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News 7/15/22

July 14, 2022 News 1 Comment

Top News

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A JAMA viewpoint article by informatics leaders Kevin Johnson, MD, MS and William Stead, MD calls for expanding use of the SAFER guides to align health systems and EHR vendors in improving safety and usability, but also to develop a similar set of SMARTER guides to protect the cognitive attention of clinicians.

Broad topics include the use of collaborative documentation, designing workflows to minimize interruption, and aligning decision support to role and task.

The authors summarize:

The term electronic health record is a misnomer. The EHR is a complex sociotechnical infrastructure for automating clinical and administrative workflows within a healthcare facility or system. It is not designed primarily to capture and present a patient’s record as efficiently and effectively as practical. It is not an additive technology, such as a new imaging modality, that works within established practice workflows. Connecting EHRs to other health system technology requires complicated interfaces; connections among health systems require even more work. Second, the EHR has many stakeholders … in the US, requirements for reimbursement, regulatory compliance, and administrative workflow automation often take precedence over clinical efficiency and effectiveness … clinical teams are challenged by repetitive documentation, alert fatigue, increased workarounds, and decreased data quality.


HIStalk Announcements and Requests

My infrequent health system encounters give me little patient exposure Epic’s MyChart, but my recent “is this COVID or something else” visit to an academic medical center’s urgent care clinic showed me how far use of MyChart has progressed. The urgent care provider notes and billing information were posted quickly, my meds list is correct since she reconciled it during that visit, appointment scheduling looks easy even though I didn’t use it, messaging is handy, and record-sharing appears easy with downloading or sending records or enabling Share Everywhere. MyChart is one of few health-related apps I’ve used that not only provides immediate value, but is just as slick and functional as anything I’ve used outside of healthcare and depth of its capabilities, which probably varies by customer site, is impressive.


Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre to present your own.


Acquisitions, Funding, Business, and Stock

EHR consulting firm Healthcare Performance Group acquires competitor Health Data Specialists.

EHR and developer tools vendor Canvas Medical raises $24 million in a Series B funding round.

Healthcare Triangle closes a $6.5 million private placement.


Sales

  • Northwell Health chooses Google Cloud as its preferred cloud platform and says it will use the platform’s AI/ML capabilities to implement clinician decision-making support.
  • Infectious disease laboratory testing vendor HealthTrackRx will implement Shadowbox to connect its lab systems to customer EHRs.

People

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Xealth hires Joe Sedlak, RN, MBA (Health Recovery Solutions) as SVP of sales and Laurance Stuntz (Massachusetts EHealth Institute) as SVP of customer success.


Announcements and Implementations

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A study involving GetWell’s remote patient monitoring technology finds that its use by COVID-19 patients resulted in lower hospitalization rates, ICU use, and length of stay.

Dubai’s Medcare Women & Children Hospital goes live on InterSystems TrakCare.

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CHOP genomics researchers develop a phenotype algorithm that analyzes EHR information and biobanking data to identify patients who have ADHD alone versus ADHD with comorbid conditions.

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Meditech announces Meditech Live, a customer leadership conference that will be held in Foxborough, MA September 20-22.


Government and Politics

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FDA Commissioner Robert Califf, MD says that US medical product evidence generation is “mediocre” once medical product development progresses beyond the early phase. He says that “everyone in the United States has an electronic health record packed full of data that could be used to do studies very inexpensively.” He cites the astonishment expressed by some that FDA’s follow-up study on questionably approved Alzheimer’s drug Aduhelm would take nine years, saying that the system should be able to quickly generate solid evidence to support post-market studies.

AMIA and the American College of Medical Informatics call for new privacy regulations following the Roe v. Wade decision that would protect digital health data from subpoena and areas that fall outside of HIPAA such as apps, websites, search behavior, and consumer location data.


Other

A report concludes that England will need to create 40,000 more hospital beds by 2030 to be able to deliver pre-pandemic standards of care to an aging population. Per-person hospital capacity has halved in the past 30 years, with high bed occupancy and overtaxed ambulance and ED services. Report publisher Health Foundation also calls for remote patient monitoring and boosting social and community care options to allow timely hospital discharges.

MIT researchers create a publicly available set of 2,000 clinical questions whose answers physicians are most commonly seeking when using their EHR, hoping to reduce the time doctors interact with the EHR user interface by extracting the answers automatically. Initial results were poor because the evaluation questions that were used were not good ones, so the team is training a model that will generate thousands or millions of good clinical questions that will then be used to train a new model to answer them. [insert your witty observation here]

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A study finds that employees in their 20s are pushing hardest for a return to in-office work, worried about the lack of community, mentorship and networking opportunities, and the physical space needed to do their jobs. Some of them are turning down job offers that call for remote-only employment. Older workers are happier with WFH because they have bigger homes, a well-establish group of friends, the freedom to transport their children, and a strong desire to avoid time-wasting commutes from the suburbs. One author says that hybrid policies that don’t mandate specific in-office days of the week can morph into remote-first work because people who show up find that colleagues and office energy are not there. One CEO says that the Great Resignation was really just people changing jobs because of their work preferences. An unintended consequence may be that younger employees work from the office, while older workers are allowed to WFH in the suburbs since companies can’t satisfy both groups with a single policy.


Sponsor Updates

  • Medicomp Systems releases a new “Tell Me Where It Hurts” podcast featuring Nick van Terheyden, MBBS of ECG Management.
  • EClinicalWorks partners with HealthEfficient to support its 40-plus member health centers across the country.
  • Everbridge adds Service Intelligence to its Digital Operations offering to help customers accelerate IT incident response, reduce time-consuming unplanned work, and maximize the value of digital service.
  • Meditech will host Meditech Live September 20-22 in Foxborough, MA.
  • Cerner describes how Fisher-Titus Medical Center replaced its hastily implemented early-pandemic virtual visit system of IPads and MIcrosoft Teams with an integrated platform from Amwell and Cerner, where a virtual rooming process mirrors in-process workflow as clinicians launch virtual visits as a video window within a patient’s Millennium chart.
  • Net Health announces that its rehabilitation outcomes management system, Foto Patient Outcomes, has been used in the 127th clinical research study published in a peer-reviewed medical and rehabilitation journal.
  • Netsmart releases a new CareThreads Podcast, “Unlocking Success in Palliative Care.”

Blog Posts


Contacts

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

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EPtalk by Dr. Jayne 7/14/22

July 14, 2022 Dr. Jayne 1 Comment

I spent some time on Wednesday attending a deep dive on “The Platform Revolution Comes to Healthcare” as part 2022 MIT Platform Strategy Summit, which is taking place in the Boston area this week. The initial speakers, Vince Kuraitis and Randy Williams, spoke to what they described as four healthcare platform megatrends:

  • Synergy. Platforms advance (and are advanced by) four key healthcare trends – value-based care, consumerism, interoperability/data sharing, and home/virtual care.
  • Investment in digital health is fueling platform growth.
  • Platforms are shaping new operational ecosystems.
  • Platforms are transforming the competitive landscape in healthcare.

One of the highlights was the keynote fireside chat with Jonathan Bush, who described his experiences in building healthcare platforms. He had an interesting analogy about Dudley Dursley in the Harry Potter books, likening healthcare to Dudley. Healthcare isn’t evil, but it still kills people every year, so “we jack the safety net up so far” that “there’s no ability to move about the cabin” and trying to figure out how to innovate without violating the social safety net.

He refers to his former clients at Athenahealth as “kooks” with great affection. He notes that in healthcare, the demand curve doesn’t function the way that it does in conventional businesses, because there really isn’t a choice to not buy the service and keep the money. He notes two things that have shifted the demand curve – the COVID pandemic, which has shifted acceptance of virtual-first approaches, and the ability to assemble robust tech stacks.

I chuckled when he described in-person care as “lumbering in and taking your pants off and sitting on waxed paper every three months.” Jonathan has certainly mellowed over time, and I always enjoy hearing his thoughts. It will be interesting to see how Zus Health plays a role moving forward.

Speaking of healthcare transformation, we’re approaching the point at which health plans and insurers have to provide pricing information to the public. As of July 1, CMS required those organizations to provide machine-readable files for in-network rates and allowed amounts respective to various medical charges. Starting in 2023, they must also provide online price comparison tools to allow patients to estimate their individual payment portion for a list of over 500 items and services. In 2024, they will have to provide price comparison tools covering all services. Organizations that fail to comply face a fine of as much as $100 per day for each violation for each affected enrollee.

I’m all for empowering patients to understand the costs and options for various services, but publishing this data doesn’t take into account the differences between the same services performed at different facilities. These nuances often inform how physicians order their tests. For example, I am extremely high risk for breast cancer, to the point where I could easily qualify for preventive surgery. Prior to undergoing consultation with an expert, I used to have my mammograms at an independent general imaging facility because it was convenient, the costs were low, and a preliminary reading was provided before I left the building.

However, after having multiple consultations with nationally known experts in the field, coupled with genetic testing, I switched to having my mammograms (and now MRIs) performed at a more costly facility that has subspecialty radiologists interpreting all the studies. The average patient doesn’t understand that subtlety, and with the devaluing of comprehensive primary care in the US, I doubt those kinds of conversations are going to be happening in the exam room.

Speaking of genetic testing, I was excited to see the announcement that Myriad Genetics has partnered with Epic to make genetic testing more nearly seamless for patients and providers. My own Myriad testing several years ago was ordered with a daunting-looking triplicate paper form, where the medical assistant had to transcribe dozens of data points that already existed in the EHR. Results came back on paper, which the office had to scan into the chart. They were supposed to mail me a paper copy, but somehow couldn’t get it out the door, so after weeks of delay and begging on my part, I finally received a PDF version of the scan, minus the pretty color that I’m sure was in the original paper result. Less than ideal, but I’m excited that future patients will have better options for receiving their results and that physicians will be able to fully explore the value that discrete data brings.

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Once upon a time during one of my work trips, I became a patient at Mercy. They recently sent an email to patients with “MyMercy” MyChart accounts asking them to take a survey about a new feature. Apparently  they are evaluating the possibility of implementing Epic’s MyChart Bedside capabilities and wanted patient input.

Having been on the health system side of healthcare IT, it’s often difficult to prioritize initiatives unless they are regulatory or otherwise mandated. Understanding how patients would use or not use a potential new feature seems prudent given the limited resources available to most IT teams. Survey participants were asked to rank a list of features based on how useful the participants thought they would be during an inpatient stay. I’m not a regular consumer of care through Mercy, but I did appreciate the outreach. I’ve got some contacts from residency that work there so will be interested to see if I can find out how the results are being used to make decisions.

Former telehealth darling (and now telehealth pariah) Cerebral tried unsuccessfully to recruit me before its fall, but I’ve ended up on one of their mailing lists. The company is conducting an all-out messaging campaign to explain its new focus on clinical quality and its vision for comprehensive mental health care. Putting on my primary care hat, I’m unimpressed by their messaging. It’s going to take a long time for them to overcome the perception that they have been prescribing controlled substances like someone giving out candy at Halloween.

Since I care for children, another physician recently asked me for my thoughts regarding the “right” age for her personal child to get a cellphone. This is often a hot topic around the neighborhood as well, with every child seemingly stating that “everyone else has one but me.” There’s a growing body of data demonstrating that mobile devices are harmful to mental health. One physician I refer to stated that smartphones are little more than “dopamine dispensing slot machines.” Discussions  at the recent Endocrine Society meeting highlighted issues with smartphone-associated behavioral issues, sleep disruption, and obesity.

Most adults I know don’t have the ability to separate from their phones, so it’s not realistic to think that the relatively underdeveloped brains of children would make it any easier for them. The article links to a number of publications in the medical literature regarding cell phone and screen use. If you’re a parent of children or adolescents, or if you are concerned about your own dependence on mobile devices, it’s worth a read.

Do you think that constant smartphone access and the prevalence of social media is making the world a better place or consigning us to a dreary future? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 7/14/22

July 13, 2022 News No Comments

Brightline Closes $10 Million Extended Series C Financing from Northwell Health as Demand for Family Behavioral Health Care Soars

Pediatric and family-oriented virtual behavioral healthcare company Brightline adds a $10 million investment from Northwell Health (NY) to its Series C funding round, bringing its total to $115 million.

Alaska DOH issues RFP for statewide health information exchange services

The Alaska Department of Health seeks proposals for a statewide health information exchange project budgeted at $6 million for the first two years.

Electronic Caregiver buys Las Cruces Tower for $8.9 million

Remote patient monitoring and virtual care company Electronic Caregiver acquires the building where it is headquartered for nearly $9 million to accommodate the addition of 770 employees over the next five years.

Morning Headlines 7/13/22

July 12, 2022 Headlines No Comments

UHG’s Optum and Red Ventures launch consumer health JV

UnitedHealth Group’s Optum Health and Red Ventures form RVO Health, which will include consumer-facing health and wellness websites — such as Healthline, Psych Central, and Healthgrades – along with Optum Store and virtual coaching platforms.

Particle Health Raises $25 Million to Accelerate Platform Growth

Clinical data exchange API company Particle Health raises $25 million in a Series B funding round.

Fold Health Raises $6M in Funding

Fold Health, a San Francisco-based startup developing technology for primary care practices, raises $6 million.

News 7/13/22

July 12, 2022 News No Comments

Top News

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UnitedHealth Group’s Optum Health and Red Ventures form RVO Health, which will include consumer-facing health and wellness websites — such as Healthline, Psych Central, and Healthgrades – along with Optum Store and virtual coaching platforms.

Red Ventures owns internet properties such as CNET, The Points Guy, TV Guide, ZDNet, and Bankrate. It acquired Healthline Media in July 2019 and Healthgrades.com in August 2021.

Optum Health operates a network of primary care, surgery, and urgent care centers.


Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre to present your own.


Acquisitions, Funding, Business, and Stock

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Enterprise performance management software vendor Syntellis Performance Solutions acquires Stratasan, which specializes in healthcare market intelligence and analytics for hospitals and other healthcare organizations.

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Clinical data exchange API company Particle Health raises $25 million in a Series B funding round.


Sales

  • Northwell Health selects EVideon’s Vibe Health interactive bedside technology, including Engage TV and Insight digital whiteboards.
  • TriZetto Provider Solutions will offer its customers Relatient’s Dash suite that includes contact center scheduling, patient self-scheduling, reminders, messaging, and chat and digital patient intake.

People

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Sage Health hires Wayne Sass, PhD (Optum) as CTO.

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Scott Gildea, MBA (Leidos) joins Nordic as VP of enterprise technology transformation.

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TriHealth CIO Cathy French, MS will retire in September after nearly 44 years with the Cincinnati-based health system. She started out as a staff nurse and then became director of IT health system products in 1979.


Announcements and Implementations

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Northwest Health (IN) rolls out PeriGen’s PeriWatch Vigilance maternal-fetal early warning system within its Birthing & Family Care Centers.

PrimaryOne Health implements Bluestream Health’s virtual care services across its 11 locations in central Ohio.

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Hansen Family Hospital (IA) and affiliates implement mobile check-in technology from Epion Health.

Mass General Brigham will expand its hospital-at-home program and has hired a home-based care president who formerly worked for for-profit Kindred at Home. The program expects to serve 200 remote patients versus today’s 25 and will expand employee headcount from 800 to 1,000.

Wellness app vendor Happify Health renames itself Twill Health and describes its expanded offerings as, “By combining digital therapeutics, well-being products, community-based care, live coaching, and clinician-trained AI, Twill intelligently guides each person to the care they need, when they need it, in the way they want.”

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The six-week CHIME Healthcare CIO Boot Camp – Digital will start on August 15, 2022. The program is open clinical informatics leaders or those who work for provider organizations, with CHIME membership not required.


Privacy and Security

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Virginia Commonwealth University Health System notifies 4,441 organ donors and recipients of a data breach that enabled their PHI to be viewed by other patients through the health system’s patient portal.

A California newspaper’s opinion piece says that patient privacy will change on January 1, 2024, as a new state law — mostly addressing expanding Medicaid to undocumented immigrants — will give all practitioners access to all of a patient’s data, with no exception for behavior health and abortion visits.

Ransomware groups create a searchable database of all the data they have stolen from hacked companies who haven’t paid their demanded ransom. It gives other hackers access to passwords and confidential information and lets patients know that their information has been exposed, pressuring the hacked companies to pay up.


Other

Amazon’s moonshot project is developing cancer vaccines in partnership with Fred Hutchinson Cancer Center and is recruiting patients for an FDA-approved clinical trial of personalized vaccines for breast cancer and melanoma. Amazon says it is contributing scientific and machine learning expertise.


Sponsor Updates

  • EClinicalWorks releases a new customer success story featuring Ninth Street Internal Medicine, “Healow Pay: Improving Collections, Reducing Phone Calls.”
  • Diameter Health publishes a new white paper, “The Strategic Role of Clinical Data in Risk Adjustment.”
  • Estonia’s Pildipank expands its relationship with Agfa HealthCare by moving the shared PACS to the Enterprise Imaging Platform.
  • Dutch care home provider Coloriet renews its service contract for Ascom’s TeleCare IP, smart sensoring, and mobility solutions.
  • Bamboo Health joins the Florida Behavioral Health Association as a corporate member.
  • Oracle Cerner has increased the total number of beds contracted outside of the US for the second consecutive year.
  • CHIME releases a 30th anniversary podcast, “Innovation with Tim Stettheimer, 2010 Board Chair.”
  • Arcadia makes its research data available through AWS Data Exchange.

Blog Posts


Contacts

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

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Morning Headlines 7/12/22

July 11, 2022 Headlines No Comments

Memorial Hermann Health System Invests in EnableComp, an Industry-Leading Specialty Revenue Cycle Management Solution

Houston-based Memorial Hermann Health System makes an unspecified investment in RCM vendor EnableComp.

Syntellis Performance Solutions to Acquire Stratasan, Expanding Healthcare Data Analytics Capabilities

Enterprise performance management software vendor Syntellis Performance Solutions acquires Stratasan, which specializes in healthcare market intelligence and analytics.

This cardiac care startup just landed $20M for virtual rehab services

Moving Analytics, a developer of virtual cardiac rehab programs, has raised $20 million in a Series A funding round that brings its total investments to $30 million.

Curbside Consult with Dr. Jayne 7/11/22

July 11, 2022 Dr. Jayne 1 Comment

I missed the initial announcement last month, but the US Department of Health and Human Services has issued guidance on “How the HIPAA Rules Permit Health Plans and Covered Health Care Providers to Use Remote Communication Technologies for Audio-Only Telehealth,” which will apply even after the Office of Civil Rights “Notification of Enforcement Discretion for Telehealth” no longer applies. Audio-only telehealth is important for populations that don’t have adequate broadband access or who can’t access video visits due to disability, cell coverage, or other factors.

Seeing telehealth patients over the last four years, I found that nearly half of the patients I treated preferred audio-only visits, for a variety of reasons. There are some interesting details in the document on the use of traditional landline phone services as compared to electronic communication technologies such as internet-based phone services, cellular service, and Wi-Fi. The HIPAA Security Rule applies to the latter technologies, but not the POTS lines, although I’m not sure how many covered entities still use copper wire for their communications.

Most large healthcare organizations are trying to forecast what their use of telehealth services will look like in a post-pandemic world. In speaking with CMIO colleagues, it seems like their ideas on the topic run across a pretty wide spectrum. There are quite a few who feel that telehealth has provided substantial benefit for patients and providers and therefore plan to continue it. Those organizations are increasing telehealth budgets, working on staffing strategies, and more.

One health system that I follow is doubling down on virtual primary care, standing up virtual clinics and virtual patient panels. From a technology perspective, it feels like they’re just replicating their in-person workflows in the virtual world, complete with staff performing intakes and then referring patients to go visit the hospital lab and pharmacy at the end of the visit. They’re not yet approaching things like home phlebotomy or medication delivery. Other than not having to leave the house, the visits are pretty much business as usual, so they should seem familiar to the patients.

Another system I’ve consulted for in the past is retreating from telehealth somewhat. They’re adding additional capacity for nurse practitioners and physician assistants to offer same-day acute visits and are reducing the options for telehealth visits with primary care physicians so that the physicians can focus on patients who need to be seen in the office. That approach likely provides less convenience for patients who have grown accustomed to telehealth, and also potentially requires more real estate square footage since they’re going to have more providers and increased foot traffic in the offices. They feel that telehealth is impersonal and that their patients want a level of care that can only be given in person. As a patient, I’d argue that in-person care also brings a level of annoyance that many of us are trying to avoid.

We’ll have to see how it plays out and whether their capacity forecasts are accurate or whether they see patients defect to the health system across town since it’s still offering plenty of telehealth availability.

A recent survey from the Associated Press-NORC Center for Public Affairs Research and the SCAN foundation asked 1,000 US adults for their thoughts about what their lives will be like after the pandemic. While 48% said that telehealth was a “good thing” that should continue to be available, 52% responded that they’re not likely to use virtual care in a post-pandemic world. The breakdown of responses by age was interesting. For adults over 50, a mere 16% said they would continue telehealth visits. Looking at a younger crowd, 22% of adults under 50 said they would opt for virtual care. Not surprisingly, respondents with concerns about being infected with COVID-19 had a higher likelihood of wanting to continue with virtual healthcare. Most of the patients I see are in the under-50 age bracket, so I think it’s fairly likely they’ll want to continue with current telehealth options.

Looking more generally at the responses, only 12% of adults felt that their lives are the same today as they were before the pandemic, where 54% feel that life is somewhat the same and 34% feel their lives are not yet the same. Still, many adults in the US have resumed their pre-pandemic activities, including socializing with friends, dining out, visiting older relatives in person, travel, and worship. Only about half plan to use public transportation, which I find surprising given the rising cost of fuel (survey responses were gathered May 12-16, 2022).

Despite increasing COVID in my community (at least according to sewer shed data, since testing numbers are no longer reliable), the majority of people seem to be going about their business without masks, even though they’re recommended. I’ve had a combination of allergies and a cold for the last week, complete with eight negative COVID tests, and am convinced that since I haven’t had a cold in the past two years that I’ve forgotten how miserable it can be. Of course, it might just be undetectable COVID, but based on the negative tests and narrow symptom profile, I’d be surprised. No one I’ve been around has reported being sick either, so it’s a bit of a mystery if it’s something beyond just some wicked allergies. I engage in most of my pre-COVID activities, although most of them tended to be outside or with small groups of people and are fairly low risk.

I’ll be increasing my risk tolerance in coming weeks, as I have a couple of leisure trips coming up. I’ll be masking on the plane and in the airport and anywhere that seems like it doesn’t have great ventilation. One of the events I’m attending promises to be a reunion of sorts with lots of healthcare IT people I’ve worked with in the last decade, so I’m excited about that, as well as the ability to spend some quality time with one of my favorite healthcare personalities. I did some checking on the places I’m headed, and it looks like some of the entertainment venues still have mandatory masking. It will be interesting to be somewhere that’s a little stricter than home as far as preventive measures. I’ll be traveling with a stash of COVID test kits just in case, although I’ll be keeping my fingers crossed that I won’t need them. Hopefully during my travels, I won’t need any telehealth services, although I know where to find them if I need them.

Have you had to use telehealth while on vacation, and what was your experience? Leave a comment or email me.

Email Dr. Jayne.

HIStalk Interviews Ashwini Zenooz, MD, CEO, Commure

July 11, 2022 Interviews No Comments

Ashwini Zenooz, MD is president and CEO of Commure of San Francisco, CA.

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Tell me about yourself and the company.

I’m a radiologist by background. I’ve been a practicing physician for most of my professional career. I made the switch a few years ago, officially, to government and policy. I worked on Capitol Hill and then moved on to continue my work in government at the Department of Veterans Affairs as an executive, then continued my work from there into tech.

Throughout that entire process, I’ve been an avid lover of what technology can bring to healthcare. From my first days as an attending or fellow, I remember all of the things that you could do to have more efficiencies in healthcare, and technology is at the core of it. I believe in the power of technology and I think we are at a great time at the intersection of tech and healthcare, so I’m excited to be here.

I joined this company because the single theme that I’ve been seeing throughout my career is that we have a lot of point solutions and they are continuing to increase. COVID just blew that out of the water. That’s great, because it brought a lot of access to patients and a lot of great solutions, but it became an even more disconnected system. The premise of this company is, how do we bring all of that health tech disconnect to make it work and empower the healthcare workforce? I love that idea, so I wanted to come here. 

We are building the first health tech operating system. Our goal is to bring in and unify multiple data sets and data services so that it is meaningful for the clinicians during those micro moments of care, help with the performance of the organization through these applications; innovate; and give the tools for the systems that are using us to have a platform for innovation that is unifying. I love that concept. We always talk about interoperability from a technology perspective, not from, how does it impact users and how do we make it work for them?  I love that we are actually bringing action to interoperability.

Who are the company’s competitors in data aggregation and API services?

The first thing I would say is that I don’t view data aggregators and API companies as competitors. In order for us to be a functional platform and operating system, it’s important that we bring multiple vendors and last-mile integration companies together. That’s important for us so we can have the data unified in a single place. That’s the first component.

When you reference data integration and APIs, some of that, especially the data integration, has different components. We don’t do the last mile of data integration. It’s once the data is coming together with all these different sources, how do we provide that unification and the unified view? For those, I would say that you could have platform companies as competitors that are out there, anything from a Microsoft or one of the other companies, but they are also partners for us because we build on top of them. Microsoft, Google, Amazon, et cetera.

I don’t think we are yet in a space where we have a competitor because we are the first health tech operating system that is actually bringing FHIR and non-FHIR data together. We are enabling different data structures and sources, and we have a solution where you can actually build on top. I don’t think that solution exists in the market as a whole. If you break down the individual components that we could have for each category, there’s a competitor.

I’m still not getting a picture of exactly what you sell and to whom. Can you give me an example?

We predominantly work with healthcare systems today. If you think of the healthcare system, they have on average somewhere between 10 to 16 electronic medical records or systems of record. They have radiology, laboratory, their main clinical EHR, and they have other data sources. They also work with multiple third-party point solution vendors. 

A lot of times, the healthcare system has to do the work of continually doing point-to-point integration with these third parties to make them effective with the vendors. By bringing in an operating system in the middle, they have found that they can scale those applications across the board by a single plugin. Once you integrate with Commure or you build a solution on Commure, the data automatically flows to anything that is connected with the Commure operating system.

Think of a switchboard, where multiple plugs are connected in. If you are connected into each other, then the data is set up in a way, structured in a way, where it has a common architecture, where you are able to communicate and have data. You have a clinician who has an EHR, they have patient data coming in from the glucose monitor, and you have third-party data that’s coming in. The system has built an algorithm, let’s say on top of Google Cloud for analytics. We can connect the dots and have a system of action. We can bring the algorithm to life and bring it to the forefront for that provider to make the decisions at that moment of care. We’re a transactional system. It’s not retroactive review of analytics. That’s who’s using us, and that’s one example for clinical.

Another example on the platform is using location services. Think about a nurse who is delivering care where there is violence in the workplace. All she has to do is push a button on the badge and we do the work on the back end, where we connect the dots between her to security and nearby employees so we can say, “Here’s the person that needs help.” We can engage. And all of this happens on the back end on the platform, whereas before, you would have to go to a nursing station, pick up the phone, call somebody, et cetera. We are able to connect the dots between clinical, operational, and financial through any app that is connected into the platform.

How do you bring EHR vendors to the table to make their data available?

For the operating system to be functional, you have to work with partners. EHRs are part of the partner ecosystem. It’s not going to work without working with the EHR partners. We have to be able to bring the data together and we have to make it useful. For us to bring the data sources together and for it to be meaningful, we have to work with the developer ecosystem that is building these incredible point solutions in the digital health market. We have to work with the existing laboratory and pathology systems that a health system might use. We have to work with the EHRs and the HIEs that are out there so that we can actually have this data come and for it to be meaningful.

With the PatientKeeper acquisition, we inherited two decades of great clinical experience and workflows that are adding to our vault of solutions. But the overall Commure operating system is going to require PatientKeeper solutions, other vendor solutions, and Epic and Cerner solutions to come together. To me, it’s all about figuring out how to collaborate and not remove these systems that are in existence and bring more cost to the healthcare system. I don’t think we should be kicking out the EHR because the services and functionality that Commure provides are additive and should be enhancing the EHR and enhancing the operational efficiency of the company.

There are a lot of things that the EHRs don’t do that a health system needs, and that a clinician needs. Those are the areas that we are providing a platform for innovation, where you can say, “You have this data. We have these templates for you.” You as a health system can work with your own team or you can work with third-party developers. You should be able to use a low-code or a no-code platform that we have to spin up the workflow that you need within a matter of weeks that it is integrated and connected to the EHR. You have an enhancement of your EHR. I don’t think we should be dislodging them. They do a great job at what they do, which is being the electronic recordkeeping system.

What will the industry look like in five years as startups build products that use existing health system data?

I think it’s fabulous. No one company can be the end-all, be-all in healthcare. If you have a monopoly in healthcare or you think that the EHR is going to be the source of all of your clinical workflows, all of your operational workflows, and all of your financial workflows, one, that’s going to be difficult.

Two, it’s not going to give the system any flexibility to think about new ways to innovate and work faster. COVID has opened up the ecosystem and has allowed for innovation. Health systems in particular realized that there is so much more that they need for a more efficient, better way to engage their patients and their providers. They saw that when we started shutting down and going to a virtual environment or hybrid environment with healthcare. That accelerated the innovation in healthcare, and I think that’s fabulous.

The only issue with that is that with so many point solutions, the healthcare system has to do the job of integrating all of those to make it meaningful for them to use it. We’re working with a healthcare system now that has over a 100 third-party vendors who provide point solutions, and some redundant solutions are being used across departments. That adds to the cost of the healthcare system, which goes against what we should be trying to do.

This is simplistic example, but if you think about the IOS or the Android ecosystem, they create a way for seamless consumer experience through this core data integration platform. Then they enable an easy app development platform and a robust suite of pre-built, ready-to-launch apps. Apple comes with Apple Maps, Apple Calendar, and Apple Mail, but that doesn’t mean that you can’t download one of the new innovative maps or scheduling apps or Waze or whatever that you want to use as a consumer. It is auto integrated. Just because you use Apple Calendar and Gmail for your email does not mean that those two don’t work together. 

I’d like to see that simplicity. That’s where we are going to head with a platform approach in healthcare, where you can have the best-of-breed solutions available to these health systems. But there’s not going to be the issue where interoperability and tech is a blocker. They will function together to reduce the friction for the user.

Has consolidation into bigger health systems enhanced demand for services like yours, as tech-savvy corporate offices connect systems that came with acquisitions?

The short answer is yes. It’s not just the EHRs when you see system consolidation. As we are moving into a new model of work, you’re going to have a lot of non-health system parties that work with the inpatient system. For example, you’re going to have multiple cardiology practices that refer patients and take care of patients inside of a central healthcare system. They are now part of the system. They don’t use the same EHR or billing or operational systems, but you need to give them the flexibility to work with each other. Solutions where you’re able to help with the network of innovation to bring all of this together so that the patient isn’t bothered when they’re going from their external cardiologist into an internal vendor — that’s where I see a lot of change.

It’s not just at the level of the EHR. It’s between the inpatient systems. How do you provide these seamless experiences for these providers, not just the patients, as they are caring for patients and they are traveling between these outpatient systems that are part of a network into the inpatient system? How do you provide the same flexibility as those providers are interfacing with the insurance companies? How do digital health companies refer in and out of a health system where they don’t belong?

That’s the new age of healthcare. It’s this hybrid model of care, the “click and mortar” system. That’s where the platform innovation is going, and we are going to see a lot more of it. It’s great for us because we truly believe that patients should have the flexibility and clinicians should have the data available when they need it without having friction from technology, which is what we enable.

What are the company’s priorities over the next few years?

Right now, we are really, really focused. You probably don’t see a lot of info from us because we are hyper-focused on working with some of our lighthouse customers. We have defined a few focused customers and we want to make sure that we are learning from them and partnering with them to come up with the best solutions. I don’t foresee us changing much from that course, because we are learning a lot and it’s helping us build our product roadmap and introduce new solutions to the market. I would say that we’re going to continue along that path.

We are seeing a lot of requests for payer-provider collaboration and how we can enable that, so we will think about how to extend our platform and the operating system to help connect the dots, as clinicians are working not only across other healthcare systems or across their networks, but also with the payers in the ecosystem.

I don’t think that there’s a silver bullet in healthcare, “one size fits all” solutions. We have to be open to the approach of collaborating and working together, including multiple EHRs working together and multiple competitive companies working together, to help provide the best care for patients and the best experience for providers.

Morning Headlines 7/11/22

July 10, 2022 Headlines 2 Comments

Cardinal Health’s Outcomes acquires smart prescription platform ScalaMed

Cardinal Health acquires ScalaMed, whose app is used by patients to receive their electronic prescriptions on their phone, giving them the ability to price-shop and choose their pharmacy after the fact.

Astria Health and Cerner reach settlement in billing system case

Astria Health and Cerner settle their legal dispute in which the health system blamed its 2019 bankruptcy on problems with Cerner’s billing system, a claim Cerner disputed with the rebuttal that Astria poorly managed its merger with two other hospitals.

OhioHealth to eliminate 637 jobs in its biggest layoff ever

OhioHealth lays off 637 employees, 567 of whom are in IT, as part of the outsourcing of its IT work to Accenture and RCM to AGS Health.

Oracle Discussed Laying Off Thousands of Workers

Oracle has reportedly considered cost-cutting measures of up to $1 billion that could include thousands of layoffs within the next several weeks.

Monday Morning Update 7/11/22

July 10, 2022 News 9 Comments

Top News

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An Oracle EVP says in a letter to two members of of VA’s Subcommittee on Technology Modernization that the VA’s Cerner system was “not operating as intended” at Mann-Grandstaff Medical Center, in which an “unknown queue” problem caused patient orders to be delayed or lost.

The company says Oracle’s expertise and technology will be used to “rethink approaches not possible before the acquisition.”

Cerner and the VA had agreed on how the queue would be used to detect incorrectly entered orders going back to January 2020, but the VA didn’t train its clinicians to monitor it.

The letter was signed by Oracle EVP and company lobbyist Ken Glueck.

This is good reporting from Orion Donovan-Smith of the Spokane Spokesman-Review.

Meanwhile, Oracle is reportedly considering cost reductions of up to $1 billion that would result in the layoff of thousands of employees as early as next month. Its recent $28 billion acquisition of Cerner added 28,000 employees to Oracle’s headcount of 143,000.


Reader Comments

From Promo Copy: “Re: remote work. Trading tomorrow’s job opportunities for today’s convenience.” I agree that you want to be a familiar company presence when career-advancing plum assignments, promotions, and cross-training opportunities are handed out. Folks who want those things – exceptions being those who mostly travel to customer sites, who aren’t looking to move up, or who work for a company whose executives are also working remotely – might want to watch how those opportunities are doled out based on where the recipient sits. Companies are fans of remote work when they can spend less for office space, pay non-metro salaries in some cases, and get longer workdays for free, but I would be slightly concerned that — other than the atypical use case of superstar Silicon Valley software engineers — executives might then extend the successful proof of concept to workers who are much further away and much cheaper. I also think that companies that skip the hybrid model and allow some but not all employees to work offsite permanently will either reel it back in or inadvertently create two classes of employees who benefit in different ways, which is perfectly fine as long as employees understand their career path options.


HIStalk Announcements and Requests

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Poll respondents don’t see a lot of clinician time being wasted doing lower-level work, which is a better result than I expected.

New poll to your right or here, related to the above discussion: Where are the C-level executives of your employer routinely working, other than when traveling? It occurs to me that maybe most employees don’t even know where the suits sit.

Thanks to these companies that recently supported HIStalk. Click a logo for more information.

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Webinars

July 12 (Tuesday) 1 ET. “Digital Data Stewardship for Trusted, High-Quality Data Exchange.” Sponsor: Clinical Architecture. Presenter: Carol Graham, MS, RN, product manager, Clinical Architecture. Organizations face challenges in ensuring that the patient data they received and send is consistent, accurate, and usable. Use cases include receiving multi-source data across health information networks with variation in formats and content; merging and de-duplicating provider, payer, and research data; uplifting legacy data for current use cases and formats; and normalizing and formatting data for public health surveillance, quality measure reporting, and providing directly to the patient. This webinar will cover Pivot, a comprehensive Digital Data Steward solution that orchestrates format harmonization, content (vocabulary) normalization, de-duplication, and data quality validation into a single solution.

Previous webinars are on our YouTube channel. Contact Lorre to present your own.


Acquisitions, Funding, Business, and Stock

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Cardinal Health acquires ScalaMed, whose app is used by patients to receive their electronic prescriptions on their phone, giving them the ability to price-shop and choose their pharmacy after the fact. I like this a lot since I’ve long maintained that e-prescribing forces patients to choose a pharmacy upfront without knowing cost or availability details, then wastes their time (and that of their prescriber) in trying to move the prescription to a different pharmacy.


Sales

  • Canada’s Niagara Health chooses Sectra’s radiology, cardiology, and VNA systems.

People

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Deana Rhoades, MBA (NTT Data) joins ZeOmega as VP of business development and channels.

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Jill Jemison, MBA (University of Vermont) joins the University of North Carolina medical school as associate dean/CIO.

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Ontario Clinical Imaging Network names Shafique Shamji (The Ottawa Hospital) as president and CEO.

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Logan Health (MT) hires Steve Garske, PhD, MBA (Pipeline Health System) as CIO.


Announcements and Implementations

Astria Health and Cerner settle their legal dispute in which the health system blamed its 2019 bankruptcy on problems with Cerner’s billing system. Cerner disputed that claim, saying that Astria poorly managed its merger with two other hospitals.

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A new KLAS report in PACS in Europe finds that Agfa, Philips, Sectra, and Visus have broad footprints and are growing, with Philips and Sectra having the largest number of high-volume customers.


Government and Politics

Public health experts say that the US is repeating its same COVID-19 mistakes with monkeypox, which should be easy to eliminate because it’s a known pathogen that spreads poorly and had tests and vaccines available before the outbreak began in May. Tests are hard to obtain, vaccines will be in short supply for months, surveillance and contact tracing are poor, and official case counts are are lower than actual. Doctors who see suspected cases must obtain approval from state epidemiologists to send patient samples to CDC, which then takes several days to run the tests and approve the diagnosis.


Other

State-run hospitals in Maharashtra, India report “chaos” as the state unexpectedly and permanently shuts down its Hospital Management and Information System in a dispute with the outsourced service provider. Officials say the contractor refused to pay penalties for poor system performance, so its contract was terminated, after which the vendor refused to provide copies of the hospital data. Those officials added that a new system is ready to install once upgrades are applied.

A Columbus TV station profiles an Epic ASAP analyst who is one of 637 employees OhioHealth is laying off as it outsources IT work to Accenture and RCM to AGS Health. Of the 637 eliminated jobs, 567 are in IT. OhioHealth says that eliminating jobs and hiring “technology and global talent pool external providers” will improve patient care.

A KHN report says that a shortage of mental health therapists is sending patients to online therapy companies, many of them backed by venture capital firms who advertise directly to consumers, whose questionable practices may include using texting with no guarantee of immediate response instead of real-time communication. One company pays therapists per word of text that they write or read. Those companies pay less and thus attract less-experienced providers who are not trained to deliver safe and effective care online. The founder of the Telebehavioral Health Institute questions whether parents should trust an online therapist to treat depression and anxiety in their children, concluding, “”What’s happening is a corporate takeover of behavioral healthcare by digital entrepreneurs.”

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Consulting firm president Fred Goldstein tweeted the result of his hour-long wait for a virtual visit from Amwell. I’ve had similar experiences with ride-sharing services, where my assigned driver decided that my fare wasn’t worth their time and cancelled, but you would think telehealth providers would have a way to reassign the visit to another doctor. Interesting to me is that the doctor who cancelled is the chief product officer and medical director of Grapefruit Health, which offers telehealth services to schools. Still, I blame the company’s platform more than the doctor, who may have had a personal emergency that would have created the same result for an in-office visit. It happened to me once – I showed up for a scheduled doctor visit, appeased the clipboard gods with a solid 10 minutes of handwriting (this was my second visit to this single-doctor practice), waited for maybe 20 minutes past my scheduled time, then was called up by the customer-indifferent front desk person to be told that the doctor had the whole day off. I complained and was indignantly told that someone had mistyped my phone number and they couldn’t each me, which of course failed to explain why they checked me in and let me sit there. The doctor, who was much better at medicine than business, apologized afterward and suggested that I call after hours to avoid her incompetent employees


Sponsor Updates

  • Symplr forms an executive customer council to drive its vision for strategic healthcare operations.
  • Net Health adds Pressure Injury Deterioration Risk indicator into its Tissue Analytics AI-powered wound imaging and analysis solution, and a Missed Visit Prediction indicator to its Wound Care EHR.
  • OneMedNet appoints Christoph Zindel, MD to its board.
  • Arrive Health publishes a new customer success story featuring UCHealth, “Arrive Health Helps Doctors Cut Prescription Costs for Patients.”
  • Spok announces that Asia Pacific value-added distributor InTechnology Distribution will offer Spok products and services.
  • Talkdesk wins Cloud-Based CX Solution of the Year at the 2022 Customer Contact Week Excellence Awards.
  • TigerConnect introduces draft mode for physician scheduling.
  • West Monroe Innovation Fellow Doug Laney publishes a new book, “Data Juice,” about the 101 ways business leaders can monetize their data.
  • Wolters Kluwer Health has expanded Ovid with SRI International’s BioCyc collection of organism-centric Pathway/Genome Databases and bioinformatics software tools.
  • Zynx Health and the Hendrich Fall Program form a joint alliance that enables providers to access comprehensive and holistic fall prevention care guidance.

Blog Posts


Contacts

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

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Morning Headlines 7/8/22

July 7, 2022 Headlines No Comments

North Korean State-Sponsored Cyber Actors Use Maui Ransomware to Target the Healthcare and Public Health Sector

The federal government warns healthcare organizations to defend themselves against potential North Korea-sponsored cyberattacks that are using Maui ransomware.

Tebra Secures More Than $72 Million at Over $1 Billion Valuation to Expand Digital Healthcare Technology Platform

Tebra, the new name for the combined ambulatory health IT businesses of Kareo and PatientPop, secures a $72 million investment from Golub Capital.

Former Theranos COO is guilty of federal fraud

Former Theranos President and COO Sunny Balwani joins his former fellow executive / former romantic partner Elizabeth Holmes in being convicted of federal charges.

Premier said to reevaluate strategic options

Premier Inc. is reportedly considering strategic alternatives that include being taken private.

$3.2 billion digital-health startup Cedar just cut 24% of its workers amid a market downturn

Patient payments startup Cedar, valued at $3 billion, lays off 24% of its workforce “in order to adapt to current market realities.”

News 7/8/22

July 7, 2022 News 1 Comment

Top News

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The federal government warns healthcare organizations to defend themselves against potential North Korea-sponsored cyberattacks that are using Maui ransomware.

FBI, CISA, and Treasury urge healthcare and public health organizations to:

  • Deploy PKI and digital certificates to authenticate network connections, including to the EHR.
  • Inactivate generic administrator accounts.
  • Turn off network device management interfaces.
  • Secure PHI with encryption at rest and firewalls.
  • Implement multi-layer network segmentation.
  • Store backups offline.
  • Use tools to monitor IoT devices for erratic use.

Webinars

July 12 (Tuesday) 1 ET. “Digital Data Stewardship for Trusted, High-Quality Data Exchange.” Sponsor: Clinical Architecture. Presenter: Carol Graham, MS, RN, product manager, Clinical Architecture. Organizations face challenges in ensuring that the patient data they received and send is consistent, accurate, and usable. Use cases include receiving multi-source data across health information networks with variation in formats and content; merging and de-duplicating provider, payer, and research data; uplifting legacy data for current use cases and formats; and normalizing and formatting data for public health surveillance, quality measure reporting, and providing directly to the patient. This webinar will cover Pivot, a comprehensive Digital Data Steward solution that orchestrates format harmonization, content (vocabulary) normalization, de-duplication, and data quality validation into a single solution.

Previous webinars are on our YouTube channel. Contact Lorre to present your own.


Acquisitions, Funding, Business, and Stock

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Axios reports that Premier Inc. is considering strategic alternatives that include being taken private. The company’s market cap is $4.4 billion, with PINC shares having gained 4% in the past 12 months versus the Nasdaq’s 21% loss.

Patient payments startup Cedar, valued at $3 billion, lays off 24% of its workforce “in order to adapt to current market realities.”

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In England, seven NHS trusts that traded de-identified patient data for shares in an AI startup lose millions of pounds, as shares in Sensyne Health are de-listed due to a company reorganization.


Sales

  • In England, two Cheshire NHS trusts will collaborate to replace their paper-based systems with Meditech Expanse.
  • In The Bahamas, Doctors Hospital Health System chooses CloudWave to host its new Meditech Expanse EHR on OpSus Healthcare Cloud.

People

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Peter Bridges, MBA (Curai Health) joins Transcarent as chief commercial officer.


Announcements and Implementations

Caris Life Sciences will integrate its molecular testing products with Epic’s Orders and Results Anywhere network.

In England, South London and Maudsley NHS Foundation Trust becomes the UK’s first 5G-connected hospital, launching a trial of Virgin Media O2 Business connectivity. A key app is vital sign monitoring and documentation of physician observations.

Teladoc Health offers members of its Primary360 primary care program in-home lab specimen collection services from Scarlet Health. Those members also receive free same-day medication delivery from Capsule.

University of Colorado School of Medicine launches the Department of Biomedical Informatics.

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A new KLAS status report on telehealth platforms finds that Caregility performs well (especially in inpatient settings), Amwell is often considered even though its legacy product has higher dissatisfaction, and Doximity works well as an easy-to-use and lightweight solution for simple outpatient settings. Customers of Caregility, Teladoc Health InTouch, and SOC Telemed report positive effects in clinical outcomes, while those of Doxy.me say it reduces missed appointments and providers patient benefits at a good price. Vidyo lost ground after Epic replaced it with Twilio. Microsoft Teams and Zoom are frequently used for multi-party calls even in organizations that use different products for regular telehealth visits.


Government and Politics

Former Theranos President and COO Sunny Balwani joins his former fellow executive / former romantic partner Elizabeth Holmes in being convicted of federal charges, in his case, that he defrauded patients and investors. Holmes was acquitted of those same charges, but was found guilty on investor charges. Both face up to 20 years for each count at their September sentencing, 12 in Balwani’s case and four for Holmes.


Privacy and Security

IT security and technology reseller SHI, which has 5,000 employees and $12 billion in annual revenue, remains down from a ransomware attack last weekend. That’s not the best look for a company that sells cybersecurity and disaster recovery solutions.


Other

An interesting article on telehealth in China, written by a Harvard public health researcher, makes these points:

  • Telehealth grew hugely in the pandemic’s early days, but the government had already been trying to build a digital health ecosystem to alleviate public hospital overcrowding.
  • Telehealth didn’t remove all geographic barriers, as some patients exhibit “home bias” in preferring to be seen by a doctor who practices in their own province.
  • Online price transparency should increase competition and lower prices.
  • Telehealth doctors are usually full-time employees of public hospitals, raising concerns that their work as private telehealth contractors interfere with their public hospital duties.
  • Affordability is a concern since telehealth is primarily an out-of-pocket expense and access to public hospital appointments may worsen for lower-income patients if telehealth referrals fill appointment slots with private pay patients.

Vermont regulators consider revoking the state license of Walgreens after one of its stores closed for months after a fire but kept billing patients and insurers for prescription refills that couldn’t be picked up. The state says the company, which runs 23 stores in Vermont, also shut down stores without notice, closed the pharmacy department for 325 days in a 21-month period because of staffing shortages, and in some cases left the pharmacy open without having a pharmacist-manager present.

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The Atlanta newspaper profiles rising local high school senior Asanshay Gupta, who in 2020 – at age 14 – developed a free app to help hospitals calculate the demand for oxygen due to COVID-19 patient requirements. Among its users was a 10-hospital chain in India who used it to ensure that ambulances were stocked with enough oxygen, which was in short supply, for patients being transported. He hopes to study biomedical engineering or medicine after his graduation next year.

My favorite recent article is “Truly Humbled to Be the Author of This Article,” where David Brooks describes those endless LinkedIn and Twitter humble-braggers who shamelessly tout their own accomplishments and all-around wonderfulness while claiming to be “humbled” or “honored.” He cleverly notes that the humble-braggers slather on a bonus layer of false humility by eliminating the personal pronoun, as in “Humbled to be …” instead of “I am humbled to be …” A snip:

You are showing the world that you haven’t let your immense achievements go to your head! You’ve remained completely egalitarian—you just happen to be a better egalitarian than most people (and you are humbled by that fact). It’s easy to be humble when you’re most people. But just think about how amazing it is to be humble when you’re as impressive as you!


Sponsor Updates

  • First Databank names Sneha Jingar senior Salesforce administrator.
  • Healthcare Triangle facilitates secure data-sharing for drug discovery through “Neutral Zone.”

Blog Posts


Contacts

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

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EPtalk by Dr. Jayne 7/7/22

July 7, 2022 Dr. Jayne No Comments

I’m back in the swing of things post-camp and am grateful that all was quiet at my day job. Now I’m wearing my blogger hat and wading through several hundred emails trying to figure out what happened in the healthcare IT world while I was gone.

There were the usual press releases, government updates, emails from my professional organizations, and what seems like more than my share of messages that should have been flagged as spam yet were sitting in my inbox. I had links to a handful of interesting journal articles, some clinical updates, and of course the latest and greatest about monkeypox (which is apparently still awaiting a new name courtesy of the World Health Organization).

The first article that caught my eye looked at using data from Twitter to better understand how the public thinks of FDA-approved versus off-label use of medications to treat COVID-19. The authors used natural language processing to evaluate 600,000 tweets that originated in the US between January 2020 and November 2021. They examined content mentioning four drugs that received a lot of attention during the pandemic. Both molnupiravir and remdesivir were FDA-approved treatments for COVID, where hydroxychloroquine and ivermectin had only anecdotal evidence for their use.

Not surprisingly, the authors found that the unapproved agents were mentioned more often, especially during pandemic surges. They also found that Republicans were more likely to support the unapproved agents than Democrats. Individuals with healthcare backgrounds opposed the unapproved agents more than the general population. The authors concluded that “social media users have different perceptions and stances on off-label versus FDA-authorized drug use across different stages of COVID-19, indicating that health systems, regulatory agencies, and policymakers should design ‘targeted’ strategies to monitor and reduce misinformation for promoting safe drug use.” This certainly becomes more difficult in states where governmental agencies and the courts took steps to promote or protect the use of unauthorized drugs. It will be interesting to see how this continues to play out now that we’re no longer in the most explosive phases of the pandemic.

The next article that caught my attention was about decision fatigue. The term refers to “a state of mental overload that can impede a person’s ability to continue making decisions.” Whether they’re small decisions or more significant ones, decision fatigue can leave individuals feeling “overwhelmed, anxious, or stressed” and can interfere with ongoing decision-making ability. According to the psychiatrist featured in the article, individuals make over 35,000 decisions during the course of a day, consciously or not. The COVID-19 pandemic has added stress for physicians as we navigate decisions in an increasingly complex healthcare environment. She notes that physicians have “had to make decisions we never had to make before, and we’ve had to manage the anxiety of our patients.”

Many of us have also had to manage the anxiety of family members as well as their healthcare needs, from helping them schedule vaccine appointments to making sure they can navigate through the web of in-person versus virtual visits over the past two years. One member of my family postponed a joint replacement during the pandemic and was just able to have surgery last month, which was a great relief. Decision fatigue can leave people feeling tired, drained, or with foggy thoughts. People are also likely to engage in unproductive processes as a result, via procrastination, avoidance, indecision, or impulsivity. We’ve all seen enough pandemic buying to explain the latter, and I’ve definitely seen the first three among my friends and colleagues as well.

Strategies for overcoming decision fatigue include creating daily routines, making lists to help avoid random decisions, simplifying repetitive processes through services such as automatic bill pay, and reducing tasks and activities that don’t provide value. The psychiatrist notes that “research shows that the best time to make decisions is in the morning” which is a time “when we make the most accurate and thoughtful decisions, and we tend to be more cautious and meticulous.” It makes sense to me – I know that by the end of the workday, my brain is pretty much fried.

The third item that caught my eye was an ONC blog that talked about health equity by design. It summarized some of the findings of ONC’s Health Information Technology Advisory Committee (HITAC) as it looked at creating equity in data collection, interoperability, artificial intelligence, bias, and crossing the digital divide. Since data collection is important to understanding outcomes and measuring change, it will be important to capture information on race, ethnicity, sex, language, disability, sexual orientation, gender identity, and social determinants of health. Although many organizations are doing a good job capturing these elements, I often see charts where many of the fields are blank.

Bias is important especially where artificial intelligence is concerned. There have been numerous articles in the last several years looking at how particular models perform when factors are different from the data set on which the model was trained, such as when a particular demographic isn’t adequately represented in the data set. There have been significant changes in how we manage certain laboratory values based on evidence versus old ideas that race is more of a factor than it should have been.

One example of this is kidney function. In the past, race was used to set different reference ranges for certain lab values. Scientists have realized that using race can be problematic since it doesn’t necessarily represent a specific genetic makeup or group of underlying biological characteristics. I’m excited about efforts to deliver healthcare in a more equitable manner, and especially initiatives that use technology to ensure quality care for all. I’ll definitely be watching to see where some of these efforts go.

Speaking of excitement, it’s July, which means the beginning of Internship year for many newly minted physicians as well as residency promotions for other trainees. My medical school recently reached out to me asking for help inspiring the incoming MD class, who will be receiving their white coats in a ceremony later this month. I trained at a time when there wasn’t any ceremony and we just felt lucky to get a coat that fit (and many in the class didn’t, which resulted in a lot of swapping after the fact) as we raced into our third year of medical school.

New students receive theirs in the first year after several orientation weeks, and they’re not only sized properly, but are embroidered with their names and the school crest. I’m sure it instills a sense of pride and accomplishment, although based on the state of healthcare today, I’m not sure I have any inspiring thoughts for those entering a system that seems more dysfunctional than it did even a few short years ago.

What do you wish you had known when you started your journey in healthcare or healthcare information technology? What would you tell today’s entering medical students? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 7/7/22

July 6, 2022 Headlines No Comments

CareConnectMD Announces $25 Million Investment from TT Capital Partners to Fuel Expansion and Hiring

CareConnectMD will use $25 million in new funding to expand its primary care services for medically fragile Medicare patients into new markets and further develop its technology, including telemedicine.

PFC USA Provides Notice of Data Security Incident

Professional Finance Corp. notifies the patients of nearly 600 healthcare providers of a February ransomware attack on its systems that may have compromised their data.

Medical Solutions Acquires North Carolina-Based Matchwell

Healthcare workforce company Medical Solutions acquires online healthcare staffing marketplace Matchwell for an undisclosed sum.

HIStalk Interviews Kyle Kiser, CEO, Arrive Health

July 6, 2022 Interviews 1 Comment

Kyle Kiser is CEO of Arrive Health of Denver, CO.

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Tell me about yourself and the company.

I’m CEO of the recently minted Arrive Health, which until a few days ago was known as RxRevu. I’m part of the original team and have been with the company for almost eight years. We have built a network that delivers cost and coverage information into the e-prescribing or ordering workflows of providers and advocate for real-time, patient-specific, location-specific, moment-in-time-specific insights to help connect effectively marketplace information with clinical decision-making at a high level.

We can all share stories about inconvenience and aggravation due to prior authorizations, prescription coverage and cost surprises, and the increased difficulty in shopping prescription prices with the move away from paper prescriptions, none of which can be easily measured except indirectly on provider satisfaction surveys. How do you think that frustration manifests itself?

There are absolutely mountains of anecdotal evidence. The way that we have structurally arranged the system is that on one end, healthcare providers make decisions based on what they perceive, how they have been trained, the clinical guidelines that exist, and maybe some influence based on the system that employs them. On the other end, health plans and PBMs have developed rules that are intended to guide the right decision to a best-cost decision. Those best-cost decisions are usually behind a curtain, to some degree. There’s a lot of mystery or maybe unique intellectual property in how those things happen and are derived.

The net of that is there are rules on one end developed by health plans, there are rules on the other end being adhered to by clinicians, and those two sets of rules are entirely disconnected. We connect those two things into one experience, because in today’s state, it’s up to the patient to manage the in-between. They have to advocate for themselves with their health plan. They have to advocate for themselves with their provider. Ultimately, their trust is with the provider. If you have a question about something that’s health related, if you’ve got a question post-visit about something or you’ve got a question about a med you’ve been prescribed, your first instinct is pick up the phone and call the clinic where you went, where the decision originated. We are empowering that provider who already has the trust and the leveraged relationship to drive the right decisions, to ultimately take the preferences of that individual’s health plan and put it into the hands of a decision-maker who is already making that decision.

As far as measuring the impact and maybe even the size of the problem, we are finding about 20% of the time when we present other options, providers are adhering to that. That’s just with the workflow intervention. That’s not with a care team or a patient intervention. Just by providing this information in a relatively passive way in workflow, providers are accepting those options about 20% of the time, which is meaningful. That means that one out of five patients aren’t having to show up at the pharmacy counter and realize that their claims have been denied. They aren’t having to call their PBM or their health plan to understand if there’s a prior auth required, and if so, how they resolve that prior auth. They aren’t having to call back the clinic and say, “I can’t afford that medication.” All of those things are resolved in that moment in time.

The way the world is moving, there’s just not a future where providers are not going to be considering cost. High-deductible health plans are ubiquitous now, and patients are bearing a price for healthcare that was never intended for them. The in-network negotiated rate was used in a calculation before, but now patients are faced directly with that out-of-pocket expense, first dollar. Clinical decision-making and cost and coverage decision-making are now one and the same. They have to become integrated, clearly not emphasizing cost and coverage over the right clinical choice, but making sure that the clinical choices that you are making are the things the patients can access and afford. Patients are demanding that.

How much inefficiency is involved with the provider making a clinically appropriate decision and then having to redo that decision without compensation for cost reasons, through no fault of their own?

I think the number I saw in a Health Affairs article years ago was 65 million calls a year to provider offices to resolve exactly what you just described. There are three therapeutically equivalent drugs. You chose A, we wanted you to choose C. The provider doesn’t necessarily have a strong opinion on one of those three options. They just don’t have the information they need to understand that choice and how the health plan is contracted to derive that preference. There’s an absolutely strong efficiency argument for provider offices in general. Making the right decision the first time prevents reworking many of them.

Have you seen a comparison of patient satisfaction with the provider when their prescription process goes without a hitch versus when the patient is bounced around as the middleman?

We are just starting to look at that. Our focus to this point has been primarily on provider adoption, because in our belief, everything starts there. If we can’t compel a provider to use the tool consistently and to influence their behavior in an appropriate direction as a result of this intervention, then everything downstream of that becomes impossible. Most of our focus has been on the behavior change aspect of the tool.

That’s where that 20% or so number that I mentioned earlier is really important. It is many times higher than most of the other things happening in the industry. Multiple times higher than other behavior change measures in the industry. It has been a huge part of our focus, and the key to our value is understanding provider engagement and how and why they use the tool. That comes from being an organization that was incubated within the University of Colorado health system and having intentionally worked with health systems as strategic partners to better understand their world, to better understand the problems they’re trying to solve, to better understand how our solution can impact those problems.

Transparency would ordinarily create a more competitive market, perhaps among insurers, PBMs, or pharmacies. Are you seeing an effect on the pharma supply side of having patients know upfront where to get their prescription filed or what alternatives are available?

Real-time benefit is a mechanism to communicate the supply-side negotiations that have already happened. PBM and manufacturer have decided on formulary placement and what tier and what reimbursement is appropriate. Real-time benefits allow the mystery that was happening in the background to be provided in a way that makes sense to an end user, to a provider trying to make that decision. It will be some time before having that information at the point of care starts to influence, well downstream, the supply-side negotiations. Because in a lot of ways, we are just communicating something that has already happened between the risk-bearing entity and manufacturers.

But I do think that over time, the fact that this is happening at the point of decision is a massive opportunity to think about these things differently. Maybe future-state thinking about other forms of affordability being communicated at the point of care and maybe even directly to patients. That’s the key to all of this, starting to expand our purview beyond just the point of care, but also to care teams and also to the patient themselves. Making sure that we are leveraging our network — which is focused on driving the right decision the first time, whether that’s a med or something beyond a med — to influence point-of-care decision making, care team decision-making, and patient decision-making, all from a common source of information and one source of truth.

That’s where we can start to change systemic decision-making, but it takes all three legs of that stool to do that well. The impact then will be some of the things you are driving at, which is ultimately that adherence will be massively impacted, the patient experience will be massively impacted, and even ultimately how some of these financial decisions around which med and why will be financially impacted. Because we will have the data end to end, from decision to fill, to understand those things, to identify the cohorts, and to understand outcomes. That’s the groundwork that we are laying, this decision network and then the access network.

How hard is it for prescribers to advise patients, using available electronic information, where their prescription will be cheapest given available pharmacies, manufacturer assistance programs, coupon programs such as GoodRx, and insurance coverage? In the paper prescription days, patients could visit multiple pharmacies for prices, then choose which one to fill it.

Today, that’s a tough thing to do at the point of care. I think your point around empowering consumers is the most relevant one. Ultimately we have to put some of this cost decision – specifically, the decision around location of fulfillment and what methods to drive affordability that patient needs — in the hands of the consumer. E-prescribing 1.0 really limited patients’ ability to have choice and patients’ ability to be an active and informed consumer. 

Real-time benefit and price transparency, like the liquidity of price transparency information more broadly, absolutely represents an opportunity to return to that. We can put these types of insights into the hands of the care team that’s trying to support that patient and the patient themselves to potentially select the lowest-cost pharmacy, to select the lowest-cost path of care in general. For sure, that is the opportunity. That’s the turn we are making as an industry and we are making as a company.

Our transition from RxRevu to Arrive Health is part of that. We see our role expanding, both with stakeholders — so not providers alone, not prescribers alone, but care teams and patients — and also around the types of transactions and services that we are able to impact. It’s not just drugs any more, it’s labs and radiology and all of the shoppable things that are coming because of the No Surprises Act, price transparency regulations that have happened, and even the Cures Act to some degree, Patient data itself is more liquid and we are required by statute to engage patients with. All of those things net out to an environment where patients being empowered to make those decisions now is possible. The technology, for a number of reasons, wasn’t capable of doing it, and that has changed.

How will the lab, pharmacy, and radiology market, as well as the company itself, change once prescribers have access to cost and alternatives information during the ordering process?

Providers care a lot about patient out-of-pocket costs. The ability for a patient to actually afford care is usually motivating for a provider, because ultimately, they can only benefit from care that they can afford and access. In some of these more discrete medical benefit site services, the out-of-pocket impact is not quite the same as drugs. We lose some of the incentive for the provider to engage, because providers care a lot about patient out-of-pocket costs, but it’s much more difficult to get providers to pay attention to, or adhere to, plan cost requirements.

This is not a criticism of providers. It’s just that when you think about the way they are trying to make that decision, it’s ultimately doing the right thing for the patient. The right thing for the patient is, can they afford it? That’s where care teams become really important, the care teams that are doing access work, the care teams that are doing referrals, the care teams that are doing prior authorizations. That’s the opportunity that I see to influence some of that other medical benefit type decision-making that’s just more appropriate workflow. That’s where that work is happening and that’s where I think the value is, in concert with a direct patient outreach. Patients need to understand their options, but it’s heavily a care team utility in that case.

What will be most important to the company in the next few years?

The continued capability of health plans to expose price transparency information to their members is really, really important. Critical, even. The continued push for data liquidity as it relates to eligibility, the straight commodity stuff that you need to understand who the patient is. To me, pharmacy eligibility is a good example of that. That should flow freely, because ultimately all you do with pharmacy eligibility is you understand that I, Kyle Kiser, am a part of Health Plan A and Formulary A. That’s more or less like a user credentialing function. 

If you think about an Amazon login, that’s just a ticket to the game. Making that flow freely and as liquid as possible, accessible to any patient who wants it, accessible to anybody working on behalf of that patient that the patient has given permission to. All those things that Cures promises — the progression of that is important because the restriction of that information is a rate limiter to innovation, period. Those two things, from an industry level, are important.

For us, as we look to the future as a company, it’s ultimately how we more tightly integrate point-of-care decision-making, care team decision-making, and the patient themselves making these decisions. How do we create as tight a feedback loop between those stakeholders as possible, so that everybody is informed in the right ways and in ways that drive the right decision the first time? That’s us spending a lot more time in how we are engaging patients and engaging patients in ways that add significant value to the decisions they are trying to make. 

Creating a whole-patient experience for care team workflows. Those are highly fragmented tools right now. If you ask a member of an access team in any health system in America what they use, they’ll give you 30 answers. Really, the truth is those 30 answers are on sticky notes stuck to the monitor, all the websites they have to go to solve these problems — one for prior auth, one for medical benefit prior auth, one for affordabilities content, one for enrollment. Creating a more consistent workflow for that team has a huge amount of value and is low-hanging fruit in the industry. 

Then ultimately, continued focus on point-of-care behavior change. What really drives decision-making in an appropriate way for providers? How do we continue to become value-add to their workflow? Not another alert, not another thing that burdens them, not another of the overwhelming amount of information that we tend to throw at them, but how do you start to drive decision-making in way that is effortless for them to engage with?

Ultimately patients are demanding, and will only continue to demand, that clinical decision-making and marketplace information are considered in one consistent workflow. How do we do that in a way that consistently drives provider engagement and behavior change, and how do we measure all of that? What is our ability to stitch together that complete patient journey from point of care to care team, to patient engagement, all the way to fulfillment? What is the underlying data that allows us to understand when that is working and understand when that is not working?. That’s our future.

Morning Headlines 7/6/22

July 5, 2022 Headlines No Comments

One Medical Considers Options After Getting Takeover Interest

Concierge primary care operator One Medical is reportedly considering its options after attracting and then rejecting preliminary acquisition interest from CVS Health.

US court trims fine on TCS to $140 million in Epic Systems suit

A federal court reduces damages in Epic’s 2016 trade secrets lawsuit against Tata Consultancy to $140 million, down from an original $940 million.

Assembly Health Committee advances CMA-sponsored prior auth bill

A California Medical Association bill would require health plans to exempt doctors from obtaining prior authorization for prescriptions if they have historically practiced within that plan’s rules 80% of the time.

News 7/6/22

July 5, 2022 News 15 Comments

Top News

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Francisco Partners completes its acquisition of the data and analytics assets of IBM Watson Health and renames the business Merative.

Chosen as CEO is industry long-timer Gerry McCarthy, who has served in executive roles with ESolutions, TransUnion, HealthMEDX, and McKesson. The company’s headquarters will be in in Ann Arbor, MI. Former Watson Health Paul Roma will transition to senior advisor to Francisco Partners. Much of the remaining IBM Watson Health executive team will remain in place.

The company, which FP acquired for a reported $1 billion versus the $4 billion IBM spent to create it from a series of acquisitions, will organize around six product lines – Health Insights; MarketScan; Clinical Development; Social Program Management and Phytel; Micromedex; and Merge Imaging solutions.


Reader Comments

From Spare Change: “Re: return to office. We are seeing the result of employees who have power like they have never had, the ability to work from anywhere.” I think that moment was fleeting. Economic and industry conditions have put bosses back in charge and they know that they need to manage costs while fretting less that their employees might flee to greener pastures. I never understood the “great resignation,” assuming (perhaps naively) that the same number of people still need to work and the total number of available jobs hasn’t changed much even though job mix has shifted. Some jobs can be performed remotely (and always could have been), but work-from-home was, like telemedicine, a temporary compromise whose adoption will settle at numbers higher than pre-pandemic but much lower than in 2020-21. I bet many executives agree with me that you can’t build and maintain a great company when employees are doing task work in their living rooms and communicating via Slack and Zoom while missing face-to-face meetings, chance encounters, personal relationships, and exposure to broader company work. I expect companies to compromise by offering a hybrid model of 1-2 offsite work days per week or maybe going with a permanent four-day workweek, which adds flexibility and reduces commute headaches but without conferring geographic freedom. Employee threats to sell their services elsewhere if they are required to show up at the office are ringing pretty hollow now versus a year ago. Have you seen a shift in the employee-employer dynamic in the last couple of months?


HIStalk Announcements and Requests

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It’s about an even poll respondent split between telehealth being more important now versus in 2019.

New poll to your right or here: From your most recent encounter, how much of the clinician’s time seemed to be spent on tasks that lower-level people could have done? My perception is mixed – sometimes it seems that being the only person in the room with the patient makes the clinician feel that it’s easier to do low-value work than to bring someone in to help, or lures them into a comfort zone of happily performing comfortably mindless work.

HIStalk sponsors: prices will increase a bit starting January 1, 2023, although the cost will still be less — taking inflation into account — than in 2014, when it last changed. This is the cue for on-the-fence companies to sign up sooner rather than later.


Webinars

July 12 (Tuesday) 1 ET. “Digital Data Stewardship for Trusted, High-Quality Data Exchange.” Sponsor: Clinical Architecture. Presenter: Carol Graham, MS, RN, product manager, Clinical Architecture. Organizations face challenges in ensuring that the patient data they received and send is consistent, accurate, and usable. Use cases include receiving multi-source data across health information networks with variation in formats and content; merging and de-duplicating provider, payer, and research data; uplifting legacy data for current use cases and formats; and normalizing and formatting data for public health surveillance, quality measure reporting, and providing directly to the patient. This webinar will cover Pivot, a comprehensive Digital Data Steward solution that orchestrates format harmonization, content (vocabulary) normalization, de-duplication, and data quality validation into a single solution.

Previous webinars are on our YouTube channel. Contact Lorre to present your own.


Acquisitions, Funding, Business, and Stock

Concierge primary care operator One Medical is reportedly considering its options after attracting and then rejecting preliminary acquisition interest from CVS Health. Shares in One Medical’s parent company have lost 75% of their value in the past year, giving the company a market cap of $2 billion.


Sales

  • Midwest Orthopaedic Center (IL) selects cloud-based EHR and RCM software from EClinicalWorks.

People

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Eric Newman, MD (Geisinger Health) joins Eon as chief innovation officer.

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Well Health names J.P. Knapp, MHA (Vocera) VP of sales.

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Brian Lancaster (Nebraska Medicine) joins Children’s Mercy Kansas City as SVP/CIO.

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Cured promotes Josh Kalscheur to VP of business development.


Announcements and Implementations

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CaringWays taps Clearwater to develop and implement a cloud-based cybersecurity and compliance program for its digital fundraising software for patients.

Cone Health (NC) implements ActX’s EHR-integrated, genomic decision-support software.

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The American Nursing Informatics Association publishes the first in a series of toolkits that support the practice of nurse informatics.

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FDA gives clearance for LiveMetric’s LiveOne, a wrist-worn monitor that takes blood pressure from the radial artery every 10 seconds and records the results over several days to help understand the connection between BP and lifestyle, behavior, and medications.

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A new KLAS report on EHRs for practices of 11 or more clinicians finds that Epic and Meditech lead the the pack in finishing a close 1-2. Ease of use and workflow is by far the most pressing concern of practices of that size. Cerner users are frustrated with outpatient workflows and the company’s focus on resolving inpatient problems, while Greenway Health’s customers are an outlier in putting functionality improvements at the top of their list of needs. Allscripts has two of the three bottom-rated products, along with poor ratings for support, relationships, and overselling product capabilities.


Government and Politics

A California Medical Association bill would require health plans to exempt doctors from obtaining prior authorization for prescriptions if they have historically practiced within that plan’s rules 80% of the time. Other physicians would be given the right to have their PA appeals conducted by a physician in their specialty.


Privacy and Security

HHS posts a review document titled “HIPAA Privacy Rule and Disclosures of Information Relating to Reproductive Health Care.”


Other

Damages in Epic’s 2016 trade secrets lawsuit against Tata Consultancy are reduced by a federal court to $140 million. The original damages assessed to Tata were set at $940 million, but were reduced to $420 million and later to $280 million.

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Norton Healthcare (KY) attributes ongoing computer connectivity issues at several facilities to an unspecified hardware problem that began July 1.

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Munson Healthcare’s virtual urgent care program sees an uptick in usage that it says is mostly due to word of mouth. It triages patients to video visits after initial phone screenings and has seen 250 patients as of early June. It is staffed by 20 Munson physicians who pick up shifts on their days off. Next up for Munson is patient text messaging and enhancing the system’s doctor-finder tool with online scheduling.


Sponsor Updates

  • EClinicalWorks releases a new podcast, “How Price Transparency Can Offer a Competitive Edge.”
  • Azara Healthcare completes the NCQA HEDIS Health Plan Measure Certification Program for MY 2022 HEDIS measures.
  • Bamboo Health hires Dana Koetz as growth director, Brian St.Amour as data integration engineer, Anvesh Muthyala as senior software engineer, Kamilla Ionesia as partnerships manager, Dean Cikins as strategic accounts director, and Milacy Travieso as project manager – data science.
  • Biofourmis releases a new Out of Patients Podcast.
  • CareMesh names Samantha Davis, RN (Medical Solutions) senior clinical project manager.
  • CoverMyMeds will exhibit at McKesson IdeaShare July 7-10 in Washington, DC.
  • Enlace Health achieves HITRUST certification to further mitigate risk in third-party privacy, security, and compliance.
  • Nuance will offer its Dragon Medical One speech recognition software to Meditech users in Puerto Rico through a partnership with health IT firm Scientia Puerto Rico.

Blog Posts


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