Curbside Consult with Dr. Jayne 9/28/20

Just when you can’t think 2020 can get any weirder, here comes the story of a copperhead snake that made an appearance during a patient’s televisit.

Every week it seems like there’s something more bizarre going on than there was in the previous week, and that’s really saying something when you’re in the 39th week of the year.

I’ve had another couple of surreal clinical shifts, to the point where I can’t even talk about them. Some of the issues are just medically complex and are nearly impossible to blind for HIPAA purposes. Others have been so traumatic for the care team that I don’t want to relive them in any way, shape, or form.

In that context, I was glad to have a low-key informatics weekend. I spent a good part of it being on call for an upgrade, playing the role of the “IT person who just happens to be a physician.” They wanted someone to be on call to do additional testing of any clinical issues that cropped up during the upgrade, as well as to test any hotfixes that had to be done on the fly.

Fortunately, my client is a solid organization that understands the value of a well-planned upgrade. They’ve been tweaking and enhancing their test scripts over the years to the point where they are super solid. We only had one small issue that turned up early Saturday morning, and fortunately, it was with a new feature that we just turned off while waiting to troubleshoot with the vendor on Monday morning. It was certainly different from the white-knuckled adventures that I had with my IT team in my early days as a CMIO.

The rest of the weekend was spent on various consulting projects. One was to help a startup company with their messaging, which I always find to be fun work. Sometimes the smart folks behind a great tech idea don’t fully understand how to translate their solution into the language their target audience is looking for. I did some proofing for a redesigned web site and editing of a potential case study. The most fun part of the messaging work was working with a couple of sales reps to help them hone the delivery of their pitches. Sometimes being able to correctly pronounce medical words is the difference between building credibility and being shown the door, so I hope I made a difference in how those individuals will be able to convey their message going forward.

Another project involved designing order sets for a mid-sized medical group, which has spent a lot of time trying to do the work without much success. The physicians struggle to agree on anything, and the IT team is trying to distill hundreds of different physician-specific order sets down to something manageable. The project was originated by the quality department, who was tired of trying to promote various quality interventions when physicians would just refuse to use the global set and use their own instead.

Essentially, I had to export all the order sets and compare them by specialty and by location, identifying the commonalities and analyzing data about their use. The physicians had agreed to get on board with a data-driven approach. When I’m done, we’ll have a real understanding of which order sets are used and which parts of order sets are manually altered. They actually allocated ample time to mine the data and achieve physician buy-in, so I’m fairly confident the project will be successful when it goes live in a couple of months.

I also started working on a new medico-legal project, which was at times exciting, but overall made me sad. If there’s anyone in a healthcare IT organization who believes they can take actions within an EHR and not get caught, they really should think twice. Sifting through hundreds of pages of audit trails isn’t what I enjoy doing on a beautiful fall day, but it’s important to my client to understand the havoc that their employee created. I’ve identified the impacted patients (which fortunately isn’t that extensive of a list) and the next step is to audit the individual charts to see whether the employee modified any of the data, and if so, what they modified. I also need to see what kinds of data was specifically visible and whether any of it falls into the sensitive category.

Stories like this are a good reminder for organizations to check their security settings and to make sure employees only have the minimum access necessary to complete their work. It’s not just “a HIPAA thing,” but it’s a major integrity issue when you have to notify patients that someone was caught snooping through their charts.

I’m getting things caught up and organized since I’ll be out of office for part of next week, this time taking a much-needed mental health break. From a clinical standpoint, I know there are a lot of us that have hit the breaking point and I can tell I’m approaching mine if I’m not already there. It’s time for three days in the desert to sort things out while trying not to think of COVID (although I’m sure it will be front of mind on the flights there and also on the way home).

My favorite desert escape is closed through at least 2021, so we’ll have to see whether VRBO can deliver. Regardless of the accommodations, I’m looking forward to lots of sun and fresh air with no mosquitoes or ticks involved. My traveling companion already sent a list of the cocktail supplies she’ll be bringing with her, so it’s looking to be a good getaway even if we have to shake our own martinis since we’re physicians who will be self-isolating. I’ve packed three good books to get me across the time zones and back with some reading material in the middle. One is serious, one is a book club pick, and one is the pure unadulterated madness that only comes from Carl Hiaasen.

What strategies have you used to refresh and recharge during 2020? Leave a comment or email me.

Email Dr. Jayne.

HIStalk Interviews Blake Marggraff, CEO, CareSignal

Blake Margraff is CEO of CareSignal of St. Louis, MO.

Tell me about yourself and the company.

I co-founded the company CareSignal, which was previously called Epharmix, and I serve as CEO. CareSignal is a simple enough concept. We create device-less remote patient monitoring solutions to help support risk-bearing providers, payers, and the patients or members they serve, with a primary focus on chronic condition long-term management and support.

What led you five years ago — as a 22-year-old coming out of pre-med — to form a company in an industry that is notoriously hard for newcomers to crack?

There’s a pragmatic answer and a philosophical answer. The pragmatic answer is that I saw an opportunity to do one of my favorite things, which is to orthogonally combine technology – which, to your point, a lot of people have thought would work by itself and hasn’t — with evidence. The basis of our company is evidence first, sales second.

Philosophically, though, if I could spend my time doing anything, I want to be able to look back in one month, one year, 10 years, 50 years, and be proud of the impact it had and the scale of that impact. I think healthcare, and specifically health technology, is the best one-two punch out there.

Some wellness technology companies offer solutions that, if they work at all, won’t deliver ROI for years, when the cost savings of improving chronic conditions will finally pay off for some other employer or insurer. How do you approach a prospect who questions return on investment?

These are two really important concepts. The credibility of the argument, fundamentally, always involves return on investment. That credibility comes in the form of defensible impact clinically and then financially, but also the time horizon of that impact. Getting a person to stop smoking is a good thing, but financially it might not actually be a good thing for one, five, or 10 years.

To the people who have abused the concept of evidence-based or clinically validated outcomes — and you can bleep this in the written version — but frankly, f*** them. They are treading on one of the most elegant and powerful parts of medicine, which is the concept that you can advance the standard of care by thoughtfully conducting high-impact research and iterating on innovation in the process.

In terms of CareSignal, we announced recently that we now take risk on any contract we sign. We are confident that we can engage through all the patients, drive clinical outcomes, and return financial benefit to our partners with the time horizon of less than a year, and generally within six months. That touches on all the points that you mentioned. It’s not enough just to do it — you have to do it in a way that is financially compelling to your partner.

What portion of patients show a willingness to interact honestly with automated messages about a concerning condition, but would not have taken the initiative to reach out directly to their provider?

You are hitting on selection bias, and maybe touching on the transtheoretical model of behavior change as well. It is true that some healthcare innovations can only help people who want to be helped. That’s always true to an extent, but I fundamentally reject that as a barrier to bending the cost curve, or even engaging the vast majority of patients who need to be engaged and supported.

The argument that I provide is a simple one. When providers, meaning physicians primarily, want to effect change, they leverage this power of the prescription. There is still an element of healthcare that is relationship driven, stemming from the strong relationships that many providers still have with their patient populations. The best technology sits at that intersection of clinical and relationship.

Does the political concept of campaigning only to the undecideds make sense in population health management in focusing resources on patients who are most likely to benefit from health messaging?

I don’t have deep background, so I’m almost wary of speaking to that and I would just be pontificating on it. I will say that looking at chronic conditions, there’s kind of an ironic behavior trend that we see across our patient population and partners. Patients who are doing just fine wind up disengaging faster than patients who are experiencing adverse outcomes or adverse symptomatology. The heart failure patient who hasn’t had pedal edema or nocturnal dyspnea for months, maybe even years, is going to be much less inclined to stay engaged and to provide clinically helpful, actionable patient-reported outcomes. Whereas the one who’s struggling is going to do so more.

A well-designed system will support people who are doing just fine for the long term, but will then allow the benefit to be had by the people who decompensate or get worse, whenever that happens, and that could happen a month or a year down the road.

Does the interaction between care managers and patients in your system populate other systems, such as EHRs?

Absolutely. CareSignal can operate as a standalone system. That’s important because a lot of groups need to operationalize and prove any new partnership or investment. We integrate with Redox and have a whole lot of respect for Niko, Luke, and the team. They can integrate with any EHRs that they touch.

Providers might react to a patient’s response to automated messages by either assuming that they are fine or that they need to come in for an office visit. What other kinds of communication do you see?

Our system is white-labeled, so from the perspective of our partners and patients, it is always their system. It’s essentially a warm line that is always ready. For patients who are in that rising risk bucket with barely-controlled chronic conditions that could go south at any moment, having a direct line to the care management team that you already know is powerful.

How is your system being used differently in the pandemic?

It’s just being used more. I’m grateful for the new opportunity from a business perspective, but the whole team and I have been pretty humbled to see that it’s doing what we always thought it could do in virtual health. Telehealth is table stakes and is increasingly quite present and quite high quality, but providers especially are emphasizing the need to defend relationships and grow revenue, and sometimes the reverse depending on their financial position. It’s the long-term engagement, ideally long-term, clinically actionable engagement, that seems to speak to them as we all go through this frustrating process.

What advice would you offer to people like you who didn’t come up through the health IT ranks or who may be disappointed by its bureaucracy and long purchasing cycles?

There’s a great mental model of Chesterton’s Fence. A couple of guys come across a fence in a field. One says, “Let’s tear this down. This is stupid. This is pointless.” The other guy says, “That’s fine. You can do that, but at least first tell me why it was built.”

That’s how I approach a lot of the conversations. It can seem like there’s too little of one type of thing and there is too much of another thing that seems unnecessary. You have to understand why it was put there in the first place if you’re going to effect sustainable change that will benefit all of the stakeholders. I guess that has  brought me to the conclusion that everybody in this space deserves a huge amount of respect, if only for their patience and often their iterative investment in a pretty weird industry over the past decades.

What is good and bad about how investors may take a company in a different direction that it originally planned?

Founders have to remember that investment is a means to an end. Folks who want to raise money so that they can raise money … most investors will not invest in that type of founder or business. More positively, I can cite investors such HealthX, UnityPoint, OSF, and others that are deep in healthcare, as well as many more that are immediately adjacent to health IT. They are run by operators and industry incumbents. It’s too complex of an industry for me to think that I can come in and figure everything out. The best investors not only provide good direction, but help you learn faster.

You started your entrepreneurial journey at a young age. What do you hope to accomplish?

Impact. Help as many people as possible live better lives and live longer lives. It comes back to the beginning. That’s what keeps me so motivated, even in a sometimes slow-moving industry, to keep pushing.

Morning Headlines 9/28/20

Allegheny Health Network, Innovation Works Announce New Startup Accelerator Focused on Health Care Technologies and Life Sciences

Allegheny Health Network (PA) and a Pittsburgh investor create AlphaLab Health, an innovation hub that will provide seed funding to companies that are involved in diagnostics, therapeutics, medical devices, and health IT.

‘Big ripple effect’: Cybersecurity issue causes problems across Neb. Med network

Nebraska Medicine officials say normal operations should soon resume across its Epic network, shared by several other hospitals across the state, as it works to recover from last week’s cyberattack.

CloudMD Signs Definitive Agreement to Acquire Snapclarity Inc., an Enterprise Mental Health Platform, Expanding Telehealth Offering to Include Mental Wellness

Canadian health IT vendor CloudMD will acquire mental health assessment and care coordination vendor Snapclarity for $2.5 million.

Monday Morning Update 9/28/20

Top News

Allegheny Health Network (PA) and a Pittsburgh investor create AlphaLab Health, an innovation hub that will provide seed funding to companies that are involved in diagnostics, therapeutics, medical devices, and health IT.

The hub will be housed in the former Suburban General Hospital in Pittsburgh’s Bellevue community, which Allegheny Health Network has mostly closed since acquiring it in 1994, leaving only an urgent care center and outpatient clinics.

A predecessor organization to Allegheny Health Network was AHERF, which went from running just Allegheny General Hospital to Pennsylvania’s largest health system, which include acquisitions of Medical College of Pennsylvania and Hahnemann Medical College and their hospitals. AHERF filed bankruptcy in June 1998 in what was then the largest non-profit healthcare system failure with $1.3 billion in debt. West Penn Hospital  was merged with the Pittsburgh assets of AHERF to form West Penn Allegheny Health system, which struggled to compete with UPMC and eventually sold itself to insurer Highmark, which was anxious to strike a deal since its relationship with UPMC was deteriorating. Highmark Health remains AHN’s parent. AHERF’s Philadelphia-area hospitals were bought out of bankruptcy by Tenet in becoming that area’s first for-profit hospital chain.

Reader Comments

From CIO: “Re: HIStalk. Just wanted to let you know that I still make my team read HIStalk and occasionally quiz them to make sure they do.” Thanks. Similarly, a CEO recently told me that a new investor made him promise to read HIStalk daily. I appreciate that even if I can’t really comprehend it since my view of HIStalk is an empty screen that I fill in solitude each day with whatever interests me.

HIStalk Announcements and Requests

Vendor experience with virtual conference exhibit halls hasn’t been good. Commenters note that the volume of leads is good but the quality is not, while low engagement leaves reps starting alone at a Zoom screen for hours.

New poll to your right or here: How has your job changed since the pandemic began? Click the poll’s comments link after responding to explain further with your anonymous thoughts.

Welcome to new HIStalk Platinum Sponsor Newfire Global Partners. The Boston-based company partners with healthcare businesses globally to make innovation happen, such as in developing custom digital health solutions, speeding up the drug development cycle, and de-risking growth without compromising interoperability and security to turn the new normal into a durable, competitive advantage. Nearly 90% of the company’s 350 employees hold advanced degrees, working from offices in the US, Ukraine, Croatia, Singapore, and Hong Kong to offer services in advisory (assessments and due diligence, strategic marketing, interim operating roles); talent (blended teams, dedicated teams, specialized expertise); and AI-powered software development management. Healthcare-specific offerings include FHIR integration, data science and analytics, provider and patient adoption, and interoperability. Chairman and CEO Stephen Hau, MS is an industry long-timer who founded PatientKeeper and co-founded Shareable Ink. Thanks to Newfire Global Partners for supporting HIStalk.

Webinars

September 30 (Wednesday) 11 ET. “The Hidden Threat: New Research on Security Vulnerabilities and Privacy Gaps in Healthcare Apps.” Sponsors: Verimatrix, NowSecure. Presenters: Neal Michie, MEng, director of product management, Verimatrix; Brian Lawrence, direction of solution engineering, NowSecure. The presenters will present research on the security risk profile of 1,000 healthcare apps in managing patient privacy, how they compare to those in other industries, and where the biggest vulnerabilities lie. Attendees will learn how to make their healthcare apps more secure in managing protected health information.

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

People

Ori Lotan, MD (Universal Health Services) will join MultiCare (WA) as VP / chief health information officer. 

Central Logic hires Maija Costello, MBA (Accenture) as VP of people and culture; Samantha Endres, MBA, CPA (West Acadamic Publishing) as CFO; and Robert Zdon (RAZR) as chief marketing officer.

Government and Politics

UT Southwestern Medical Center Assistant Professor of Radiology Lorraine De Blanche, MD pleads guilty to intentionally misleading federal agents who questioned her in a telemedicine fraud investigation that occurred while she was employed as a radiology professor at University of Arkansas. She admitted that she prescribed durable medical equipment and compounded prescription drugs without talking to the patients involved. She faces five years in prison and will pay $213,000 in telemedicine proceeds and fines. 

COVID-19

HHS takes $300 million from CDC’s budget to run a “defeat despair” advertising blitz that features celebrities and administration officials discussing the pandemic and the White House’s response to it, with airings to begin before Election Day. Interviews have already been recorded with Dennis Quaid (who has publicly praised the administration’s COVID-19 response) and CeCe Winans (who was chosen for improving messaging with black viewers). HHS spokesperson Michael Caputo said before he took medical leave that President Trump demanded personally that he create the campaign, which he says will draw ire from Democrats and “their conjugal media and the leftist scientists that are working for the government” because he’ll be running $250 million worth of taxpayer-funded ads.

A White House aide demands that FDA justify its toughened standards for a COVID-19 vaccine on the same day that the President branded the changes as a “political move.” FDA planned to release the guidance last week, but is instead working on its explanation of extending safety studies to two months after the second injection, which makes a pre-Election Day vaccine release unlikely.

Minnesota stops a door-to-door coronavirus survey after public health workers were intimidated by people who shouted ethnic and racial slurs, followed the workers, videotaped them, and threatened to call police. The mayor of one small town says it is reasonable that residents become concerned when they see a car with California plates.

Just about all infectious disease experts warn that it will be a gloomy US winter as people move back indoors, schools and business return to some degree of normal with increasing contact, and people gather for holidays. The predicted post-Labor Day case jump is already happening. IHME projects 372,000 US COVID-19 deaths by January 1, with daily deaths increasing from today’s 780 to 3,000 (or 6,600 if mandates are eased) and ICU bed demand rising from 8,400 to 31,000. California’s HHS secretary warned Friday afternoon that he expects COVID-19 hospitalizations to double by late October.

ProPublica reports how the CEO of a telemedicine vendor, who was also an ex-convict, convinced two South Texas elected officials to promote local government use of his telemedicine services during the pandemic and to urge other leaders to buy his unapproved COVID-19 tests.

Other

USA Today lists several new consumer gadgets devices can serve – now or down the road — as a dedicated Zoom devices, including Amazon’s Echo Show 10 for $250, a webcam plugged into a Fire TV Cube that can be displayed on large-screen TVs, and Facebook Portal TV. Benefits include freeing up hands and computer screens for taking notes and untethering webcam placement. The Echo Show 10 even auto-frames the user with pan and zoom. It will also connect with Amazon Chime pay-per-use service for business calls and meetings. Amazon sells the Alexa-powered Facebook Portal TV for $149. I suspect remote work and videoconferencing is here to stay, so the modest investment to make it better and easier seems worth it.

Contacts

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Weekender 9/25/20

Weekly News Recap

• CMS is reportedly preparing to notify the 76% of US hospitals that aren’t submitting daily COVID-19 reports to HHS’s new reporting system that their Medicare payments may be halted.
• A business associate of Community Health Systems will pay $2.3 million to settle charges that it failed to secure its systems even after the FBI warned it that hackers had penetrated them.
• FDA launches the Digital Health Center of Excellence that will advise it on digital health policies and regulatory approaches.
• Microsoft launches Cloud for Healthcare.
• A KLAS Arch Collaborative survey finds that EHRs are not a significant cause of nurse burnout.
• The Carlyle Group acquires a majority stake in global health research network TriNetX.
• Healthcare robotic process automation vendor Olive raises $106 million.
• Informatics pioneer Bill Stead, MD announces that he will retire from Vanderbilt University Medical Center’s senior leadership team after a 29-year career.

Best Reader Comments

A person’s birth sex matters in lab results and medications. How they feel does not and could get them misdiagnosed or possibly killed if I am asked to send how they identify in PID:8. If HL7 wants to add an additional field for delivering how a patient feels about their gender identity, Interface Engineers will deliver it, as we do with all fields. (Don’t Blame The Interfaces)

You aren’t wrong about birth mattering in some situations, but also important to keep in mind that deliberate mis-gendering or dismissiveness of patient gender identity can present a lot of harm to a patient. (Alex)

Congratulations to Dr. Stead. I had the pleasure – as many – at McKesson to work with him on the CPOE system. A gentleman and obvious scholar who was practical is his approach to many of the problems faced by physicians and informatics folks at the time. Dr. Stead, may the sun shine on your face and wind be at your back always. (Mark P)

Your employer / insurer wants to decrease your use of healthcare so that they don’t pay as much. Sending you advertising for healthcare (services) typically increases utilization. Care coordination is expensive in itself and often actually drives up utilization. The majority of Americans at this point are putting off some healthcare issue. Get them into a care management program and suddenly you’re paying for the issue they neglected for the last five years in order to make rent. Pay close attention to their issue and now you catch all the stuff that needs more medical attention. In conclusion, the answer to the question “Why don’t they X?” Is because X doesn’t make them money. (IANAL)

Watercooler Talk Tidbits

Readers funded the Donors Choose teacher grant request of Ms. M in Michigan, who asked for two interactive learning tablets for her elementary school class. She reported in mid-March, “The PBS Kids tablet is a wonderful edition to our classroom. The already installed games really excite our students and help them in the areas of literacy and math. The students are also able to explore with music, art, audible stories and more. They honestly know more about the tablet than I do through exploring. We use the tablet during choice time and also during individual learning time. This tablet really helps the students to have fun, develop technology skills and learn all in one. We could not have gotten this obviously without all of you generous donors. Thank you for caring about our classroom.”

The Los Angeles Chargers team doctor punctures the lung of starting quarterback Tyrod Taylor while administering an injection into his cracked ribs just before kickoff, sending him to the hospital with breathing problems.

Time names Johns Hopkins University engineering professor Lauren Gardner, MSE, PhD as one its 100 most influential people in the world. She led the team that developed the COVID-19 Dashboard in late January in working with first-year PhD student Ensheng Dong, MS while COVID-19 was still contained to China. Her Hopkins role is as associate professor, which seems a bit light for someone who has changed the world. 

A Virginia TV station profiles Nigerian-born otolaryngologist Samkon Gado, MD, who played football for Liberty University, spent six years as an NFL running back, went to medical school and residency, and is now back in Virginia working in an ENT practice with his former college roommate and football teammate. His dream was medical school, not pro football, so he hoped for a four-year NFL career to pay for medical school. He finished his residency caring for COVID-19 patients in St. Louis.

Friends and family of a former World War II Army nurse celebrate her 100th birthday with drive-by greetings. Georgia-born Virginia George says of her post-war move to Binghamton, NY, “I came here over 70 years ago and I haven’t been warm since.”

In Case You Missed It

• News 9/25/20
• EPtalk by Dr. Jayne 9/24/20
• Readers Write: Food for Thought About Apple and Google COVID-Tracing Technology
• HIStalk Interviews Scott Weingarten, MD, Chief Clinical and Innovation Officer, Premier
• News 9/23/20
• Curbside Consult with Dr. Jayne 9/21/20
• HIStalk Interviews Bill Grana, CEO, HCTec
• Monday Morning Update 9/21/20

Get Involved

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• Sign up for email updates
• Connect on LinkedIn
• Contact Mr. H

Morning Headlines 9/25/20

Trump Administration Plans Crackdown On Hospitals Failing To Report COVID-19 Data

Internal government documents suggest that CMS will threaten to stop paying the 76% of US hospitals that aren’t sending COVID data daily and will also add new reporting requirements for influenza.

The Dark Overlord Member Receives 5 Years Prison Term in the U.S.

The extradited UK national is also ordered to pay $1.5 million in restitution for stealing and selling information from businesses, including hospitals.

HHS Announces Health IT Awardees Focused on Data Sharing to Support Clinical Care, Research, and Improved Outcomes

HHS and ONC award $2.7 million to four health IT acceleration projects.

News 9/25/20

Top News

CMS will threaten next week to terminate the Medicare participation of the 76% of US hospitals that aren’t submitting daily COVID information to the new HHS Protect system, according to an NPR review of internal documents.

The pending update will allow hospitals to submit PPE and ventilator data weekly instead of multiple times per week, but it will also add several new data elements that are related to influenza patients.

HHS previously justified the need for the abrupt system switchover from the CDC’s system in July by saying that the 85% of hospitals that were reporting voluntarily was inadequate and that the White House Coronavirus Task Force requires 100% participation. Since then, only 24% of hospitals are complying with the new mandatory data submission requirements.

HIStalk Announcements and Requests

I wanted to schedule a checkup from a former provider and remembered that I have an associated Epic MyChart account that has been dormant for several years. I logged back in and it was impressive, especially compared to my experience with an academic medical center’s MyChart deployment a few years back in which I concluded that their mediocrity spanned both technical and clinical domains. This provider’s version contained useful health reminders, strong security (such as two-factor authentication), easy appointment scheduling, provider messaging, complete medical records, and the ability to update my own medication and health issues lists subject to provider confirmation. It even let me know of a study I could participate in. I would have given it a perfect score other than my submitted insurance information has yet to be verified by the provider’s office after several weeks, so I still don’t know what to expect when I show up waving my card.

Webinars

September 30 (Wednesday) 11 ET. “The Hidden Threat: New Research on Security Vulnerabilities and Privacy Gaps in Healthcare Apps.” Sponsors: Verimatrix, NowSecure. Presenters: Neal Michie, MEng, director of product management, Verimatrix; Brian Lawrence, direction of solution engineering, NowSecure. The presenters will present research on the security risk profile of 1,000 healthcare apps in managing patient privacy, how they compare to those in other industries, and where the biggest vulnerabilities lie. Attendees will learn how to make their healthcare apps more secure in managing protected health information.

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

Acquisitions, Funding, Business, and Stock

KKR acquires 1-800 Contacts – which has branched beyond COVID-boosted lens sales with technology that allows consumers to perform at-home eye exams and to scan their glasses to generate prescription details — in a deal worth $3 billion.

People

Nuvance Health promotes interim SVP/CIO Geoff Hook, MBA to the permanent role.

Announcements and Implementations

NYC Health + Hospitals launches a telehealth solution for non-urgent needs, powered by NYC-based Bluestream Health.

Change Healthcare expands its pharmacy claims billing solution to include COVID-19 tests, which pharmacists can order, administer, and bill under recent HHS rules.

CareSignal offers an at-risk pricing option for its Device-less Remote Patient Monitoring, allowing providers and payers who are paid under value-based contracts to maximize their return on investment.

Redox announces new integrations with Salesforce Health Cloud and MuleSoft.

NantHealth releases APIs that will allow provider and revenue cycle organizations to connect to payers via the NaviNet Open Platform.

Government and Politics

HHS and ONC award $2.7 million to four health IT acceleration projects:

• CRISP, which will work on using FHIR for participating in the American College of Cardiology’s disease registries.
• MedStar Health Research Institute, which will demonstrate using bulk FHIR data extraction for research.
• Children’s Hospital Corporation, which will develop tools to allow researchers to annotate data extracted by bulk FHIR for analytics, de-identification, and cohort assignment.
• Missouri Department of Mental Health’s developmental disabilities division, which will implement the integration of standardized data to advance person-centered planning, outcomes, and value-based payment models.

COVID-19

A fourth coronavirus vaccine candidate begins Phase 3 clinical trials as Janssen starts testing of its single-dose regimen with up to 60,000 volunteers.

The presidents of the National Academy of Sciences and National Academy of Medicine issue a statement insisting that pandemic policymaking, especially that involving vaccines, “must be informed by the best available evidence without it being distorted, concealed, or otherwise deliberately miscommunicated.” They add that they find that “the politicization of science, particularly the overriding of evidence and advice from public health officials and derision of government scientists, to be alarming.” 

Helsinki’s airport deploys two coronavirus-sniffing dogs in a pilot program for voluntary passenger testing. Travelers wipe their skin, deposit the wipe in a sample, and the dogs then smell it to detect coronavirus with near-100% accuracy within 10 seconds.

California expands its home address confidentiality program that was designed for victims of violence and abuse to include public health workers, following the resignation of a dozen workers after they were harassed at home or received death threats after enforcing masking and stay-at-home orders.

Missouri Governor Mike Parson, who shunned mask-wearing in saying that most people can figure out how to stay safe without government intervention, tests positive for COVID-19, along with his wife. The state reported its highest-ever COVID-19 death total of 83 on Wednesday, although the state attributes the high number to delayed reporting of death certificates.

President Trump says in a press conference that the White House “may or may not” approve FDA’s just-announced higher standards COVID-19 vaccines, saying that the change is politically motivated and that he “has tremendous trust in these massive companies” that are developing the vaccines. The White House’s authority to override FDA decisions is not clear. White House advisor Scott Atlas, MD said in the same press conference that CDC Director Robert Redfield, MD “misstated something” in reporting that CDC blood sampling indicates that 90% of Americans are still susceptible to infection in the absence of antibodies, saying that T cells and exposure to related viruses “make the antibodies a small fraction of the people who have immunity.”

Google Maps will add a COVID overlay that displays the seven-day confirmed COVID-19 case count per 100,000 people for each state, county, and some cities.

New York Governor Andrew Cuomo announces that the state will perform its own review of coronavirus vaccines that have been approved by FDA, saying that President Trump’s criticism of FDA’s more rigorous standards as a “political move” has led him to determine that “we can no longer trust the federal government.” The state would have little say in the matter other than determining its own rollout plan.

Other

A US federal court sentences an extradited UK citizen who is a member of The Dark Overlord hacking group to five years in prison. Nathan Wyatt will also pay $1.5 million in restitution for stealing the data of several companies since 2016, several of them hospitals, and threatening to sell their data unless they paid a Bitcoin ransom. Among his big scores is the sale of 9.3 million patient records that he obtained by breaching an unnamed health insurer.

Specialty EHR vendor Net Health moves to a permanent Work From Anywhere model, which it says will improve recruiting, increase retention, and reduce costs. It hopes to encourage community building with virtual team meetings, CEO emails, one-on-one video meetings that include pets and kids, virtual field trips and happy hours, and development of affinity groups.

As noted by @Cascadia: the care plan that Amazon is piloting for its Seattle-area employees posts a job opening for a healthcare-experienced Business Development Manager – Network Strategy, with responsibilities that include defining an executing a strategy for acquiring and managing provider networks; creating the highest-quality, lowest-cost referral network; and driving customer adoption via insurance company partnerships. Amazon Care, whose pilot started in September 2019, offers employees text chat with clinicians, video visits, nurse visits in the home or office, and courier delivery of medications.

Contacts

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EPtalk by Dr. Jayne 9/24/20

An article published last week demonstrates the ability for health systems to save money though implementation of clinical decision support (CDS) tools within their EHRs. One major outcome was the ability of CDS tools to help reduce waste by reducing unnecessary laboratory tests and antibiotic prescriptions. Researchers also noted issues with CDS systems, including maintenance costs and malfunctions that could have an adverse impact on bending the cost curve.

The authors “could not draw a sound correlation between vendor-purchased or home-grown systems’ costs to their economic benefit,” however. I would go further to state the need to look at the middle choice in that continuum as well: the heavily-customized vendor system, which sometimes is closer to homegrown than not.

Further studies are needed, and one of the elements that should be included is the impact of alerts on clinicians and the time they spend managing those alerts. They also need to assess the impact on extensive computerized physician order entry (CPOE) order sets that may add orders to a patient’s record when those orders aren’t entirely necessary. There’s always a balance between the technology, the needs of the patient, the needs of the care team, and the bottom line. A well-configured EHR can make your day go well, but a poorly-managed one will be your worst enemy.

On days that I see numbers of patients that would have been considered impossible before COVID, I’m truly grateful that my organization has stripped the EHR down to only the bare essentials that are needed to document quickly, without any extraneous content. The downside to that approach is that sometimes I find myself in a situation where I wish I had a fighter jet, but I’m piloting a Stearman. I’d love to see the vendors that are bragging about their ability to create documentation through voice recognition and artificial intelligence spend a day in my well-worn shoes. I’m sure what they see would be shocking, but we can’t solve problems that we don’t understand.

The US Food and Drug Administration is launching a Digital Health Center of Excellence within the Center for Devices and Radiological Health. Digital health technology within its purview includes mobile health services, wearables being used as medical devices, Software as a Medical Device (SaMD), and technologies used to study medical products. The FDA plans to create a network of digital health experts and to get technology to patients faster by providing technological advice, coordinating work being done across the FDA, advancing best practices, and reimagining the oversight of digital health devices.

I almost missed this one in my overflowing inbox, but apparently a new national system is being developed to track administration of the COVD-19 vaccine. Millions of people who are used to walking into a retail clinic or their local Costco and walking out with an influenza vaccine are going to be surprised by the complexity of the new coronavirus vaccine. Patients must receive two doses and the products are not interchangeable between manufacturers.

Public health officials are justifiably concerned that this new system will bypass existing state immunization registries, while watchdogs are concerned about its $16 million cost. Consulting giant Deloitte has been engaged to develop the Vaccine Administration Management System, which will use underlying Salesforce technology. It’s apparently been piloted in four states over the summer, but details are scant on what data fields are required or when states will be able to obtain access to test versions.

We’re all familiar with the COVID-related hospitalization data debacle from earlier this year, and it looks like we’re teeing up another not-so-successful deployment. Without appropriate user acceptance testing or the involvement of actual stakeholders in the field, software projects usually fail. I’ve seen this enough as a clinical informaticist and it baffles me that in such a critical moment we’re making so many systemic mistakes. Not surprisingly, patient matching is a concern in this effort. Who’s wishing we had a national patient identifier now?

I’m practicing in a community in a surge situation, where we have been featured on several “worst places for COVID” lists. It’s not an enviable position. I’m continually challenged by patients who are wearing what are essentially “non-masks” rather than accepting one of the medical masks that we offer at the front desk. Today I saw a family for COVID testing and every single one of them was wearing a bandana. When offered medical masks by my staff, the parent declined, stating that they were only wearing the bandanas to humor our request for masks, and they refuse to wear a medical mask because they cause lung disease. Unfortunately, we’re not allowed to deny service to non-maskers.

Trying to educate around those beliefs is a losing battle, and since they were there for COVID testing, I certainly didn’t want to spend a minute longer in the room than I had to. If masks are deadly, how are any operating room nurses or surgeons still standing? Why haven’t the attorneys come calling? Kudos to Dove for its “Courage is Beautiful” video that shows what we really look like under our masks. Even though many people across the US have moved back to their normal lives, our lives (and our faces) will never be the same again.

Just when you think you’ve reached the pit of despair, you’re sometimes surprised. When a pediatric patient started crying about having a COVID test, my scribe offered to show her how it was done, and literally took off his mask and swabbed himself right there. Her eyes were wide and so were mine, and the patient went along after seeing how easy it was. I’ve never seen someone perform a nasopharyngeal swab on himself, let alone do it blind, so I was impressed. We did, of course, have a conversation about how he probably shouldn’t do that again since he was unmasked and the patient / family had no way of knowing that he recently recovered from COVID and is considered noninfectious at the moment, but it was a touching gesture.

For those of you in the clinical trenches, what has been your wildest moment during COVID? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 9/24/20

HIPAA Business Associate Pays $2.3 Million to Settle Breach Affecting Protected Health Information of Over 6 million Individuals

CHSPSC, a management services provider and business associate of Community Health Systems, will pay $2.3 million for failing to secure its systems following an FBI warning that a cyberhacking group had gained access to the information of 6 million patients.

GoodRx closes up 53% in market debut

The prescription discount vendor’s first-day market close values the company at $20 billion. 

NHS Covid-19 app: How England and Wales’ contact-tracing service works

The delayed release of the app on Thursday will support exposure notification, a check-in barcode scanner for business and public venues to help with contact tracing, a postcode-based risk-level checker, a symptom reporting tool, instructions for obtaining a coronavirus test, and isolation countdown timer.

Mary Lanning working around medical record system outage

Mary Lanning Healthcare (NE) and several other hospitals work around downtime of Epic due to an unspecified security incident at Nebraska Medicine, which provides access to Epic and whose own systems have been down since Sunday morning.

Readers Write: Food for Thought About Apple and Google COVID-Tracing Technology

Food for Thought About Apple and Google COVID-Tracing Technology
By Robin Cavanaugh

Robin Cavanaugh is chief technology officer of GetWellNetwork of Bethesda, MD.

The recent announcement by Apple and Google to move to the next phase of their contact tracing initiative is a positive step for both the general public as well as application developers and data users. Any effort to embed this type of capability directly into the OS of the mobile device — versus relying on a user locating, downloading, and registering an application — will result in a massive increase in the adoption rate of contact tracing. Further, lowering barriers to data exchange will likely have a positive effect on data collection and, in turn, help halt the transmission of current (or future) infections.

Contact tracing in countries like ours, where privacy cannot easily be bypassed by our government, is complicated for those wanting it and suspect for those who are being traced. Tracking and tracing, while preserving anonymity, require carefully architected controls and the lulling of a wary “what’s in it for me” public by extolling the virtues of these large datasets in a way that will clearly benefit them.

The initial phase of this contact tracing API, at least for Apple, was limited to government health organizations or developers who have been endorsed and approved by a government health organization. This was done to ensure the security and privacy of the data collected through this protocol. 

Having just come from a visit to the state of Vermont for a college drop-off, I was witness to the low-tech solution implemented as an alternative to this technology, which was in place at every eating establishment we visited: “Hi, before we can serve you, please fill out your name, email address, and cell phone number on this piece of paper.”

Can I trust this kid earning minimum wage to safely process, store, and dispose of my personal information? Would I like fries with the spam I am undoubtedly going to receive as a result of this disclosure? Which of my enemies’ contact info should I use instead of my own? 

These and many other questions caused me to wonder whether my privacy was worth the “world’s best double bacon cheeseburger?” I could imagine instead that this paper was collected by the staff and likely put in a large pile somewhere for later use. I had serious doubts that this information would be entered into any kind of searchable, accessible database, or that I would actually be notified should one of the many diners in this restaurant present with COVID-19 symptoms. 

Manual processes such as these pose a significant privacy and security concern for all participants. Traceability and accountability for entities like Apple and Google that are collecting this data are critical to gaining the trust of the people, and to avoiding a tremendous amount of manual effort and false data. Instead, embedding this capability ubiquitously in the cell phone of every user with little or no action required by them to support it — coupled with a modicum of additional trust in those entities over an unregulated and ad-hoc process — will be a boon to the entire operation. Leveraging the contact tracing protocol as implemented by Apple and Google would be a significant improvement in a number of ways, including security, expediency, accuracy, and convenience.

As the need for this data evolves, and it can be safely and securely exchanged and leveraged by other organizations and entities, there are hundreds of uses that could be derived. As it relates to this pandemic, we could use the determined potential exposure not only as a data point, but as a trigger to educate people on what to do with this new realization that they could have been exposed. 

We could help mobilize a user’s support and care circle to help ensure that they are following the required protocols. We could predict other likely exposure, not dissimilar to the “Six Degrees of Kevin Bacon” phenomenon, and arm users with means of notifying their community to help keep them safe. The data could be used to get ahead of the transmission model and help with deployment of PPE or planning for spikes in testing or visits to health centers or providers. 

Certainly Apple and Google and others will need to ensure that the appropriate privacy controls are in place to avoid misuse of this information, but this is an important next step in the process. In short, more data, collected with greater ease across a wider base, can only lead to better outcomes.

HIStalk Interviews Scott Weingarten, MD, Chief Clinical and Innovation Officer, Premier

Scott Weingarten, MD, MPH is chief clinical and innovation officer, Premier; professor of medicine and consultant to the CEO, Cedars-Sinai; and health sciences clinical professor at the David Geffen School of Medicine at UCLA.

Tell me about yourself and your work.

I’m an internist by background. I have been associated with Cedars-Sinai for many years. I have a passion for improving the quality of patient care. I have been focused on clinical decision support and information technology as a means to an end, with that end being better patient care. I started a company out of Cedars called Stanson Health. It was acquired by Premier about two years ago, and I’m now chief clinical and innovation officer at Premier.

How is Premier, along with its companies Contigo Health and Stanson Health, addressing clinical variation and waste?

Premier has rich data and analytics assets that can identify opportunities to improve outcomes of care, mortality, morbidity, and cost of care. The question then becomes, after you’ve found an opportunity, how do you realize that opportunity and demonstrate improvement?

One of the most effective, scalable, and sustainable strategies is providing context-specific information to healthcare providers that are integrated into the workflow, offering suggestions to the doctor or other healthcare provider to inform care that, in some cases, will change care for the better to be more consistent with the evidence. That’s a way to close the loop in not only identifying opportunities for improvement, but implementing those improvements and being able to measure their impact or being able to measure the actual improvement.

After the acquisition of Stanson by Premier, Contigo was formed. Contigo, as a company that is part of Premier, works with employers who have a vested interest in improving the quality and reducing the cost of care for their employees.

Is information sharing among peer health systems, as is done through Premier and vendor-sponsored programs such as Epic Health Research Network, having a significant impact on patient care?

Yes. Data is critically important to understanding the gaps between current care and optimal care. In addition to data, it’s what you do about the opportunity you recognize. How do you bring about those improvements and be able to demonstrate to your satisfaction and everyone’s satisfaction that care has improved, and significantly improved?

So sharing of data is critically important, but perhaps equally or more important is being able to change care. When I say change care, it’s the interactions among doctors, nurses, pharmacists, and the patient that lead to better care with lower mortality, morbidity, and cost.

Sharing of data is the beginning. It’s necessary, but far from sufficient. Sharing of data alone will not bring about improvement.

Is it a positive development that COVID has created an urgent demand for data in the form of anecdotal findings, observational studies, and pre-print research results that would have been delayed for years otherwise to meet formal research standards?

With a caveat. The Institute of Medicine – now the National Academy of Medicine – shared years ago that there was a 17-year delay between the discovery of important data that could save lives  and the time when that knowledge is translated into practice. That’s bad. Seventeen years is far too long, and efforts were made to shorten that gap significantly to save lives and improve care. I applaud that effort to disseminate valid scientific evidence as quickly as possible.

Pre-print publications, as we’ve seen with COVID-19, can be very helpful.  But it’s also important that the information be rigorously reviewed for scientific validity, because invalid information that is disseminated and translated into practice can be potentially dangerous. We want to shorten the gap for scientifically valid, scientifically credible information, that gap between when the discovery is made and when all patients benefit from that information. But we want to remain responsible that the information that’s disseminated proves to be scientifically valid.

Clinical decision support and evidenced-based medicine are sometimes seen by physicians as intrusive, where they trust their personal experience and practices more than the results of someone’s study. Are we seeing any new capabilities or use cases that would lead to their wider acceptance?

I believe so. The key is providing physicians, nurses, pharmacists, other healthcare providers with information that is integrated in the workflow that they find helpful, that will help them take better care of patients rather than being annoying. One of the best ways to do that is to suppress the information when it just validates what the physician or healthcare provider was going to do anyway. Only provide that information when it’s incremental to what the healthcare provider is already doing or informing them when whatever they are doing is in conflict with the evidence.

There may be many good reasons that it’s in conflict. Maybe they offered the patient a treatment where the evidence has shown that the treatment can be effective, but the patient, for whatever reason — sometimes a very good reason — refuses to take the treatment. But you always want to make sure that the care is informed by the latest scientific evidence.

Another development to improve the precision and value of the information is to examine the free text information in the electronic health record. Not only discrete data elements — such as demographic information, medications, or laboratory values — but the notes that the provider has written in the electronic health record. To be able to read, interpret, and contextualize the notes to further guide the clinical decision support that can be potentially be most effective for an individual patient. It’s really a type of precision medicine, where to the best of your ability, you get to know the patient based on what is recorded in the electronic health record and tailor the guidance for that specific patient when the evidence suggests there is a testing strategy or treatment that would be best for the patient.

Have EHRs gotten better at surfacing information that tells the key story of the patient and the clinicians who have treated them so that a quick glance at the electronic chart provides the most situationally relevant information?

Electronic health record vendors have worked very hard at solving this problem. They’ve certainly heard from healthcare providers that this is an important issue that needs to be solved, and that it contributes to burnout. But I have heard that in the United States, notes of healthcare providers are much longer than those of our colleagues in other countries in Europe and so on. If that’s true, then we may be inadvertently contributing to this issue.

The question is, how can we — in addition to the electronic health record vendor — help solve this problem? Can we have shorter notes, where the high-value information, the clinically important information, is still available to other healthcare providers, and potentially the patient if OpenNotes or other strategies are used to enable patients to retrieve the information in the notes? How do we, together with the electronic health records vendors, make the notes more concise, easy to read, and easy to interpret in a short period of time?

What is the status of large health systems, such as Cedars-Sinai, getting involved with health IT accelerators, health IT investment, and acquiring commercial businesses?

I think you’ll see some health systems, not all health systems, having a greater interest in accelerators, venture capital funds, and even creating companies or spin-outs for a variety of reasons. Out of Cedars-Sinai, my colleagues and I created two companies, the order set company Zynx and my current company Stanson. We were able to commercialize the IP, which was largely related to clinical decision support, and sell both of those companies. 

You will see this trend continue with some health systems, in particular, with academic medical centers. They are in the business of creating a new knowledge and discovery and disseminating that information to improve patient care, not only at their own organization, but across the country and potentially globally.

In addition to publishing the results in peer-reviewed journals, a way to increase the impact to a greater extent is to commercialize or productize that IP so that it can be used across the country and around the world. Many health systems will say that is consistent with their mission, including academic medical centers.

The second thing you will see is that patient care revenue is increasing very slowly. In many cases, wages are increasing faster than patient care revenue, so some health systems are looking to diversify their sources of revenue. You hear about health systems thinking about creating startups, creating accelerators, and having venture funds.

What technology and data needs have been exposed by COVID that will accelerate future development and adoption?

The American Recovery and Reinvestment Act was a very large subsidy of electronic health record purchases, installments, and implementations in physician offices and hospitals. However, with that investment, there was a very small investment in comparison in public health infrastructure. We’re finding that public health information technology infrastructure has lagged significantly behind, and we are reading almost daily of the consequences of not having state-of-the-art information technology for our public health professionals across the country during a pandemic.

COVID-19 will change healthcare and the way it is practiced for the foreseeable future in many ways. We’re going to see investments made to upgrade to 2020 standards the public health information technology infrastructure to benefit from the information in the electronic health records, so that we are ahead of the curve and ready for the next pandemic, for bio-terrorism surveillance, and for understanding the next carbon monoxide poisoning or diarrheal disease outbreak.

What personal characteristics and practices allow you to be involved in so many things simultaneously?

I have a certain intellectual curiosity that causes me to do a number of different things. Some might question how well I do any of those things. But the underlying theme is that I have a passion for improving care. My mission is to make a contribution to improving patient care. I’ve set out to fulfill that mission through a variety of things — direct patient care, academics and teaching, implementing quality improvement and value improvement strategies across a health system, and creating businesses that hopefully will enable health systems across the country and beyond to improve care. That’s the underlying theme of all of my attempts to make a difference.

Do you have any final thoughts?

As someone who has been in clinical decision support for over two decades, I’m now quite bullish on the field. I feel like the advances in technology, electronic health records, natural language processing, machine learning and AI, and speech recognition will enable transformation and significant improvements in the field of clinical decision support. I’m quite hopeful and optimistic that we’re going to see greater improvements in patient care from clinical decision support in the future than we have in the past.

Morning Headlines 9/23/20

FDA Launches the Digital Health Center of Excellence

The Center will provide expertise and advise FDA on modernizing digital health policies and regulatory approaches.

Microsoft launches Cloud for Healthcare in general availability

The managed service will includes Dynamics 365, Azure, 365, Teams and its new EHR connector, and Healthcare Bot Service for developing self-assessment tools.

A call for social informatics

A JAMIA article calls for creating an informatics subfield that focuses on social determinants of health.

NCDHHS Launches SlowCOVIDNC Exposure Notification App; Available for Download Today

North Carolina Department of Health and Human Services launches SlowCOVID19, a contact tracing app that uses the Exposure Notification System from Google and Apple.

News 9/23/20

Top News

FDA launches the Digital Health Center of Excellence, which will provide expertise and advise FDA on modernizing digital health policies and regulatory approaches.

Bhaku Patel, MSEE, MBA will serve as the first director of the center, which will operate within the Center for Devices and Radiological Health.

HIStalk Announcements and Requests

Welcome to new HIStalk Gold Sponsor Alcatel-Lucent Enterprise. The mission of the Colombes, France-based company is to make everything connect to create the customized technology experience customers need. It delivers on-premise, cloud, and hybrid networking and communications solutions that work for your people, processes, and customers. A heritage of innovation and dedication to customer success has made Alcatel-Lucent Enterprise an essential provider of enterprise networking, communications, and services to over 830,000 customers worldwide. The company has a global reach and local focus with more than 2,200 employees and 2,900+ partners who serve over 50 countries. Thanks to Alcatel-Lucent Enterprise for supporting HIStalk.

I’m about to assess time-outs to overly aggressive PR firm people who keep sending me bulk-emailed pitches for their “story ideas” (apparently unaware that I do not run such “stories” on HIStalk) that ask me to respond if I’m interested, then “circle back” or “just pinging you” a couple of days later when I’ve already conveyed my incuriosity precisely as instructed by not responding. Gmail’s filter rules should work nicely to delete their messages automatically, although without some minor hacking it can’t automatically reply that they’ve been squelched.

Webinars

September 30 (Wednesday) 11 ET. “The Hidden Threat: New Research on Security Vulnerabilities and Privacy Gaps in Healthcare Apps.” Sponsors: Verimatrix, NowSecure. Presenters: Neal Michie, MEng, director of product management, Verimatrix; Brian Lawrence, direction of solution engineering, NowSecure. The presenters will present research on the security risk profile of 1,000 healthcare apps in managing patient privacy, how they compare to those in other industries, and where the biggest vulnerabilities lie. Attendees will learn how to make their healthcare apps more secure in managing protected health information.

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

Acquisitions, Funding, Business, and Stock

Carlyle Group will acquire a majority stake in global health research network TriNetX for an unspecific price and valuation.

Teladoc sends a letter to competitor Amwell warning that its digital scope, stethoscope, and some of its telemedicine carts infringe on Teladoc’s patents.

Walmart-owned Sam’s Club offers its members text-based primary care telehealth services through 98point6, expanding a pilot project from last year. Individuals pay $134 per year plus $1 per visit, which is conducted via text messaging through the app of the company, which has 39 doctors.

Sales

• Mount Sinai South Nassau selects Infor Cloud Cloverleaf for interoperability that includes API standards such as FHIR.

People

Behavioral EHR/PM vendor Therapy Brands hires Jessica Kasirsky, DO (NextGen Healthcare) as chief medical officer / VP of regulatory affairs.

Announcements and Implementations

A new KLAS Arch Collaborative report finds that while 25% of nurses report that they are experiencing burnout, EHR satisfaction isn’t a significant cause, and organizations should instead focus on the work environment, employer-imposed bureaucracy, improved teamwork, shared values, and control over schedules.

Decentralized clinical trials software vendor Medable announces GA of a remote consent and re-consent product that allows patients and clinicians to sign up from any location. The company also offers remote patient and site monitoring, telemedicine, and patient engagement tools for clinical outcome assessment.

Optimum Healthcare IT completes virtual Epic training and a go-live at Australia’s Royal Melbourne Hospital.

Cerner will integrate Vynca’s advance care planning system with Millennium to display end-of-life preferences to clinicians and in the patient portal.

Microsoft announces Cloud for Healthcare, a managed service that includes Dynamics 365, Azure, 365, Teams and its new EHR connector, and Healthcare Bot Service for developing self-assessment tools. GA will be October 30. 

QliqSoft will offer patient self-scheduling in its virtual care platforms in partnership with Blockit. The company offers the Quincy chatbot as well as its Virtual Visit telehealth solution.

COVID-19

CDC publishes guidance Friday acknowledging for the first time that coronavirus spreads by almost exclusively by air, but then pulls the guidance down Monday in saying that it was posted prematurely before full approval. CDC says it will publish revised guidance soon. The recalled guidance – which says the virus can survive for long periods while suspended in the air and can travel more than six feet — would have had an impact on people (avoiding indoor gatherings, restaurants, and bars), businesses (improved ventilation and and filtration systems), and hospitals (increased use of negative-pressure rooms for infected patients). It would de-emphasize the importance of handwashing and physical cleaning given the low incidence of spread.

Scotland-based infections disease and virology professor Muge Cevik, MD, MSc, MRCP summarizes what we know about coronavirus spread:

• Risk is related to contact pattern (duration, proximity, activity), individual factors, environment, and socioeconomic factors (housing, job security).
• Sustained close contact drives the majority of infections and clusters. Contact with family and friends as well as gatherings create higher risk than brief contact while shopping or in the community.
• Non-household contacts dining together involves especially high risk.
• Transmission is 20 times higher indoors than outdoors, making those beach-shaming media photos pointless.
• Attack rates are highly correlated to symptom severity. Asymptomatic spread is less important.
• Susceptibility increases with age.
• Much of the world’s outbreaks involve nursing homes, homeless shelters, prisons, and meat-packing plants where people share communal spaces for long periods. The largest US clusters have been associated with prisons and jails.
• Lower-paid essential workers are at risk because they cannot isolate, often use public transportation, and are exposed to more people.
• Residents of urban area are at higher risk due to lower incomes, denser living conditions, and a higher proportion of immigrants. Social distancing worked best in more affluent households during the H1N1 pandemic of 2009.
• Viral load peaks require immediate self-isolation as soon as symptoms appear, which will require policies to support that isolation.

Rural hospitals that received federal pandemic aid are afraid to spend the money on COVID-related improvements since the funds were officially in the form of a loan that is due to be repaid this month, with those that aren’t able to repay then having their Medicare payments withheld.

Only 51% of polled Americans would get a COVID-19 vaccine if it were available today, down from 72% in May as people worry that a vaccine will be distributed without adequate testing or with unknown side effects.

CDC tells a federal advisory group that the first people who receive COVID-19 vaccines will be monitored by daily text messages and emails. The 20 million essential workers who are expected to be among the first recipients will be sent daily text messages asking about side effects for the first week afterward, then weekly messages over six weeks.

Sanford Health (SD) is sponsoring a 5,000-attendee, masks-optional October country music concert along with the state’s governor, who previously endorsed the Sturgis motorcycle rally of 500,000 people who have spread infection to an estimated 260,000 new COVID-19 cases. Ticketmaster shows mostly packed spectator sections with no distancing, with the 50% capacity limit being technically accomplished by closing the upper deck while crowding attendees into the lower level. The health system itself – which has 46 medical centers, 210 clinic locations, 233 senior living centers, 158 skilled nursing and rehab facilities, and 48,000 employees — is limiting patient visitors, screening employee and visitor temperatures, mandating social distancing, and requires clinic employees to wear masks at all times.

FDA is reportedly preparing tougher standards for Emergency Use Authorization of COVID-19 vaccines that will require manufacturers to follow participants for at least two months after they receive their second dose, which is likely to push back release until at least December. The requirements will also include having at least five severe cases of COVID-19 in the placebo group, as well as some cases involving older people. 

Other

A JAMIA article calls for creating a sub-field of informatics called social informatics, which would drive research on the data, interoperability, and ethical challenges that are involved in integrating social and medical care.

Madison magazine ponders what will happen to the Wisconsin area’s “Epiconomy” when Judy Faulkner leaves Epic. It questions how the foundation to which she will donate her shares will operate within IRS guidelines that require it to distribute 5% of its endowment each year, says the company’s planned return to on-campus work was a “spectacularly bad decision” that may have tarnished the brands of both Epic and Madison in the eyes of the new college graduates Epic hires, and observes that Faulkner does little mentoring and the company doesn’t invest in Madison companies even though its former employees formed several of them. It also notes that Faulkner and her husband donate heavily to liberal political candidates, but Epic has engaged in several legal battles to limit worker rights, such as forcing its employees in its employee agreements to accept binding arbitration instead of filing class action lawsuits. A business professor says that founders who try to “control the [company’s] future from the grave” often mess it up in limiting how much it can think and adjust on its own without them.

Real-time website privacy inspector Blacklight went live today. HIStalk did well with only a couple of traffic counters that I’ve installed but rarely use, but boy is HIMSS.org loaded with questionable stuff, including the Hotjar keystroke tracker. AHIMA’s site, in contrast, is about the same as HIStalk, while CHIME’s gets a perfect score.

Count me out. Airlines are filling seats for “flights to nowhere,” in which people who miss flying so much are buying expensive tickets to board a plane that circles around for a few hours, then lands back at the same airport. I’m personally thrilled to avoid the ever-increasing indignities of American Airlines, including one memorable flight in which my first class upgrade (to avoid AA’s industry-leading cramming of an extra seat in every row of steerage) got me a “lunch” of a few stale triangles of pita orbiting around a sad puddle of hummus. People for whom flying is a fond memory need to get out less.

Sponsor Updates

• InterSystems releases HealthShare CMS Solution Pack to help customers meet the interoperability and patient access final rule that takes effect on January 1.

Contacts

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

Morning Headlines 9/22/20

Orthopedic Clinic Pays $1.5 Million to Settle Systemic Noncompliance with HIPAA Rules

Athens Orthopedic Clinic (GA) will pay the HHS Office of Civil Rights $1.5 million to settle potential HIPAA violations related to a 2016 data breach by The Dark Overlord.

Carlyle Makes Strategic Growth Investment in TriNetX; Acquires Majority Stake in Leading Global Health Research Network

The Carlyle Group will acquire a majority stake in global health research network TriNetX.

Teladoc accuses Amwell of infringing on its telehealth patents

Teladoc accuses Amwell of infringing on patents related to its digital scope, stethoscope, and some telemedicine carts.

Nebraska Medicine addressing ‘security incident’ impacting IT systems

Nebraska Medicine reverts to downtime procedures after an unspecified security incident on Sunday takes its IT systems offline.

Curbside Consult with Dr. Jayne 9/21/20

I’ve given up trying to count the number of healthcare organizations I’ve worked with during the last several years. Each one has had its unique challenges and fun memories.

From an organizational standpoint, though, if you’ve seen one care delivery process, you’ve seen one care delivery process. They are different. Although many things are common, each organization has different issues, and that makes healthcare IT work challenging.

Sometimes it’s a regional variation in care delivery. Hospitals on the East and West Coasts tend to be closer to the cutting edge than do some of my rural clients. Looking at a different aspect, some of my rural clients deliver amazingly coordinated care because the team is personally invested in the patients through their community connections.

I work with some organizations that are part of religious ministries, where their affiliation directly impacts the care they deliver and what can be featured in the EHR. For example, I worked with one large health system that had a contractual agreement with its patient education vendor that no family planning information could be featured in any of the monographs. Religious restriction of EHR content can be tricky when working with patient populations where sex, gender, sexual orientation, and other sensitive factors must be documented in order for the clinical team to deliver culturally competent care.

One of the issues that I’ve run across with increasing frequency is the disparity in various healthcare IT systems with regard to management of the data points around sex and gender. Some systems seem to think the terms are interchangeable, which tells me that they probably didn’t have a clinical informaticist involved in the design of their product.

I worked with one vendor that initially had a field for sex, but wanted to add one for gender. Unfortunately, in the upgrade script where the field was added, they just copied the contents of the old field into the new one, creating false assumptions about patients in thousands of practices. Needless to say, one of their clients that works closely with the LGBTQ+ population was less than amused. It took some custom work to revert the content and allow the fields to be populated as patients came in for their next visits.

This issue is often compounded when interfaces are involved. Engineers either don’t understand what the fields are used for downstream or don’t understand the negative impact of mis-mapping these data elements. Major EHR vendors vary in how they handle this information, even though it was required for certification under the 2015 EHR standards.

I still see a lot of customization in the social history portions of client EHRs as they try to meet needs unmet by the base product. Due to some of my past client engagements, I tend to have a little more expertise in this area than the average clinical informaticist, so I was glad to see an article in the Journal of the American Medical Informatics Association that documented “A rapid review of gender, sex, and sexual orientation documentation in electronic health records.”

The authors looked specifically at literature in peer-reviewed journals and identified 35 core articles that involved gender, sex, sexual orientation, and electronic health / medical records. They note that although certified EHRs must provide for documentation of sexual orientation and gender identity, users of those systems are not required to document the data. In my experience, going beyond the historical documentation of birth sex is confusing to many people, and organizations that are strapped for time and cash aren’t likely to focus educational funding on a minority group, even if they are known to be marginalized.

The core articles identified specific needs for data collection that play directly into hot technology areas, including personalized medicine. Having accurate data is important when you’re looking at therapies that may target the patient based on the genetics of their birth sex as opposed to what an observer might infer from the patient’s outward appearance. The authors give examples of why terminology is critically important, and include a table defining various terms (including birth sex, legal sex, gender, administrative gender, gender identity, and gender expression). I thought it was well done and bookmarked it as a reference for future client engagements.

The authors also provide some illustrative cases that can help in understanding why these data elements are so important in the healthcare community. Patients want to be cared for by organizations that understand their needs and meet then where they are. Their records are best managed in systems that can reflect clinical scenarios, such as a transgender man who needs breast and cervical cancer screenings. Patients may also want to opt out of providing these data elements if they don’t feel comfortable sharing that information, which may require a field to be documented as “not provided” or something similar.

I had a patient recently who walked out of a chain pharmacy, where she had gone to get a flu shot, because they asked about her sexual orientation. She felt it was none of their business because she was just there for a vaccination. In discussing her concerns, it never occurred to her that what she perceived as just a pharmacy also provides limited primary care services, where the question would have more relevance. She never thought about the fact that they were trying to be comprehensive rather than invasive, and I could tell she was really thinking about her own reaction to the question.

The article notes a couple of organizations that have been successful in managing this data, and one might not be the first one you think of. It’s not a progressive academic center or specialty center, but the US Department of Veterans Affairs. The VA took several steps, including creating a patient safety education work group, to address inconsistencies with sex-based EHR rules. The VA then developed informational sheets for patients and staff to help them understand the use of various fields in the EHR and provided training on how to have conversations with patients regarding these data elements.

This area of EHR work may seem like a small niche, but if it impacts you as a patient, it’s tremendously important. It’s an example of the challenges that makes CMIO work exciting, because you know that when you help solve these problems, it can really make a difference for the patients involved. As caregivers, we want to do the best by our patients and it’s helpful if the systems we use support us in those efforts. For those of us doing work in lesser-known realms of clinical informatics, it’s nice to see an article that lets us know we’re not alone.

Has your organization tackled the management of gender, sex, and sexual orientation documentation in the EHR? Leave a comment or email me.

Email Dr. Jayne.

HIStalk Interviews Bill Grana, CEO, HCTec

Bill Grana, JD, MBA is CEO of HCTec of Brentwood, TN.

Tell me about yourself and the company.

I am a technology entrepreneur, going on nearly 30 years. I have been involved in starting, investing in, and leading high-growth tech product and tech services companies, many of which have been related to healthcare or HIT. I’ve been with HCTec for three years.

We are an IT services business that is focused exclusively on the hospital system sector and other specialty providers. The tagline of a German multi-national chemical company used to be, “We don’t make the products you use. We make the products you use better.” In HCTec’s case, we don’t make the technology that is used by hospital systems. We make the technology work better through our team of talented IT professionals with specialized IT skills.

How has your business changed with the pandemic?

Like many other businesses, we transitioned to full remote work in early March. I’m very pleasantly surprised and proud of my team for how well that they executed that change. We haven’t missed a beat in terms of service delivery with our clients, more specifically with our two primary business lines of consulting and managed services.

We’ve seen the consulting business negatively impacted. As hospitals experienced stress, particularly financial stress, one of the first things to be cut was contingent labor. A number of our contract consultants were released. But we are seeing that pick back up. On the managed services side — where we provide both an IT help desk solution as well as application support for current generation and legacy systems, primarily focused on the enterprise EMR — that business has stayed robust. We have seen huge volume increases on the help desk side tied to the transition to remote work, but particularly telehealth. So it’s been a tale of two different worlds in terms of how COVID has impacted our business.

Is remote work for go-lives and support here to stay, or will onsite work bounce back once travel limitations ease?

Much of that is going to be here to stay. There is no reason to revert back to what it was pre-COVID, assuming that from a service delivery and outcome perspective, it can be equally effective. From a cost perspective, it’s certainly better for hospitals to do it that way. In many cases, it’s better for the consultants who are providing the work to be able to do it remotely, whether it be from an office setting or from their own homes, rather than having to get on a plane at the beginning and end of each week.

How are health systems prioritizing their IT projects differently?

The projects that were put on hold in March and April are beginning to be resurrected. The contingent labor that is necessary to execute those projects is coming back as well. I think that the demand will return to pre-COVID levels. We will see more openness to remote work by consultants. Many of our hospital clients have moved the entirety of their IT organizations to remote work. That will give them a greater comfort level that their vendors and partners can do the same thing.

The COVID experience has opened the eyes of health system IT departments and leaders to the importance of having partners that can be nimble and react quickly in unforeseen circumstances like this. We have demonstrated that in a number of ways.

I hate to use the word “outsourcing,” because it is considered a dirty word in many circles. But I think we will see health systems take a hard look in the mirror, not just with IT functions, but more broadly, in asking the question, what are truly our core competencies? For many hospitals, that is provider support and high-quality patient care. Everything else, in many cases, can be performed as effectively or more effectively at a lower cost by a partner or some sort of alternative labor arrangement beyond just hiring full-time staff.

We’ve seen Optum announce a couple of deals over the last 12 months where they are taking over all non-clinical operations. I think that trend will continue. Maybe not necessarily a full partnering, but more of a best-of-breed approach, where companies like HCTec will step in and provide services that are important, but that aren’t necessarily core competencies of hospital systems.

We’ve seen those deals ebb and flow, however, where hospitals outsource core functions but then bring them back in-house within a few years. What are the success factors in making outsourcing more than just a short-term experiment?

There has to be a clear cost justification, where the partner can provide the same service at the same or lower cost. The same principle applies to quality, where there must be service level agreements and metrics that the vendors are held to, with penalties or other consequences to the extent that they fall short.

These things go in cycles, but I believe that the COVID experience will encourage hospitals to look at partnering with firms in non-core functions in a much bigger way than we have seen.

How do you explain strong investor interest in the health IT sector even as its health system prospects are struggling, at least temporarily?

Some categories have been really hot. A lot of money has been invested in telehealth following the boost it received as the result of COVID. Artificial intelligence and analytics solutions represent huge opportunities in the long term. Outside of the IT segment, a lot of investment has gone into services side and into different specialty ambulatory practices as well.

I don’t know that any of those things will last into the future and provide an opportunity for growth. Sectors get overheated. It’s hard to fathom the valuations that go along with some recently announced deals. I guess my small brain is not smart enough to get wrapped around that.

But overall, I think the health IT segment is a very attractive long-term investment sector. As we think about what healthcare looks like in the future, it involves a greater adoption, prevalence, and reliance on technology to support clinical service delivery and hospital operations. We will certainly not see less of that in the future. You could probably say this to a degree about any market sector, but I healthcare is particularly ripe for technology that can benefit its performance.

Telehealth boomed early in COVID, but now it seems to be cooling off everywhere except on Wall Street. How will it play out in the next two to three years?

We’ve already seen the levels pull back from what they were as people become more comfortable returning to their physician’s office. But there are certain use cases for telehealth. Behavioral health is one example, where it can arguably be delivered even more effectively via telehealth, in a way that makes the patient more comfortable or more apt to seek help where there may be some behavioral health challenges.

But clearly, if you need a physical — at least given where we are with technology right now – you have to go to the doctor. Over the next five to 10 years, I think that could change with different and improved patient-facing technologies and monitoring devices, where much of your regular physical could be done from home or outside of a doctor’s office.

What technologies hold promise now that EHRs and stable infrastructure are universal?

It’s probably overused, but the digital front door, creating a single entry point for customers, or patients in this case, to provide an improved overall digital experience. It is disjointed with many health systems and across providers today. It’s hard to navigate, even for folks who are technology savvy and Millennials. Effort and emphasis will be placed on that.

You see the same thing in the financial services marketplace, even though it’s probably several years ahead of healthcare. I’m on the board of a financial technology business and I chuckled at our last board meeting, where they were talking about all these banking institutions that are focusing on the customer digital front door. The exact same thing is happening in hospitals.

We are in the nascent stages of bringing a mature experience to market. It’s about the customer, or again, in this case, patient experience. As systems compete for patients, it will be important to give them a strong digital experience.

Will small health systems lose to the bigger ones that just keep getting bigger, as happened in banks that bet big on expanding outside their regions and deploying technology such as ATMs and online banking that customers valued?

It is probably not necessarily the best thing for the marketplace, but I do think that that’s the case. COVID has accelerated that with the financial stress that has been placed on smaller institutions that don’t have the balance sheet to weather the storm. We’re already seeing consolidation happen that would not have without COVID. The same holds true for the ability to invest in these digital and patient-facing tools that drive the whole experience.

What will the company’s direction be in the near future?

The future is bright, despite the fact that we still have COVID hanging over us. It will dissipate, hopefully sooner than later. From a service portfolio and capability perspective, we are well equipped to meet current and future demand, and with some incremental changes, to realize some additional opportunities.

We’ve put a great team in place. I wouldn’t have wished COVID on us, but it has given us a little bit of breathing room to focus on operational improvement that is already making a difference in our current business of quality of service delivery to our clients, and will continue to make a difference in the future. Growth and improvement remain continuous and will be future themed.

Do you have any final thoughts?

The pandemic has put healthcare clinical workers in the spotlight in a well-deserved way that was not seen previously. We also need to recognize the people who are behind the technology that is used by hospitals, the improvement in healthcare delivery and the extra hours and work that they put in during this challenging time.

Technology doesn’t always work as it was designed, and in those cases, we need experienced people with specialized skills to provide support and continuous care and feeding to maintain the health of these hospital tech ecosystems. That is the essence of who we are and what we do at HCTec.

Morning Headlines 9/21/20

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