’s US pharmacy operations delivered disappointing results because of a mild flu season and a de-emphasis of tobacco.

The company says it has created a new digital leadership team and embedded Microsoft within it.


Reader Comments

From Clarence Oveur: “Re: exhibiting at HIMSS. We’re questioning the value. Wondering if you are hearing that from other companies?” I’ve heard from a couple of folks who asked me what I thought about moving their multi-hundred thousands of dollars of exhibit hall expense into something that might generate actual leads (which for them, HIMSS19 did not, and I’ve heard that quite a bit). Most of those who have toyed with that idea in past years got scared into paying up over fears (likely justified) that competitors would create innuendo around their absence. Consider these points:

  • Make sure customers and prospects don’t see an exhibit hall pullout as a sign of financial challenges. Tell them well beforehand why you’ve changed strategies and where you’ll spend the money instead.
  • You’ll still probably want a convenient way to connect with people during the conference, which might be an exhibit hall meeting room, a staffed HIMSS Bistro table (if they offer that service again), or either a single event or a series of dinners with an executive. HIMSS locks down basically everything in sight of the convention center and then some, so solve the real estate issue early (a la the JP Morgan Healthcare Conference, which to many attendees is held in unofficial hotels, coffee shops, and park benches because the main venue is sold out).
  • Don’t fail to work the hall even if not exhibiting in it. You might find a prospect, partner, employee, acquirer, or acquiree just from wandering around in the right places as a plain old registrant.
  • Figure out the kinds of activities that offer better ROI than a glitzy booth. Maybe it’s a series of webinars, regional events, testimonial videos, or sponsorships (OK, that was self-serving) that work all year instead of for just three days.
  • Take that tiny part of exhibiting that represents education and make that the focus instead of just watching unengaged passersby offloading swag from your podium.

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I’m interested in what readers think about companies who decide to stop exhibiting at the HIMSS conference, so tell me here. Do you care? What other ways can they connect with prospects? I’m especially interest in hearing from companies that have moved their exhibit hall expense into other forms of marketing that turned out to be more effective.


Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre for information.


Acquisitions, Funding, Business, and Stock

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NTT Data Services acquires Cognosante Consulting, which provides services to state Medicaid programs. It will operate as NTT Data State Health Consulting.

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The Knoxville paper covers PerfectServe’s three 2018 acquisitions, its 220 local employees, and the use of its secure provider communications solution by UT Medical Center.


Sales

  • In England, Great North Care Record chooses Cerner for information exchange.
  • San Francisco medical group Brown & Toland will implement Epic for ambulatory for its 2,500 independent physicians. The network manages insurance functions for its members and says Epic is the only system that can support both patient care and insurance administration.

Announcements and Implementations

UnitedHealthcare and the American Medical Association will work together to create 20+ ICD-10 codes related to social determinants of health that can be used to trigger referral to social and government services.

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KLAS looks a patient privacy monitoring solutions, with Protenus, FairWarning MPS, and Maize Analytics topping the list. Purchasing decisions are often driven by reducing false positive warnings, at which FairWarning MPS was found to excel.

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MIT Technology Review notes that DeepMind demonstrated a prototype of its AI-powered retina scanning device in London last week. The 30-second scan can detect retinopathy, glaucoma, and macular degeneration. It’s still years away from availability, however, since the company hasn’t yet submitted it for UK regulatory review.

Meditech expands its Meditech as a Service offering, which was initially offered only to critical access hospitals, to all community health systems.


Government and Politics

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The VA joins DirectTrust’s anchor bundle, which will allow its employees to use Direct messaging and information exchange to communicate with 1.8 million providers.


Privacy and Security

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“60 Minutes” visits Hancock Regional Hospital (IN) to talk about its January 2018 ransomware attack in which it paid a hacker $55,000 to regain access to its files. The hospital notes that not only was it back in business on the Monday following the Thursday attack, it has since learned that antivirus software that can only recognize a particular technical signature would not have helped (since the strain was new) and it has since added a system that instead looks for patterns of malicious behavior. The hospital also contracted with cybersecurity vendor Pondurance because “if we’re attacked by humans and the only thing we have to defend ourselves is software, then the humans will win.”

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An Indian state’s health agency exposes the information of 12.5 million women who had undergone pregnancy-related testing by leaving the Internet-connected database unsecured. The agency didn’t respond to warnings that its information was exposed and the problem was fixed only when India’s Computer Emergency Response Team removed the health information three weeks later. The MongoDB server is still online and exposed, with other agency information still accessible by anyone. The medical data was especially sensitive since it involves data collected to support India’s ban on prenatal sex determination tests, which it implemented to prevent widespread selective abortion of unborn females.


Other

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Epic’s April Fools’ Day home page makeover contained some Onion-worthy gems:

  • Epic hires CNBC host Jim Cramer as a financial advisor after he urged Apple to buy Epic on “Mad Money.” The funniest part about that bit is Judy Faulkner’s actual response at the time, when she asked a reporter with puzzlement, “Who’s Jim Cramer?” which apparently annoyed him based on his tweets about it afterward.
  • The rollout of MyMom, which encourages a health lifestyle with “a dose of love, a firm hand, and perhaps a little guilt.” It will include “genetic test processing filters that predict the likelihood that one day, you’ll have one just like you, and see how you like that.”
  • Epic adds a 200-member support team for Fortnite by Epic Games after its reception employees take 400 calls per hour that were intended for the gaming company (that’s apparently a real statistic).

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Dear PR people: “discreet” means watching what you say or being modest, which isn’t really an adjective you want to use when referring to data points (that would be “discrete.”)

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Kaiser Health News calls out respected hospitals such as Swedish Medical Center, Mayo Clinic, Cleveland Clinic, and University of Miami for offering profitable but medically unproven stem cell-related therapies even as FDA tries to shut down clinics that do the same thing. Some hospitals are even employing informercial-like sales pitches and enthusiastic but anecdotal patient stories to lure cash-paying patients in. One area in which evidence is ample – hospitals and medical practices will do whatever people pay them to, regardless of scientific merit. Just because hospitals are non-profit, unlike medical practices, doesn’t mean they don’t relish bringing in the cash through any legal (and sometimes illegal) means.

Researchers find that Ontario’s experimental payment of bonuses of up to $36,000 for PCPs to keep their patients out of the ED created unintended consequences, with most of the money going to small-town doctors whose patients had fewer PCP visits, less after-hours care, more ED visits, and higher ambulatory costs. The bonus-earning doctors also had lower-acuity patients. The authors identify a problem in creating rewards for those who are already exhibiting the desired behaviors instead of changing those who aren’t, also noting that the payment rules encouraged doctors to send patients to the ED or to specialists instead of to a walk-in clinic.  

Pharma bro Martin Shkreli is sent to solitary confinement for using a contraband cell phone to continue running his renamed, price-jacking Turing Pharmaceuticals from his federal prison cell. I’m pretty sure we haven’t heard the last of him since people who are willing to do most anything for money somehow keep finding new ways to take it away from someone else.


Sponsor Updates

  • Imprivata will offer its PatientSecure biometric patient ID solution with Verato’s cloud-based MPI as a comprehensive solution to address patient identification and record matching.
  • PatientBond will exhibit at the 2019 UCA Urgent Care Convention & Expo April 7-10 in West Palm Beach, FL.
  • Meditech publishes a case study on the use of its CAUTI prevention and surveillance tool by RCCH Healthcare Partners.
  • AdvancedMD will exhibit at the American Society of Addiction Medicine meeting April 4-7 in Orlando.
  • Aprima will exhibit at the CORHIO Forum April 4-5 in Denver.
  • PatientPing and Lightbeam Health Solutions will exhibit at the National Association of ACOs spring conference April 24-26 in Baltimore.
  • Avaya works with Nuance to develop new self-service automation capabilities with easy-to-navigate conversational interfaces integrated in its Avaya IX Contact Center solutions.
  • CompuGroup Medical will exhibit at the AZ HIMSS Annual IT Summit April 11 in Phoenix.
  • DocuTap will present and exhibit at the Urgent Care Association Convention & Expo April 7-10 in West Palm Beach, FL.

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Morning Headlines 4/2/19

April 1, 2019 Headlines No Comments

Brian Tyler Becomes McKesson’s New CEO

McKesson COO and President Brian Tyler succeeds John Hammergren as CEO.

NTT DATA Services Acquires State Healthcare Consulting Practice from Cognosante

NTT Data Services acquires Cognosante Consulting, which has supported IT projects for HHS departments and state agencies.

We’ve Got to Have More Time

Healthcare trade groups including the AMA, MGMA, and CHIME call for a 30-day extension of the comment period on the ONC’s 21st Century Cures Act proposal and the CMS interoperability rule.

Critical Alert Completes Acquisition of Sphere3

Former Sphere3 CEO Kourtney Govro becomes VP of Critical Alert’s business development and managing director of the its new Sphere3 Clinical Advisory Division.

HIStalk Interviews G. Cameron Deemer, President, DrFirst

April 1, 2019 Interviews 1 Comment

G. Cameron “Cam” Deemer is president of DrFirst of Rockville, MD.

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Tell me about yourself and the company.

I’ve been president of DrFirst for about 14 years. DrFirst is primarily a technology platform company working in the medication management space. To de-jargonize that, we provide core technologies such as electronic prescribing, controlled substance prescribing, and a lot of things around medication history and interoperability. Those are often included in EHR platforms, hospital systems, HIEs, and pharmacies. We have a pretty broad footprint across the industry.

What is the best source for an accurate medication list other than asking the patient or their family members directly?

I would say DrFirst, of course. [laughs] Seriously, the medication history lists have come a long way. There has been a core medication history list provided by Surescripts for many years. We take that list and add medications to it from sources that aren’t providing their med history to Surescripts.

Getting a complete list is one issue. The other is making sure that the list is in a format that a hospital can intake into their own system. We do considerably massaging of the feed to make sure it has the right data elements. We clear up any discrepancies, such as around drug descriptions versus the NDC numbers and things like that. Then we help hospitals be ready to intake information from outside.

The best source is really a hospital or a physician that is using a very strong industry feed. It’s continuing to get better all the time.

It has always seemed hard to get old medications off the list, which could be done either by asking the patient if they’re still taking it or checking their refill records. Is that still a problem?

One of the things that’s exciting right now is being able to involve the patient more in that discussion. Medications they are no longer taking are one thing, but probably the more relevant issue these days is that patients are deciding how to medicate themselves. For example, it’s difficult to get a good, complete list of nutritional supplements that a patient might be taking.

But the other issue is that if I prescribe you a drug and you have some kind of reaction to it, maybe you decide that you’ll only take half a pill instead of a whole pill. Or maybe you discontinue it for a few days, you feel better, then you take it again and you feel bad again, so you discontinue it. Knowing how you’re dosing yourself versus how the therapy was prescribed to you needs to be addressed. We’ve been working on that primarily through more mobile interaction with patients, helping them understand how the doctor views their medication records and giving them a chance to update those appropriately for the physician.

I’m interested in your Link app, in which the patient receives a message under their doctor’s name listing the medication that was ordered, where their prescription was sent, and how much money they will owe as their co-pay. It even allows them to schedule a pick-up time with the pharmacy. Does offering a patient-facing application give DrFirst a way to grow in a new way?

It does. You and I talked about two years ago when we were starting beta testing of Link. We went into full-blown production with it within the last several months and have sent it to millions and millions of patients.

The way it works is that we know you’ve been to your physician, so we will reach out to you and try to make sure that you don’t abandon your prescription. We try to deal with what’s on your mind at that time. How much is it going to cost? What am I taking this for again?

A survey we did recently found that nearly half of all consumers aren’t sure they can take the medicine the way they were directed to take it because they can’t remember. The physicians usually are in kind of a hurry and the patient’s not thinking because they’ve just been diagnosed with some issue. Imagine that you were just diagnosed with diabetes or with high blood pressure and you’re not sure what that means. You’re not sure how you’re going to tell your spouse about it. You’re worried about how it will affect you physically. You may not be listening that carefully while the doctor is running through how you’re supposed to take your medicine.

We try to fill those gaps by reminding the patient. These are the meds that were prescribed. Here’s the pharmacy that has your prescription. Here’s some information about that therapy to remind you of the things your doctor told you. If you’re worried about how much it’s going to cost, here is the co-pay amount. Here is a financial assistance program, or maybe a consumer discount card if you don’t have insurance, which a lot of people don’t these days, or maybe they’re in a high-deductible plan. We take that cognitive load off the patient of not being able to remember what to do, being afraid of what they might have to do, and worrying about it. We ease them into starting their therapy.

I’ve always felt less empowered with e-prescribing. Before, I had a piece of paper that I could carry around to shop prices, I could get the prescription filled whenever I wanted, and I could research the drug before going to the pharmacy. Now I’m barely out of the doctor’s office when Walgreens starts the robocalls telling me to come pick up my prescription. Does Link re-empower the patient?

That’s an excellent observation. I actually feel the same way when I get a text message from the pharmacy telling me to come pick up a prescription. I may not have even been thinking about that at all. It’s just all happening in the background somewhere.

Another element of that is the rise of patient portals. On the one hand, it’s positive that we’ve been getting federal pressure for patient portals to be available in every EHR system, every hospital system. But it’s another way of taking some control away from the patient. Their data gets scattered between many electronic systems. It’s hard for them to bring it all together in one place. It’s hard to even just remember how to get to your portal a lot of times.

By going after the patient with this mobile solution only when they need it, we are trying to empower the patient to have all of their information in one place so they don’t have to remember what to do in order to get their questions answered. That’s probably the key here. As things become more electronic, there’s no reason that the patient should have a miserable experience of trying to navigate those electronic pathways.

Is the prescriber notified if the patient uses Link and decides for whatever reason to not pick up their prescription?

Not today, but we will have that shortly. We are incorporating a secure messaging channel from the patient back to the physician.

This is a new concept. Historically, physicians haven’t communicated with patients through text messaging, secure text, for a number of reasons. But that recent survey I mentioned found that an enormous number of patients, like 90 percent, said they would rather receive a text message from their doctor than a phone call, being steered to a portal, or being contacted via any the other methods they would normally get. We’re trying to meet patients where they are and give them the tools to be able to communicate something back to their physician in a manner that’s efficient for both the patient and the doctor.

This is a brave new world of trying to address what we call the care triangle. Think of a triangle with the physician on the top, a pharmacy at one corner, a hospital at the other corner, and the patient in the middle. Everybody needs to interact with and talk to the patient. But also, everybody at the corners needs to communicate back and forth with each other. We’re using secure collaboration tools to let all of those entities talk to each other in a real grassroots way so that we don’t have enterprise boundaries any more, or divisions between the medical professionals and the patients they serve. Letting everyone have the tools to be able to talk back and forth.

We hope that will be an important next step in making sure that all of the people who are working on behalf of a patient can synchronize and coordinate their care and to allow the patient to understand what’s happening and to be a part of it.

It would be interesting to put the patient instead of the provider at the center, with each patient having their own Facebook-like page in which all those messages and the patient’s replies are collected in one place that the patient themselves controls. Is that possible?

That’s actually what it is today. From a provider’s point of view, when they’re in our secure collaboration tool, they’re seeing one thread for a patient. It’s like text messages, with topics bouncing all over in the thread. In the collaboration tool, it’s centered around this patient that the care team is working on. From the patient’s point of view, everything comes into one queue where they can see a consistent record of the communications they have had.

What is the impact of an app that targets the patient specifically?

Link is quite powerful. We’re seeing close to 25 percent improvement in prescription abandonment just through Link. But we know that some patients, and particularly those who care for patients, need a more persistent experience.

But we also know at the same time that patients don’t care as much about their health as we would like them to. They don’t consistently focus on it in a productive way, which is why we forget where our portals are. We’re not in them all the time checking on things and sending messages back and forth. It might be because people don’t want to be defined by their illness. It might be that it’s just too psychologically heavy to continually think about your illness. But we tend to be concerned in spurts when we’re ready to pay attention.

A key focus for DrFirst is reaching the patient only at those times that they really care. During the times when they have less concern, we are just being available if they need us. We aren’t trying to get their attention during those times. We think that most patient applications fail because they assume the patient will be interested enough to continually interact with the application. We’re trying to put ours together in a way that addresses actual patient needs when they are occurring without requiring a lot of other activity otherwise.

What’s being done with opioid prescribing?

With all the pressure for physicians to use EPCS, it’s now about efficiency. Physicians not only are required to order the prescriptions electronically, but they also have to check the PDMPs, the state controlled substance registries. That is such a burden.

I saw my family physician recently and his office gave me three pieces of paper when I walked in. The first one said, you need to acknowledge that we don’t write controlled substance prescriptions out of this office. They made me sign that. The second one said, if I do write you a controlled substance prescription, I’m only going to write a three-day supply, and then you have to come back and see me again and pay for another office visit. I signed that. Then the third one said, the state of Arizona requires me to check the PDMP and they won’t pay me to do that and neither will your insurance company, so you have to pay me $15 for every controlled substance prescription I write for you. I had to sign that.

That’s happening all over the country. Doctors are pulling back from prescribing opioids because they don’t want to check the PDMPs. It’s too onerous. We’re starting to create a crisis of pain as opposed to a crisis of overdose.

To alleviate that, we’ve been putting a lot of effort into making electronic connections to every available state PDMP and then bringing the information into the physician’s workflow. Instead of leaving your EHR, authenticating into another system, entering patient demographics, and then going back to your system and typing the information in — because typically you’re not allowed to download it, you have to retype it — we make it so that right in the process of writing the script the opioid history is just right there, with no effort required. This addresses what unintentionally has became the next issue of patients — their doctors being unwilling to care for their pain at all as a rebound to the epidemic in the form of “let’s just not write them.”

It has been gratifying to see how enthusiastic physicians have been about making it this intuitive. It ought to be this simple and we’re we’re making it work that way for them.

Do you have any final thoughts?

We’re entering a time when there is so much pressure on the EMR community to continue to build features into their EMRs. We’re starting to lose the connection to the patient. The next big opportunity is getting all this information that impacts patient care in front of the patient at a time when they are ready to accept it and in a format that they can put to practical use as part of their therapy.

Patients for too long have been treated like miniature doctors who are laser-focused on their care. People don’t really work like that. I’m excited about digging in at the grassroots level to provide solutions to the real problems patients have trying to initiate and maintain their therapies over time.

Curbside Consult with Dr. Jayne 4/1/19

April 1, 2019 Dr. Jayne No Comments

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It’s time for a trip through the reader mailbag. I apologize that I’m not able to respond to emails as often as I’d like, but sometimes it’s hard to manage not only a full-time job but my HIStalk gig and the volunteer work I do. I love hearing from readers and I feel like I’ve really gotten to know a handful of them even though we’ve never met or spoken. I’m always impressed by the thoughtful comments that people send my way.

Props to Epic’s MyChart team, who reached out to me in response to last week’s Curbside Consult detailing my experiences with Share Everywhere. They are concerned that it seems to not be working as designed and offered to troubleshoot it for me. I don’t want to risk de-anonymizing myself by revealing the institution, but they did have some good questions to help me further explain what I’m seeing so they can take a look. 

I also asked them to help me understand how patients are supposed to report issues since the hospital hasn’t seemed interested in the past at hearing about technical problems I was having with the billing side of MyChart. I would be interested in hearing from readers at other Big Health Systems on how they handle patient concerns about their patient-facing systems, whether Epic or not. It might make for a good post.

A reader sent some comments on my experiences with Share Everywhere vs. MyChart, further illustrating the issues with client-configurable features.

Like many tools made available by Epic, the healthcare organization makes choices and configuration decisions regarding MyChart, Care Everywhere, Share Everywhere, and Lucy. At our organization, problems, allergies, medications, test results and immunizations are all displayed with date information at the summary level as well as at the visit or encounter level. I had not looked at Share Everywhere for some time and was surprised that we do not display provider office notes in the Share Everywhere view. We do make office notes available to our patients, however. We need to explore whether this is an Epic limitation or a configuration option that we have not enabled. New functionality that we are almost ready to enable is sharing radiology images across the Care Everywhere network. Again, Epic provides the capability, we are responsible for configuring and enabling as is every other Epic customer that has chosen to participate in Care Everywhere. We also must choose to make incoming images available to our caregivers, just as other organization will need to decide if they choose to accept and make available images.

No props for the handful of emails I found in my box from people asking if I’m interested in guest posts from the people they represent or asking how they can contribute to HIStalk. It’s immediately obvious when I see those that they’ve never actually read the site or they would know about Readers Write.

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Props to the couple of people who reached out to wish me a happy Doctors Day. Although it’s celebrated on March 30 in the US, other days are used in other countries. For example, Iran commemorates it on Avicenna’s  birthday, at least according to Wikipedia. In the US, it recognizes the anniversary of the introduction of general anesthesia using ether in 1842. I’m truly glad we don’t have do bite-on sticks after a slug of whiskey and that we now have less-flammable options.

However, I’m giving negative props to the American Academy of Family Physicians, whose celebratory email offered a discount on AAFP products and conferences, but only for the day. Most physicians I know have AAFP communications routed to their work email addresses and it was a Saturday, so I wonder how many takers they had. I would think they’d have a better handle on how busy their members are and consider offering the discount for at least a couple of days to allow people to take advantage of it.

One of my favorite correspondents sent some thoughts on interoperability and mental health and substance abuse data. They also sent their comments around my mention of the Duke whistleblower settlement:

As to whistleblowing, I was much more idealistic in my youth and pointed out issues to people in authority at my institution that I thought were problematic (generally related to serious patient safety issues, occasionally compliance issues).  Suffice it to say, these minor attempts at whistleblowing never went well for me and never resulted in any significant changes either. I’ve been tempted to “drop a dime” on my hospital to Joint Commission or the department of health, but they always seem to eke through CMS visits with immediate jeopardy in the balance, so the likelihood of any action on a higher scale seems minimal.  It is clear that hospital and departmental leadership can be vindictive to people who throw shade on them despite touting a “just culture.” Without an airtight case, which is virtually impossible to get, whistleblowing seems like more trouble than it’s worth. For every person who gets a big cash payout for whistleblowing, I’m sure there are many more well-intentioned people who will struggle to find another job as a result of their efforts.  For these reasons I’m much more circumspect in my old age and focus on flying under the radar and not making waves.

I’ve had that experience as well, being branded as “frequently dissatisfied” in an evaluation by one member of my residency’s faculty because I used to bring suggestions for improving the program or making things better for the learning environment. I learned quickly that they didn’t see feedback as a gift and that any suggestion would be received as a criticism. Needless to say, when I was selected to be chief resident, my first order of business was to implement the majority of things I had been asking for since I was an intern. Rumor has it that the “New Intern Handbook” we created that year is still in circulation, providing information that no one tells you in medical school, such as how to pronounce a patient dead when you get that call in the middle of the night.

On the topic of EHRs being responsible for the downfall of the patient-physician relationship:

Not too long ago, our group surveyed members and only one person made any remarks about the computer and that was “the EMR sucks.” Everyone else mentioned low salaries, poor communication from leadership, deteriorations in workplace safety and increased staff injuries, excessive emphasis on RVUs, and lack of respect for clinicians by leadership. I really don’t believe EHRs are the root of all evil.

I didn’t have to worry about anonymizing the comment, since those are the same issues I heard at the last meeting I attended of my hospital’s emergency medicine attending physicians.

I’m going far into the wayback machine on this one, but I posted in February about my flashback on the Addressograph machine. Apparently extinct technology is a hot topic:

The addressograph brought back memories! One of my first tasks in healthcare was to write program for the machine that produced those cards. We reprinted those cards every other day for inpatients because the numbers and letters would wear out. Later when I was in management I worked to replace them with stickers. The ward clerks did not want to give up their addressograph machines!

Addressographs were definitely a lot of fun! (Though the smell wasn’t quite as good as freshly printed mimeograph,) They were also very practical in terms of quickly getting an index card with the key patient info at the top that could be used to keep signouts much more efficiently than our current electronic physician handoff page. A saved index card was also like gold when the patient bounced back, unlike the current physician handoff that gets deleted at discharge.

I had forgotten about those signout pages. For those of you who are not on the provider side, when the resident physicians leave for the day, they sign out to the on-call team, which is responsible for covering patients they may never have met. In the olden days, we would meet with the on-call resident before we left the hospital. We would pull those sheets from our white coat pockets and give a brief rundown on the patients we had been caring for. The sheets might have included med lists, labs, problem lists, and other tidbits of information that would help the on-call team know what to do if an issue came up with the patient. Some of us even got fancy and created templates for our sheets to ensure we wouldn’t forget important information. The size limitation forced you to be concise and only focus on the most important information, which is probably becoming a lost skill from the voluminous charting we have in the EHR.

Another reader waxed poetically about dial up modems:

I also found there was something satisfying about hearing the sounds that meant your modem had connected and the old acoustically coupled dialups (where your phone receiver went into the rubber connector) were very amazing at the time.  It definitely beat standing in line at the computer center with a giant stack of keypunched cards (praying that you didn’t drop them and have to put them back in the right sequence.)

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The “antique” technology that had the most mentions isn’t antique at all since it’s still in use at many hospitals — the beeper:

My favorite old technology has to be the old versions of beepers. When I was an intern, beepers just beeped. Nothing else. You called the paging operator and they gave you your message. These beepers had two advantages: you could cross your arms in a boring lecture and surreptitiously turn them off and back on again, which would make them beep. Then you could quickly escape to go outside to the hall phone and address your “page.”

The Motorola Adviser was my workhorse pager during residency, and according to one reader:

It has been granted eternal life. We still have them (and fax machines). Everyone has been saying for years that we should switch to cell phone “paging,” but there are cell phone dead zones and the beepers have much better coverage.

I’m closing up the mailbag for now. Keep those virtual cards and letters coming!

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Morning Headlines 4/1/19

March 31, 2019 Headlines No Comments

West Michigan doctor’s office hacked, doctors held for ransom

A two-doctor ENT practice in Michigan closes for good and its partners retire after they refuse to pay a hacker $6,500 to restore their ransomware-encrypted systems.

Queensland Health rejects call to pause electronic medical record rollout

Queensland Health officials reject the Australian Medical Association of Queensland’s calls to halt the rollout of the Cerner-powered IEMR, saying all of AMAQ’s issues with the software have been resolved or are in the process of being addressed.

UM Health Spinoff Fifth Eye Nabs $11 Million VC Round

Post-operative patient monitoring startup Fifth Eye raises $11 million in a Series A round.

Mount Sinai and Hasso Plattner Institute Launch New Institute for Digital Health

Mount Sinai Health System (NY) and the Hasso Plattner Institute will spend $15 million to develop an institute that will develop digital health products with real-time predictive and preventive capabilities.

University Healthcare System to invest $170 million in new medical record technology

University Health System (TX) will spend $170 million to implement Epic over a three-year period.

Monday Morning Update 4/1/19

March 31, 2019 News 6 Comments

Top News

A two-doctor ENT practice in Michigan closes for good and its partners retire after they refuse to pay a hacker $6,500 to restore their ransomware-encrypted systems.

Some of their patients worry about starting over at new practices that can’t get their previous records.

The partners decided not to pay because they had no guarantee that the hackers would restore their data or that they wouldn’t extort them further afterward. They also didn’t want to rebuild their practice from scratch.

The doctors apparently practiced within Swedish American’s Brookside Specialty Center. They declined a TV interview, saying the FBI is now involved.


Reader Comments

From Cyrus of Persia: “Re: [vendor name omitted]. Rumor is they’re for sale after raising $80 million but failing to keep up with their valuation. The co-founder left in December for VC-land, a high-profile client ripped and replaced because the product didn’t work, and none of the company’s sales have gone live.” Unverified, so I’ve omitted their name for now, but I welcome readers to comment.

From Mawkish: “Re: [vendor name omitted]. I heard they have abandoned their development efforts to create an enterprise behavioral health EHR/PM system for the community mental health center and larger mental health / substance abuse agency marketplace after three years of signing up customers who paid deposits with promises that they would be involved in product design, with the remainder not due until go-live. This removed those customers from the marketplace for legitimate solutions. At least the company is refunding the deposits after laying off 40 developers and returning  to their roots of selling EHR/PM to the small practice marketplace.” Unverified, so again I’ve left the name out until I can ask for a company response. I’m not a big fan of pre-announcing software since the only possible reason is to convince prospects to hold off buying an immediately available competing product, but then again, customers who fall for that rather obvious ploy probably would have found a way to screw up their selection and implementation anyway. Still, it’s good news that the company is providing refunds, which isn’t a given in the rough-and-tumble world of health IT.

From Irritable Cereal Bowl: “Re: opioid lawsuits. Good for the states that are suing McKesson and other drug distributors who shipped enormous quantities of opiates that they had to know were being misused.” I disagree – every dose that was sent to those states was dispensed by a state-licensed pharmacy, on the order of a state-licensed prescriber, and under the jurisdiction of the DEA, which tracks every dose of opiates that is shipped to a pharmacy. Clearly those states were asleep at the wheel in expecting the deep-pockets drug wholesalers to provide oversight of legal but inappropriate drug use. If I were McKesson, I would sue the boards of pharmacy and medicine in those states, and perhaps their attorneys general and law enforcement agencies, for failing to do their jobs in protecting the public. Maybe individual prescribers and pharmacies as well since every single transaction is readily available. Drug distributors are required to report unusual usage patterns to the DEA and they failed to do that (not that the DEA isn’t already inspecting pharmacies and prescribers), but blaming them for the immoral and probably illegal behavior of prescribers and dispensers is clearly deflecting blame long after the fact. You can’t tell me that a tiny town from which flowed millions of doses of opiates that were being dispensed to patients who lined up around the pharmacy’s block every single day was too subtle of a problem for their police departments to detect.


HIStalk Announcements and Requests

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Most poll respondents say EHR design is not a major cause of physician burnout.

New poll to your right or here: How much impact will AI have on patient satisfaction, outcomes, and cost in the next five years? Click  the poll’s “comments” link after voting to explain, especially if you punt with the safe “some” option.

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About 20 percent of poll respondents call their PCP by their first names instead of “Doctor  XXX.” Some agree with me that the PCP is working for them and therefore there’s no need for academic formality, at least once the relationship has been established, while others prefer that both patient and doctor use formal titles (Mr. Ms., etc.) One respondent says they call anyone who has earned a doctorate as “Doc,” but that’s a slippery slope when you separate a medical practice degree (MD/DO) from other medically related doctorates (PhD, DNP for nurses, PharmD for pharmacists, etc.). That doesn’t even consider saying “No fries, thanks, Dr. Jones” in answering the drive-through query of your philosophy PhD. Or, what to do when both patient and doctor have earned doctorates in any academic discipline — do they call each other “Doctor” in the exam room? Or if the poetry PhD patient is called “Mr.” or “Ms.” by their PCP, do they correct them with academic haughtiness? We’ve polluted the etymologic waters quite a bit by assuming holders of doctorates of medicine, dentistry, chiropractic, podiatry, and veterinary medicine should get an extra dose of respect beyond those who hold every other doctorate. My experience is those who are most insecure about their doctorates (usually DO’s and DC’s) are the most likely to insist on being called “doctor.”


Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre for information.


People

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Medical imaging software vendor Novarad names Paul Jensen (Microsoft) as president.

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Julie Flaschenreim (Fairview Health Services) joins Hennepin Healthcare as CIO.


Other

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I really dislike the headline of this article from HIMSS, and not just because they misspelled “ZIP” as “Zip,” used unrelated stock photography, and pitched their recent acquisition Healthbox. ZIP codes do not “define” health outcomes, although situations that are common in the economic demographics of those who reside in a given location certainly do. As the headline fails to indicate, people who live in South St. Louis would not get instantly healthier by moving to Palo Alto since there’s no guarantee their social determinants of health would change along with the relocation to an area with a closer Whole Foods, or that their healthcare journey isn’t already set in stone to some degree. There’s also the meme-bursting phenomenon of a single ZIP code covering wildly disparate income ranges, such as parts of San Francisco and Atlanta in which multi-million dollar apartments are flanked by the homeless and working poor (if you like digging deeper, check out census department’s Gini Index measure of income concentration.)  I agree with the remainder of the article, just not the simplistic concept that knowing someone’s address is all you need to understand their health.

Former Microsoft CEO Steve Ballmer gauges return on investment in healthcare by looking at the average age of death, which he says has increased only 0.6 years in the past 20 even as healthcare spending rose dramatically. He says employers should look at their prices and costs, such as whether end-of-life spending really increases overall value, but adds that a non-transparent system of healthcare management and delivery makes such analysis nearly impossible.


Sponsor Updates

  • Meditech produces a new podcast, “Clinical efficiency and the journey to Expanse.”
  • Mobile Heartbeat and Clinical Computer Systems, developer of the Obix perinatal data system, will exhibit at the BGHIMSS & INHIMSS Annual Spring Conference April 4-5 in Florence, IN.
  • NextGate will exhibit at the CCI Symposium April 4-6 in Greenville, SC.
  • Netsmart will exhibit at the LeadingAge IL Annual Meeting April 2-4 in Schaumburg, IL.
  • Nordic will present at the Quality of Care Outcomes Research Scientific Sessions April 5-6 in Arlington, VA.
  • Medhost congratulates its 19 hospital customers that earned CMS’s five-star quality rating.
  • Practice Velocity, T-System, Wellsoft will exhibit at the 2019 UCA Urgent Care Convention & Expo April 7-10 in West Palm Beach, FL.
  • Cooper University Health Care (NJ) expands its use of Access Passport’s electronic forms solution to oncology and surgical services.
  • The Oliver Wyman Health Podcast features Qventus CEO Mudit Garg.
  • SymphonyRM will sponsor the Women in Data Science Pittsburgh @CMU event April 4.
  • Visage Imaging will exhibit at the 2019 SBI/ACR Breast Imaging Symposium April 4-6 in Hollywood, FL.
  • Vocera will exhibit at the Beryl Institute Patient Experience Conference April 3 in Dallas.

Blog Posts


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Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
Get HIStalk updates. Send news or rumors.
Contact us.

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Morning Headlines 3/29/19

March 28, 2019 Headlines No Comments

Teladoc Health Launches Telemedicine Service in Canada, Expanding Portfolio of Available Healthcare Solutions

Teladoc Health will launch its services in Canada.

FDA Chief Calls For Release Of All Data Tracking Problems With Medical Devices

Departing FDA Commissioner Scott Gottlieb, MD says the agency will make good on its promise to release thousands of patient safety reports.

Hackers attempt to access Northampton General Hospital computers 240 times a day

Officials at Northampton General Hospital in England say they are fending off 240 data-breach attempts a day, and worry that the problem will only escalate as NHS facilities become paperless.

News 3/29/19

March 28, 2019 News No Comments

Top News

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Medicare Advantage payer Clover Health lays off 140 employees as part of a restructuring that will eventually add more staffers with health insurance and clinical backgrounds. The company, which has touted its predictive analytics capabilities since launching in 2012, has raised nearly $1 billion. It operates in seven states including Tennessee, where it plans to open an office in Nashville.


Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre for information.


Acquisitions, Funding, Business, and Stock

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Healthcare CRM vendor SymphonyRM expands to Pennsylvania with the opening of its Health AI Center of Excellence in Pittsburgh.

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Teladoc Health shares rise on the news it will launch its services in Canada.

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Digital prescription startup Xealth raises $11 million in a funding round led by McKesson Ventures, Novartis, Philips, and ResMed. The company has developed software that enables providers to prescribe apps, devices, and services from their EHRs. It has raised nearly $20 million since launching out of Providence St. Joseph Health (WA) in 2017.


People

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Max Hanner (HCTec) joins Pivot Point Consulting as VP of business development.

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Clarify Health names Imran Qureshi (Health Catalyst) chief data science officer.

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Medication tracking company Kit Check promotes Doug Zurawski to SVP of clinical strategy and MaryAnn Jensen to VP of strategic marketing; and names Amy Langan (Fresenius Kabi) CMO and Eric Bolling (Cardinal Health) EVP. I interviewed Kit Check co-founder and CEO Kevin MacDonald last December.


Sales

  • OSF HealthCare (IL) will use Redox’s interface capabilities to connect its clinical systems with third-party applications.

Announcements and Implementations

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Sutter Health (CA) will pilot an AI-enabled digital voice assistant developed by Suki in primary care, dermatology, and orthopedics.

The multi-state Lewis and Clark Information Exchange adds PatientPing’s real-time care alerts and patient utilization details to its HIE services.

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Inspira Health (NJ) implements Intraprise Health’s wayfinding technology at its three hospitals.

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United Regional Health Care (TX) will go live on Epic next week.

Thirty-five bed Lackey Memorial Hospital (MS) rolls out Evident’s Thrive EHR.


Government and Politics

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Departing FDA Commissioner Scott Gottlieb, MD tweets that the agency will make good on its promise to release thousands of patient safety reports after Kaiser Health News found manufacturers have for years been taking advantage of a secretive, alternate summary reporting program that kept patient safety impacts hidden from public view.

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The Australian Digital Health Agency will offer qualifying vendors $30,000 to integrate interoperability standards into their clinical software so that providers using different systems can share health information. The incentive is part of the country’s larger effort to do away with paper-based communication and faxes by 2022.


Privacy and Security

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Officials at Northampton General Hospital in England say they are fending off at least 240 data-breach attempts a day, and worry that the problem will only escalate as NHS facilities become paperless. They list phishing email campaigns, unpatched software, and a lack of cybersecurity expertise as their biggest concerns.

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CynergisTek adds around-the-clock monitoring to its line of cybersecurity, privacy, and compliance services for healthcare.


Other

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Prosecutors say the former Vanderbilt University Medical Center nurse on trial in Tennessee for a medical injection error made at least 10 mistakes that led to the death of a patient, many in line with findings from a CMS investigation. The nurse has pled not guilty despite admitting she made a mistake. Errors included:

  • Being distracted by an unrelated conversation with another staff member when she grabbed the wrong drug from the dispensing cabinet.
  • Overriding a cabinet safeguard even though it wasn’t an emergency situation and she hadn’t checked with the hospital pharmacy.
  • Ignoring four warnings or pop-ups about the medication being withdrawn.
  • Not noticing the drug in hand was a powder instead of a liquid.
  • Overlooking a boldfaced warning immediately before injecting the drug.

Sponsor Updates

  • Elsevier Clinical Solutions will exhibit at the Beryl Institute Patient Experience Conference April 3-5 in Dallas.
  • EClinicalWorks and Imprivata will exhibit at the AMGA 2019 Annual Conference March 28-30 in National Harbor, MD.
  • Ensocare will exhibit at the American Case Management Association Conference April 13-17 in Seattle.
  • FormFast and Iatric Systems will exhibit at the Health Connect Partners Spring 2019 conference April 1-3 in Anaheim, CA.
  • Hayes Management Consulting welcomes Nancy-Linn Swain as director of training and engagement, and Bo Zhang as senior financial analyst.
  • HGP advises Clearwave in its significant growth investment from Frontier Capital.
  • Healthwise will exhibit at the EClinicalWorks Enterprise and Urgent Care Summit April 1-3 in Fort Lauderdale, FL.
  • InterSystems releases the latest update of its IRIS data platform featuring enhanced performance and scalability, cloud support, integration capabilities; and enhanced support for Java, Python, and C# development.
  • Intelligent Medical Objects will exhibit at the AORN Global Surgical Conference & Expo April 6-10 in Nashville.
  • Spok publishes “The Non-CIO’s Guide to Interoperability.”
  • The local paper covers Nordic’s move to new, expanded office space.
  • With help from Pivot Point Consulting, Acumen Physician Solutions adds legacy data archiving technology powered by SMART on FHIR from Trinisys to its Acumen 2.0 powered by Epic software for nephrology practices.
  • Glytec announces that its Glucommander Outpatient insulin dosing management software is now capable of receiving data from DarioHealth’s smart glucose meter.
  • Lightbeam Health Solutions and AMGA have developed a collaborative to help providers maximize the effectiveness of Medicare Advantage and other value-based contracts.
  • Health Catalyst receives top marks for healthcare analytics in Chilmark Research’s latest report.
  • Cooper University Health Care (NJ) expands its use of Access Passport e-forms to oncology and surgical services.
  • Vail Health (CO) improves care team communication with Spok’s Care Connect solution, and continues to expand its use of the software.
  • The Chartis Group hires Beth Price (North Highland) as director of its oncology solutions practice.

Blog Posts


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Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
Get HIStalk updates. Send news or rumors.
Contact us.

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EPtalk by Dr. Jayne 3/28/19

March 28, 2019 Dr. Jayne No Comments

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For your entertainment pleasure, ONC has released the public comment submissions received on the “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs” document. More than 200 comments were received, with the majority being in the areas of HIT usability and clinical documentation. My personal favorites:

  • I believe that part of the reason that only 30 PERCENT of physicians practice independently and that most are now employed is the push for EMR usage and all the administrative burdens associated with it. Add the “click the button” game and more will leave. (Michael Richter MD)
  • Thank you for finally throwing a life to all physicians! One of the biggest blunders made when HER’s (sic) were approved was not mandating interoperability. This single mistake is costing the Health Care System in the United States billions of dollars every month. Please act now on this blatant oversight / mistake. The time to correct it is overdue. Also, it is time to spend some money on plane tickets to visit countries like Italy, France, Germany and Japan to name just a few, and learn how they have better outcomes at half the price we pay. Being ranked 37th in the world is not good. Our infant death mortality statistics and ranking is pathetic! (Joseph S. Testa MD)
  • i have not seen any reliable study that has concluded that the adoption of electronic health records in doctors’ private offices has led to improved health care or reduced costs of health care. As a frequent recipient of electronic health care records, I have found this mode of information retrieval is more often an impediment than an asset; as vital data is never highlighted and is usually either omitted or buried within a large file of irrelevant data. Within the hospital setting, I have found electronic health records to be a life threatening obstacle to patient care. When a computer monitor takes the place of a simple vital sign monitor, I’ve had to wait for as long as ten minutes for nurses to acquire the simplest of vital sign measurements. In my community, had the local hospital been motivated to spend the same money on health care that was wasted on an overly complex and inefficient computer system, our town would be enjoying the finest health care at no cost whatsoever. Instead, tens of millions of dollars leave the community to pay for a large computer service corporation. (Michael Steiner MD)
  • Our staff and physicians have nicknamed our system The PDS (practice-destroying software). (Howard Green MD)
  • The cost and complexity of EMR system maintenance and exponentially increasing regulatory requirements force doctors into large groups where we are relegated to data entry and coding tasks rather than the patient care we trained for. We are clearly expendable… End direct to consumer advertising for medications and durable medical equipment. (The author didn’t include his identifying information in his document, so once I downloaded it, I had no idea which submission it was.)
  • EHRs have been created for effective billing tools. CMS contractors are NOT following the CPT coding guidelines agreed to by all other stakeholders creating tremendous chaos and dissatisfaction. So adding EXTRA work to a process that was already stressed expecting a different result is insane. So payments should include costs for scribes to input the data in order to reduce physician burn out as we have aging population and will need MORE physicians to care for them. AI will not do it. (Another one that became de-identified when I downloaded it.)
  • The EMR was not designed with the end user in mind. It was designed with government and insurers in mind. It was never designed to help improve “quality” but rather make it easy to mine data and make insurance companies look good. I have opted not to participate in obtaining such a system because there is no compelling reason to do so. (see above) If you want physician buy in, you would have to scrap the current systems and start with the physician in mind. You would need to make the physicians job easier, not harder. You would have to be honest about the motivation to pursue an EMR. It should be made optional, and let it be bought on its own merits. If it has no merit; it won’t be bought. Remember that physicians are not stupid. Any attempt to market an EMR with hidden agendas will be discovered, and the reception lukewarm at best. Good luck. (Also de-identified on download – learn to sign your documents, folks!)
  • In healthcare, focus not on cure. but care. Ailing patients need care and it can even be provided by 3rd, 4th, 5th, or even any one person outside the family. Exceptional cases are there that at times like Tom Hanks in Cast Away was being motivated by a basketball which he perceives as a man talking to but its rare and it needs a healthy young man to do so but A Patient is a Patient. (Anonymized by download.)
  • However, the draft Strategy does not appear to recognize the investment that providers must make to train staff, procure and implement new systems, migrate and secure data, and respond to patient requests for assistance with healthcare data. For example, for the past several years my PCP requires an annual fee of $150 to help offset the cost of compliance with insurer and regulator IT standards. We just received a letter notifying us that his annual fee will raise to $1,800.00 per patient in 2019. My family of six cannot afford to spend $10,800 to be his patients. Neither can my elderly family members who were patients of the same PCP but who now struggle to find local providers who accept Medicare patients. HHS can begin to address these issues with a recognition of the costs and challenges faced by providers– and ultimately their patients. For example, the CMS fee schedules should be revised to reflect the costs of training, IT infrastructure maintenance, and patient educaton. The cost of annual IT Security training should included as directly attributable to the cost of care. (Martin O’Connor)

Most of the vendor submissions were lengthy, but I commend Epic for their two-page submission that calls out two key elements, one of which is the fact that “the electronic patient access timelines for Medicaid Promoting Interoperability are not aligned with Medicare Promoting Interoperability or MIPS, causing additional complexity for provider organizations and software developers, despite previous indications that the programs are intended to be aligned.” Whoops!

Healthfinch included the adorable Charlie on their submission as they championed the need for ONC to include delegation of routine tasks into strategic goals. They also ask for recommendations that state boards “address inconsistent and unclear “scope of practice” guidelines.” Can I have an amen from the congregation?

Intelligent Medical Objects (IMO) sent a very organized submission with a table of contents. The fact that they cited the original text then followed with their comments for each point they were making helped tremendously compared to other submissions. I was also interested to learn about an organization called the “Partnership to Amend 42 CFR Part 2” whose goal is to align various privacy rules to allow appropriate sharing of health information around substance use disorders.

One community hospital quality coordinator sent a submission that had at least seven fonts in it, which forced me to stop reading since it felt like a ransom note. I was surprised by the number of typos and grammar errors in some of the submissions, as if spelling and grammar checks weren’t run. It’s hard to take comments from a Top 3 EHR vendor seriously when the author hasn’t edited properly for its vs. it’s. Another submission was clearly written in Notepad, which is always entertaining for us IT folks.

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The only other exciting conversation this week was around the Duke University whistleblower settlement. Lung researchers were caught faking data for inclusion in grant applications to the National Institutes of Health, resulting in a $112.5 million False Claims Act settlement. The whistleblower is a former staffer in the department. He’ll receive 30 percent of the settlement, which is a good amount since his career as a research biologist is likely to be over. The US government will receive the balance. There was a fair amount of misconduct in the involved labs, with the need for retraction of 17 scientific articles to date as lab technicians either falsified data to document a desired result or sometimes failed to even conduct experiments where data was recorded.

Would you ever risk it all to be a whistleblower? How serious would the situation have to be? Leave a comment or email me.

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Email Dr. Jayne.

Morning Headlines 3/28/19

March 27, 2019 Headlines No Comments

Artificial Intelligence (AI) Health Outcomes Challenge

CMS announces the AI Health Outcomes Challenge, which will award up to $1.65 million to winners who develop AI-powered technologies that can predict unplanned hospital and SNF admissions, and adverse events.

Health care leaders back Xealth with Series A funding to digitally enable patient care

Digital prescription startup Xealth raises $11 million in a funding round led by McKesson Ventures, Novartis, Philips, and ResMed.

Sutter Health, Suki Introduce Digital Voice Assistant to Support Patient Care

Sutter Health (CA) will pilot an AI-enabled digital voice assistant developed by Suki in primary care, dermatology, and orthopedics.

Centene to Buy WellCare in $17.3 Billion Health-Care Deal

Public and private payer Centene acquires WellCare Health Plans for $17 billion.

Alphabet-backed Clover Health is cutting tech jobs after realizing it needs more health-care experts

Medicare Advantage payer Clover Health lays off 140 employees as part of a restructuring that will help it focus more on healthcare rather than software expertise. 

Book Review: Deep Medicine

March 27, 2019 Book Review 5 Comments

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Eric Topol is one of the highest-value of the few people I follow on Twitter. He consumes information voraciously and summarizes it well without talking down to his audience. He loves technology, hates EHRs, and weighs in on the practice of medicine even though I suspect his practice isn’t very much like that of the typical doctor or even the typical cardiologist. He is quick to point out those seemingly great ideas that have had zero real-world validation in a healthcare setting. He also holds researchers accountable for proving improvement in outcomes – just making a lab value move in a seemingly good way doesn’t cut it with ET.

I have mixed feelings about this book. Topol provides an exhaustive (and sometimes exhausting) review of all the work that’s being done with artificial intelligence in healthcare. Trust me, it’s a lot. The downside is that this book was nearly obsolete the moment the first copies rolled of the presses, meaning I had better get return on investment for my $20.69 quickly.

“Deep Medicine” is a firehose of who’s doing what with AI. By nature, a lot of that work is early-stage, experimental, and unlikely to see front-line use for a long time. Most of all, we have no idea of how it will integrate with the US healthcare industry (and make no mistake, it’s an industry). We’re not really that much different than other industries no matter what we would like to believe. 

I found the book somewhat of a chore to read. It has some personal stories, a bit about the history of medicine, background about companies, and of course who’s working on healthcare AI. I didn’t find it conclusive, but then again it really can’t be so early on.

Will AI Really Make Healthcare Human Again?

The subtitle “How artificial intelligence can make healthcare human again” sounds good and probably draws readers who are less interested in the nuts and bolts of AI. But to me, the book fails to deliver a convincing reason that Topol thinks that will actually happen.

I didn’t gain any confidence that healthcare will be even a little bit more human just because AI might save clinician time. If “making healthcare human again” was a business priority, we would have done it already, AI or not.

Topol expresses hope that doctors who are “given the gift of time” will be allowed to use that time to practice medicine the way they really want, to get personal with patients and to focus on their stories. That ignores the fact that most doctors these days are assembly line workers paid to treat ‘em and street ‘em in whatever way maximizes billing. It’s questionable whether the gift of time also offers the gift of higher income, and safe bets are always to assume that people do whatever it is that rewards them financially.

The other issue is that given Topol’s rigor in demanding that outcomes be proven, we don’t know that spending more time with patients in “deep medicine” actually improves outcomes. We don’t even know that patients want such attention. They seem happy with the urgent care model of dropping by with a problem and leaving with a prescription. AI could amplify the impersonal nature of those interactions, pushing patients to be triaged by chatbots or kiosk-based questionnaires. We don’t know whether that would make overall outcomes and quality of life issues better or worse.

I don’t recall any industry where the goal of automating the factories was to make workers happier or more self-actualized. Mostly it’s a reason to hire fewer of them or to restructure their work into something else that’s profitable. Assuming that healthcare is different is dangerously naive.

AI Hasn’t Been Tested on Humans

This is the most important reminder of the book. The AI work being done is interesting, but unproven. What works in a lab doesn’t necessarily work in an exam room. What works in analyzing heaps of data doesn’t necessary translate well to the frailties and idiosyncrasies of humans in their time of medical need.

It’s an easy leap to become overly exuberant when reading articles claiming that AI reads images better than radiologists, that somebody’s AI system passed a medical board exam, or that IBM Watson Health is smarter than an individual clinician. None of this has been studied and proven effective in the real world. Maybe it could improve outcomes or reduce cost,  but that’s just conjecture. A lot of those systems were rigged to do one thing, like Watson winning at “Jeopardy” only because it memorized Wikpedia, which is were the show’s staffers get most of the questions.

AI Is Good at Recognizing Patterns

Topol says properly trained AI can recognize patterns better than humans. Medical work that involves pattern recognition – diagnostic radiology and some aspects of dermatology and pathology – could perhaps be performed better by machines, leaving those doctors with time to perform other value-added services (if they can find them and if someone is willing to pay for them).

How Doctors Think

Topol has interesting thoughts on the Choosing Wisely initiative to get doctors to make better-informed decisions. He says it was a noble effort to get medical societies to define low-value tests and procedures, yet they are being ordered just as often even now. He gives these reasons:

  • Doctors overestimate the benefit of what they do
  • No mechanism exists to educate them
  • Compliance can’t be measured
  • No reward is offered for complying
  • Doctors think it’s OK to perform questionably useful surgeries as long as they aren’t likely to be harmful

The book says that doctors are burned out by EHRs that contain inaccurate information and don’t share information. He gives those doctors a pass in simply blaming EHR vendors rather than those who select, implement, and use EHRs, often with the specific goal of not sharing information and not being willing to correct mistakes, especially those the patient could easily identify.

I’ll be honest in saying that I don’t trust the EHR commentary offered by authors like Topol and Bob Wachter, MD. They are often impatient in demanding an easy answer, like making EHRs as easy to use as Facebook, ignoring the fact that EHRs are designed to meet the requirements of our screwed-up health system.

I do like this idea from Topol – get the patient’s consent to make an audio recording of their visit, have it transcribed, and then turn that into an office note that doctor and patient review together. Key point – auto-delete the recording in 24 hours to minimize malpractice concerns.

Topol says doctors diagnose by reacting to a few patient descriptions and use internalized rules and experience to arrive at a conclusion. Their diagnostic accuracy rate is nearly perfect if they figure it out within five minutes, but it drops to 25 percent if they have to think longer. Topol also makes this point, which seems to conflict with the theme of the book – diagnostic accuracy doesn’t improve when doctors slow down and think more deeply. Clinicians who were “completely certain” about their diagnosis were wrong 40 percent of the time, based on an autopsy’s cause of death.

The #1 reason a diagnosis results in a malpractice lawsuit is that the doctor didn’t consider the diagnosis that was eventually found to be correct. Doctors say they could improve given better chart documentation.

The challenge for doctors is that they see a small number of patients, often of specific demographic composition. Personal experience can’t stack up to analyzing large patient data sets. This is an important point. Doctors don’t consistently incorporate evidence into their practice. They also can’t see their own deficiencies.

The assumption made here is that lack of accurate diagnosis is a big problem and AI can improve it. I’m not so sure from a public health perspective that it’s the most important problem to solve, although if AI can plow through the patient’s record, the literature, and data about similar patients to improve diagnostic accuracy under the doctor’s supervision, then that’s certainly a win.

Medicine versus Self-Driving Cars

I liked Topol’s comparison of self-driving cars to medicine. The steps are:

  • Level 1 – driver assist, such as warnings to stay in the lane
  • Level 2 – partial automation, such as automatic speed and steering control
  • Level 3 – conditional automation, where the car drives itself but with human backup
  • Level 4 – high automation, where human backup is not required, but it works only in limited circumstances
  • Level 5 – full automation, where the car drives itself in all circumstances with no human involvement

Topol doesn’t expect medicine to get past Level 3. The clinician will always be personally involved to some degree.

Where AI Could Change Physician Roles

  • To initially read radiology images and classify them as normal or abnormal, which given the large number of imaging studies, would save time and allow radiologists to change their role from being “the reader of scans.”
  • To analyze surgical, cryopathology, and possibly dermatology images, where conformity across pathologists is lacking and error rates are high. The demand for “microscopists” should decrease.

In this regard, Topol suggests combining radiology and pathology into a single discipline of “information specialists” instead of “pattern recognizers.” That’s an interesting thought, although again tinkering with the lucrative incomes of doctors who are backed by politically astute societies usually doesn’t work.

The Economic Disparity Question

My overriding feeling in reading this book is that like much of healthcare, the benefits of AI won’t be spread evenly. You have the challenge of making sure that AI is trained given a broad set of demographics to avoid bias based on location, race, economic status, etc. but those people are already underrepresented in the healthcare system. AI can’t fix that.

AI could also be like self-monitoring tools such as the IPhone’s arrhythmia detection. Not everyone can afford an IPhone, is motivated to use it for self-monitoring, or has a clinician on standby to respond to the hypervigilant monitoring of the economically well off. On the other hand, we don’t have the research to know if those tools have any effect on outcomes or cost anyway. They sound inherently good, but so does robotic surgery, which Topol notes has done nothing to improve key outcomes.

My Conclusions

This is a fairly interesting book, assuming you like deep literature and news searches summarized loosely into a sometimes unconvincing narrative about AI in healthcare. Topol doesn’t follow the Silicon Valley mantra that AI will eliminate jobs, but instead lays out ways it could help rather than replace clinicians. That’s a compelling but simplistic view of how our healthcare system works.

The underlying assumptions are far from certain. We’re a profit-driven healthcare system, and attempts to wrest that profit back in the form of reduced costs rarely work. We also don’t know what patients want or what really moves the outcomes needle, so just throwing AI at interesting healthcare problems isn’t necessarily a huge step forward.

There’s also the question of who’s willing to pay for all this technology, which is being developed by startups and tech giants that expect hockey stick growth and endless profits. What they want may be directly at odds with what patients want.

Also in play is whether Eric Topol the exuberant futurist can represent the average frontline clinician whose day looks a lot different than Topol’s. It’s nice that he has the time and resources to write a book about AI and paint a picture of medicine that incorporates it, but I’m not so sure his worldview is accurate for the industry, especially the business aspects of it. He’s made himself an expert in this narrow AI niche that may or may not make him the best person to assess its use. People with hammers are always looking for nails.

We already have a lot of problems to fix. We’re probably not choosing medical school classes optimally or training doctors the right way. We are certainly not compensating them for doing the right things, and a fee-for-service system encourages practicing medicine that is clinically unsound but financially desirable. We don’t really know what patients want, or how they see the role of a PCP (if at all). We have ample evidence already and much of it isn’t being used on the front lines to make clinical decisions.

In short, while judiciously applied AI might provide some modest diagnostic and efficiency gains, I remain unconvinced that it will transform a healthcare system that desperately needs transforming.

Morning Headlines 3/27/19

March 26, 2019 Headlines No Comments

The end for Obamacare? Trump administration says it will ask a court to throw out entire health law

The Justice Department won’t dispute a federal court’s decision that the Affordable Care Act is unconstitutional and should therefore be eliminated in its entirety.

Philips expands its radiology solutions offering with advanced teleradiology services

Philips acquires teleradiology practice Direct Radiology, whose 70 radiologists provide services to 300 hospitals, imaging centers, and practices.

‘Desperate’ risk delayed electronic medical record, meeting minutes show

Australia’s Queensland Health was so desperate to prove the financial viability of its Cerner-powered IEMR that it planned to go live at Princess Alexandra Hospital in mid-2015 even though the project was in “cannot meet objectives” status.

Alexander Says New HHS Rules Should Improve Electronic Health Records To Give Patients Better Outcomes, Better Experiences At A Lower Cost

HELP committee chairman Lamar Alexander (R-TN) says HHS’s proposed interoperability rules will provide a definition of information blocking, require insurers to give patients copies of their data, mandate that EHRs support API access, and require hospitals to send ADT notifications to a patient’s doctors.

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