News 3/15/19

Top News

Rutland Regional Medical Center (VT) notifies 72,000 patients of a breach after discovering that the email accounts of nine employees had been hacked late last year.

Hospital officials believe the hack originated outside of the US.

RRMC did similar damage control in 2017 after an employee exposed patient information by sending a bulk email to patients using CC: instead of BCC:.

Webinars

March 27 (Wednesday) 2:00 ET. “Waiting on interoperability: What can payers and providers do to collaborate?” Sponsored by Casenet. Presenter: Amy Simpson, RN, director of clinical solutions, Casenet. A wealth of data exists to identify at-risk patients and to analyze populations, allowing every payer and provider to operate readmissions intervention and care management programs. Still, payer and provider care managers are challenged to coordinate and collaborate to improve outcomes because of the long road ahead to interoperability. Attend this webinar to learn what payers and providers can do now to share information and to coordinate their efforts to create the best healthcare journey for members and patients.

Previous webinars are on our YouTube channel. Contact Lorre for information.

Acquisitions, Funding, Business, and Stock

Health research network TriNetX raises $40 million in financing, earmarking the funds for enhancing its analytics software and further expanding in Asia, Europe, and South America.

Medical record retrieval and image-sharing company EHealth Technologies secures $41 million in financing.

People

Haven hires Sandhya Rao (Partners Healthcare) as VP of clinical strategy.

PatientPoint names Wes Staggs (Blue Ridge) as its first EVP of customer success.

Australia-based Telstra Health names former New Zealand National Health IT Board Director Graeme Osborne, who also spent seven years leading New Zealand’s EHealth Program, to run its hospital software business unit, which includes the EHR it acquired along with Emerging Systems in 2014.

Wendy Hill (Cerner) joins Netsmart as its first chief people officer.

Sales

• In Australia, SDS Pathology will replace its Triple G Ultra lab system with SCC Soft Computer.
• Val Verde Regional Medical Center (TX); Bayamon Medical Center (PR); Puerto Rico Women’s and Children’s Hospital; and Massachusetts Health Collaborative members Harrington Healthcare, Holyoke Medical Center, and Heywood Healthcare will implement Meditech Expanse.

Announcements and Implementations

Johns Hopkins Health System (MD) goes live with Bluetree’s Service Center for Epic users.

Partners HealthCare leverages Appriss Health’s PMP Gateway interface to become the first health system in Massachusetts to integrate its EHR with the state’s PDMP.

OhioHealth goes live on Epic.

Privacy and Security

Emerson Hospital (MA) notifies patients of a data breach that occurred last May when an employee of its billing vendor, MiraMed Global Services, sent electronic patient files to an unauthorized third party. The hospital’s forensics team found the files to be of such poor quality that the data was likely not used in further malicious activity.

Other

• The overriding theme, beyond company paranoia, is the willingness of Holmes to “fake it until you make it.”
• Gibney likens Elizabeth Holmes to Thomas Edison in that both invented larger-than-life celebrity personas to sell themselves and their inventions. His footage of her in-house interviews shows that she worked hard to present that contrived version of herself. “[T]hat was precious to us,” he says, “because, if you’re talking about the psychology of deception, now we had an opportunity to show from the inside out how that deception was manufactured.”
• After a team member interviewed Holmes in 2017, Gibney concluded that, “Elizabeth perceived herself to be a victim. Not somebody who was contrite, but somebody who was brought low by forces who were out to get her because she was a woman.”
• After acquiring footage of Holmes and her boyfriend and company executive Sunny Balwani jumping in a bouncy house to MC Hammer’s “U Can’t Touch This” in celebration of FDA’s marketing clearance for one of its tests, Gibney admits, “It was jaw-dropping to see the delusional behavior inside the company.”

Sponsor Updates

• Nordic names Michael Malecha (Huron) senior director of ERP solutions.
• Elsevier adds new assessment capabilities to its ClinicalKey Student medical education platform.
• EClinicalWorks and InterSystems will exhibit at the Rise Nashville Summit March 17-19.
• HBI Solutions will present and exhibit at the Population Health Colloquium March 19 in Philadelphia.
• The University of Florida recognizes The HCI Group CEO Ricky Caplin as one of its outstanding young alumni.
• HGP publishes the results of its 2018 health IT private equity survey.
• Imprivata will exhibit at Texas HIMSS March 25-26 in Austin.
• Medhost recaps its 2018 business growth.
• Spok releases a new case study featuring Vail Health (CO).
• EHealth Exchange expands its use of InterSystems solutions by selecting its HealthShare unified care record to power its HIE.
• Meditech releases a video showing how its solutions deliver real results to executives, providers, and patients.

Blog Posts

• HCC: Gauging Risk in the Real World (EClinicalWorks)
• How “bots” improve patient engagement and save money (Formativ Health)
• Jordan Messler, MD: Improving the Quality and Cost of Diabetes Care (Glytec)
• Best Response to the CMS TPE Program? Be Prepared. (Hayes)
• Purge the Pager? At Your Own Risk (Spok)
• Healthcare IT Integration is Never Straightforward (The HCI Group)
• Epic Training and Learning Management Systems (Optimum Healthcare IT)
• Huntzinger Applauds Geisinger for Earning HIMSS Analytics Validation (Huntzinger Management Group)
• Planning for a Multi-Hospital Communications Program – Where to Begin (Impact Advisors)
• Patient safety has its own week. Here’s why. (Imprivata)
• Beyond Secure Messaging: Rich Communication via Video Calling (PMD)
• Healthcare Innovation in 2019: Keeping the Consumer Top of Mind (Dimensional Insight)
• Five hospitals, two organizations, and one eMAR come together to improve patient safety (Meditech)

Contacts

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

EPtalk by Dr. Jayne 3/14/19

Today was a Google Cloud kind of sock day, and I have to say these made me smile with their stethoscopes, microscopes, and miniature DNA. These beauties (along with many of the other socks given out at HIMSS) are from Sock Club, which designs their socks in Austin, Texas and manufactures them in North Carolina using cotton sourced from the southeastern US. Perhaps I see some locally-sourced HIStalk socks in my future.

CMS has released an updated version of its Security Risk Assessment tool. Many organizations I’ve encountered fail to appreciate the importance of the Security Risk Assessment, which is required under HIPAA. Some clients think that SRA is something their EHR vendor does for them and don’t understand that it’s not just about the technology, but also about compliance with physical, administrative, and technical safeguards. CMS has always had free tools, but they hadn’t been updated in a while. This one was release in October 2018.

Speaking of CMS, there is less than one month remaining for eligible clinicians to submit their MIPS Year 2 data for the Quality Payment Program. The system closes at 8 p.m. ET on April 2, 2019. CMS Web Interface users must report their Quality performance category data by 8 p.m. ET on March 22, so that deadline is even shorter. Good luck to everyone who is making the final push before submission.

It’s also time for the annual Call for MIPS Quality Measures. CMS is looking for measures to consider for future years of the Merit-based Incentive Payment System (MIPS). Recommendations can come from the domains of: patient safety, person / caregiver-centered experience and outcomes, communication / care coordination, effective clinical care, community / population health, and efficiency / cost reduction. Measures can be submitted through the ONC-JIRA system. You can learn more about the measure selection process here.

Congratulations to the 178 physicians who recently became board certified in clinical informatics, bringing our overall number to more than 1,800. There are yet more physician practicing in our field who are unable to be certified because they may have let their primary board certifications lapse. I’m looking forward to the day when we can be either primarily certified in clinical informatics or when we will be allowed to recertify without a current primary board certification.

As a former family medicine physician with a traditional practice, I realized all too quickly in practice that a good portion of my job was sales – trying to convince patients to “buy” something they didn’t want, such as healthier behaviors or medication compliance. Even in the urgent care setting, I’m constantly trying to sell patients on the benefits of symptomatic treatment for their viral illnesses rather than throwing antibiotics at anything that sneezes, runs, or coughs. I enjoyed this Health Affairs article  that looked at the idea of rewarding patients financially when they choose lower-cost alternatives.

The study looked at more than two dozen employers with almost 270,000 eligible employees and dependents. It was in play for more than 100 elective procedures, including advanced imaging (MRI, CT) and joint replacement surgeries. Patients who chose lower-cost alternatives received between $25 and $500 cash depending on the nature of the procedure and the relative cost of the provider. Although the savings only translated to a 2.1 percent reduction ($8 per patient), it resulted in an overall $2.3 million in savings annually. The largest effects were in MRI and ultrasound imaging. There was no savings seen with surgical procedures. The authors note that “this structure is appealing to employers, because compared to alternative programs such as high-deductible health plans or reference pricing, it encourages patients to price shop without exposing them to increased out-of-pocket spending.”

Until recently, I received my mammograms at an independent physician-owned imaging center that delivered high-quality services at a fraction of the cost of the local hospitals. Some quirky genes led me to enroll in a local medical center’s high-risk breast cancer surveillance program, which includes alternating mammograms and MRIs with increased frequency along with input from genetic counselors, surgeons, and other members of the support team. The cost is certainly higher than the independent imaging center and I’m able to understand the risk/benefit equation better than the average patient, for whom this could be challenging. Data is evolving so quickly it’s difficult at times to make these choices. I’m still not sure about the risk of gadolinium contrast deposition in my brain and whether it’s making me wacky, so if anyone is a neuroradiologist and has an opinion, let me know.

A team from Harvard University is partnering with the US Department of Health and Human Services to better understand attitudes towards health data, accessing it, and what patients know about their rights. Take a minute to complete their survey. Thanks to Amy Gleason @ThePatientsSide for sharing.

Not all tech is good: The US Food and Drug Administration issues an alert that patients and providers should be cautious regarding robotically-assisted surgeries for mastectomy and other cancer-related surgeries. The FDA has not granted marketing authorization for any cancer-related surgeries and states that “survival benefits to patients when compared to traditional surgery have not been established.” Robotically-assisted surgeries use small surgical site incisions and can reduce pain, blood loss, and recovery time compared to open surgeries. The FDA goes on to say it “is aware of scientific literature and media publications reporting poor outcomes for patients, including one limited report that describes a potentially lower rate of long-term survival when surgeons and hospital systems use robotically-assisted surgical devices instead of traditional surgery for hysterectomy in cases of cervical cancer.”

Hospitals love to use the robotic devices for marketing campaigns because being high tech is sexy. As a physician, it’s more important to me to make sure I have a surgeon who has a high-volume practice in a particular procedure and performs that procedure at a facility which also has a high volume of those procedures. Those two factors have been shown to improve outcomes compared to lower-volume surgeons and facilities. The amount of training that providers receive on robotically-assisted procedures can be highly variable and is an important question for patients to ask as well.

Medscape released its 2019 “Family Medicine Physician Lifestyle, Happiness, & Burnout Report” last month. Here are the takeaways that caught my attention:

• Plastic surgeons are the happiest, at 41 percent
• Family physicians are nearly twice as happy (52 percent) outside of work than they are at work (23 percent)
• We cope with burnout by eating junk food (35 percent), drinking alcohol (22 percent), and binge eating (19 percent) but we’re not using marijuana (0 percent)
• We drive reliable, economical cars: 23 percent Toyota, 18 percent Honda
• Nearly one-fifth of us don’t have spiritual or religious beliefs
• 17 percent of us have had suicidal thoughts and 1 percent have attempted suicide

The last item is particularly sobering and weighs heavy on me as I approach a milestone reunion for my medical school class. We lost one of our dear classmates during the last semester of our fourth year. The American Foundation for Suicide Prevention has resources specifically for health professionals. If you are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or text the Crisis Text Line by texting TALK to 741741.

Email Dr. Jayne.

Morning Headlines 3/14/19

TriNetX Secures $40 Million in Series D Funding

Analytics-enabled global health research network TriNetX raises $40 million in a financing round led by Merck Global Health Innovation Fund.

ImagineSoftware Acquires RCM Software Company ProviderAlly

Medical billing company ImagineSoftware acquires healthcare payment automation and analytics vendor ProviderAlly.

Mental health providers, others ask for delay to electronic health record requirement

Citing high EHR costs and lack of selection, behavioral health providers in North Carolina are pushing for more time to connect to the statewide HIE ahead of the mandated June 1 deadline.

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

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

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

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

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

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

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

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

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

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

1. Searching for Clinical Data

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

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

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

2. Managing the Inbox

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

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

3. Entering Orders

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

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

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

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

4. Documenting the Encounter

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

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

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

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

HIStalk Interviews Mike Mardini, CEO, National Decision Support Company

Mike Mardini is founder and CEO of National Decision Support Company of Madison, WI, which is part of Change Healthcare.

Tell me about yourself and the company.

I’m a healthcare IT veteran. I’ve gone through three companies in the utilization management and documentation space. We were acquired by Change Healthcare about a year ago.

How will the acquisition change your business?

We had been working with McKesson for two years and they were acquired by Change. We had a good relationship. We knew what we were getting into when the conversation about them owning us started. We knew the people and we knew what the synergies were. We lived together before we got married. That was a big advantage, not only for us, but for them, too. It happened the right way.

It’s content integration and connectivity to impact care. To share data between providers and payers. A lot of assets come together.

How do you balance the big picture of growing the business, raising money, and considering who might acquire you or who you might acquire, all while you are still running the company day to day?

I’ve done it three times and I’ve asked myself that question. Each time was a little different. The first time was the first time. The second time, the strategic buyer was different. But it is a balance. You have to be true to the company and the company’s mission as opposed to a personal type of mission.

Some would say it was harder or easier for me since I never raised money. I never had a bank or a VC dictating what they wanted out of it. It was always personal. Whether it’s running the business or finding a partner, you’re in it every day. You have to be true to the mission of the company and to evaluate how the company is better off, whether it is run independently and we keep on going, or whether we’ve found the right partner to advance the mission. It becomes easy.

Change wasn’t the only one that wanted to us. From the day that we got started, I would say inside of a year, we were courted. We found the right partner.

CEOs have told me that instead of the champagne corks flying once the deal was done, the due diligence was like a colonoscopy and then it was second guessing about whether it really is the right partner, the right price, and the right thing for the company and its employees. Is it hard to balance the negatives and positives of multiple offers?

It was a lot easier this time around than the other two times, whether it was experience or that we had been working with them for two years. It is difficult. It is the colonoscopy. It’s all of that. But this time around was a lot smoother. We knew what to expect, we knew the people, and everybody’s heads and hearts were in the right place.

How hard would it be for a health system to set up and maintain ordering appropriateness checks on their own?

It’s a huge project. They all have a few dozen alerts and advisories. When we install our imaging product, it’s 15,000. Maintaining and managing with native EHR tools is a huge task. That’s why they only do dozens. All the content is managed locally.

Governance is an issue. Tracking the impact and the effects. It is a huge undertaking for sites to do it alone. I’m not sure they even realize how big the problem is. But as the market starts to evolve, they’re starting to ask all the right questions. We want an enterprise partner. We want to understand your analytics. We want to understand all the components, not just whether you put this alert in my EMR.

How do doctors react to that extra level of review or entry that is required to ensure clinical appropriateness?

The docs who are complaining about alert fatigue are primarily correct. When you install your EMR, you have people putting all these alerts. There’s not a lot of thought that goes into it, and even if there is on the front end, there’s not a lot of thought on an ongoing basis. They’ll add five alerts, then two years later, they add another five without taking a look at the original five. A doc does something in the EMR and three boxes pop up with kind of related, yet unrelated alerts. All they do is X through it. There’s no response, there’s no impact, it’s just these things that pop up and they pop up all the time. Nobody says anything, because they’re just X-ing through it.

Thoughtful implementation of guidelines to where they really have an impact, and putting them in place where we’re using the data from the EMR to fire guidance when it’s appropriate. When the end user connects, you understand what the value of it is.

That being said, we still see see doctors who don’t want to see them because they don’t want to see the EMR. They don’t even want to work inside the EMR. There needs to be an improvement in the thought process and the implementation of these advisories to ensure that they’re optimized so we’re not wasting people’s time.

The “revenge of the ancillaries” must play a part, where anyone in any department who wants to collect more information or make their own job easier dumps a new documentation requirement into the newly installed EHR. Is it easier to sell the idea that your recommendations were created by the societies to which those physicians belong?

It all depends on the use case. Sometimes the information is from societies. Sometimes it’s a local rule that a facility wants to implement. Sometimes it’s a payer rule. We try hard to make sure that the guidelines that are actually put in are relevant and respected by the end users.

Imaging is particularly hard. We took on the absolute hardest part of it. An entire service, in some cases 3,000 orderables, 7,000 clinical reasons for why you would want to use those 3,000 orderables, as well as variants used by every specialty in healthcare. It’s not something like, let’s put an alert in there for blood management if the patient’s hemoglobin level is above seven. Everything that we do beyond imaging is much easier for us to hit the target.

Why does CMS keep pushing out the mandatory date for implementing advanced imaging appropriateness rules?

This next date is set in stone, short of a big lightning strike. But I think the market is constantly making CMS aware of just how huge this implementation is. Everybody orders imaging, so they are communicating to CMS that it’s going to impact everybody. They’re getting a lot of push-back. They’re getting a lot of blowback from the market. They want to get it right.

It’s not just that they pushed it back, they have refined it, too. It is not all imaging, it’s certain clinical scenarios. But beyond just that, it’s figuring out how the data gets on the claim forms. There’s a whole process, not just on the provider’s interaction with CMS, but how all this data is going to flow and how they’re going to keep track of it all.

Do I think that they could and should have gotten this done faster? Yes. Am I surprised that it has taken this long? No.

Hospitals get paid well for imaging that best practices say it is inappropriate. Are they interested in ensuring the appropriateness of imaging until CMS forces them to?

That is almost the norm. They want to use it for the stuff that they’re at risk for, but they’re not as excited about it for the stuff that they’re not at risk for. We have seen that.

But the market is moving in a different direction. As the risk shifts to providers, this concept of a standard of care and making sure that there is no waste becomes tantamount. Not just to patient care, but to profit as well. As the risk shifts, everything looks like a DRG. Everything looks like a bundle. We are starting to definitely see a shift in wanting to adopt more and more as this risk shifts. They start acting like payers.

How is Choosing Wisely, which is endorsed by Consumer Reports, being implemented and what results are we seeing?

It’s another set of criteria. Some of it is really good. Some of it is impacted by evidence. The single greatest thing that Choosing Wisely did was create a market awareness that it’s workable to put guidelines in place to impact decision-making. It’s possible and it should be put into place. It has created an awareness.

Many of the Choosing Wisely guidelines are obvious. There’s no debate on them. So it has done a great job of creating an environment where the market is willing to accept putting guidelines in work flow to impact decision-making. The guidelines themselves are good, some better than others, but the awareness that it created is the impact that it has had.

What causes the gap between what a competent practitioner wants to order versus an insurer or hospital that thinks they need to tell them they might be wrong?

There is new data out there that docs may or may not be aware of. The average CME credits that docs get every year can’t begin to cover and keep docs updated with the latest knowledge. One of the points of implementing an EMR is to solve this gap in data. This ability to shed a light to docs on data that is available that would help them in their decision-making. I don’t think anybody could reasonably argue that doctors can’t benefit by being made aware at clinically relevant times that guidelines out there are proven or should be followed. It’s not for every case, but this is science, and information is being found all the time.

We talked about how risk shifts. Let’s go to the extreme and say you have a full-risk model on a provider’s side. Now, when a third part is paying, it’s the third party’s money and they are trying to save on unnecessary testing. Once the risk shifts to the provider, the issue is reversed. How do we prevent the provider from cutting corners? How do we prevent the provider from doing things to save money? It’s not based on bad things or evil or greed. It’s about keeping the lights on.

The only thing that protects providers from liability around cutting corners is to reduce variation in care, to establish a standard set of “this is what we do in this clinical scenario.” It doesn’t mean that somebody can’t veer off of it if there is a variant that exists. But it’s a standard that everybody follows. That ultimately will have to happen to give the provider not only protection from liability, but credibility. Why should the same type of patient with the same scenario walk in and get two different protocols?

Do you have any final thoughts?

I want to go back to the synergies with Change Healthcare and what we’re actually doing here. NDSC came to the table with a content management solution that is designed to deliver provider-focused guidelines seamlessly integrated into EMRs. In a standard way, extract data, calculate that data against guidelines, and then send that clinical data wherever it needs to be sent. We have a large provider footprint and success in the market. Change brings a host of criteria through its InterQual asset, a dominant product in the market that is used by health plans. They also have advanced business intelligence, a large investment in AI and machine learning labs, and a very large network of payer connections with a whole host of claims information.

We are working together to close the loop on delivering guidelines into the physician workflow, then being able to share that information with payers or whoever is financially risk to insure that the right things are done and to mitigate waste.

Morning Headlines 3/13/19

Mach7 Announces Restructuring to Accelerate Sales and Achieve Cash-flow Break Even

Australian imaging software vendor Mach7 fires its CEO and eliminates the CTO role as part of a restructuring and cost-cutting program that it hopes will propel its US growth.

NIH cancer chief to serve as acting FDA commissioner

National Cancer Institute Director Ned Sharpless, MD will take over as acting FDA commissioner once Scott Gottlieb, MD departs next month.

Apple’s Likely Healthcare Roadmap

An investment analyst thinks Apple will expand the Watch’s medical sensors and then sell the data of wearers to their doctors for $10 per patient per month.

2019 Top 10 Patient Safety Concerns

Warnings against relying solely on EHR information for diagnostic stewardship and test result management, managing patient expectations around antibiotics, and physician burnout awareness and review top ECRI Institute’s annual list of patient safety recommendations.

News 3/13/19

Top News

Hill-Rom will acquire mobile clinical communications vendor Voalte for up to $195 million. Hill-Rom hopes to enhance its point-of-care delivery of actionable insights and to drive its growth and margin.

Voalte’s annual revenue is $40 million. It has 200 healthcare customers.

Reader Comments

From Boston Beanboy: “Re: Salesforce. You might enjoy this article – replace ‘Salesforce’ with any EHR vendor’s name and ‘sales rep’ with ‘clinician.’ It’s the same story.” A biased but interesting article written by  the CEO of a sales platform that runs on Salesforce says sales reps hate Salesforce because the system wasn’t designed for them, it doesn’t help them meet their goals, and it turns them into highly-paid data entry clerks where which they enter the bare minimum of information required for them to collect their commissions. As a result, 75 percent of sales managers don’t trust the information in Salesforce users want a system that is personalized, flexible, integrated, and that helps them close deals instead of requiring more work. Comments posted that have EHR counterparts include:

• Salesforce wasn’t designed for the sales rep – it was designed to get information into a database so that work can be inspected and shared
• Sales reps are like everyone else in avoiding the use of a system that provides them no personal value
• Companies sell bots that can do some of the data entry work for users
• Sales teams that use a defined process love Salesforce because it tells them what to do to close more deals, but reps who pride themselves on using their own methods hate it
• Lack of Salesforce integration is often a problem with the implementation, not the platform
• Companies use CRM as a tax on salespeople, a way to capture their information to make replacing them easier

From Grand Padano: “Re: Athenahealth. Any plans to interview its new CEO? The chatter about what’s happening there post take-private is enormous.” I usually turn down interview requests from companies whose CEO is a new hire (thus giving us little to talk about except his or her optimistic plans) and has no healthcare experience (which Bob Segert does not). But I’ll consider it.

From Junto: “Re: Epic on EHR-caused physician burnout. Judy is officially out of her depth if she thinks hiding behind loose research from KLAS is an appropriate response to physician burnout. It would be nice to hear from her how Epic can be part of the solution instead of deflected the EHR as a non-issue. It’s also beyond comical that KLAS, which makes an exponential percentage of revenue from EHR vendors, conveniently has research at hand for Judy saying EHRs are all that bad.” Epic CEO Judy Faulkner cites an upcoming KLAS report’s study as evidence that minimal correlation exists between EHR and physician burnout. The surveys came from KLAS’s Arch Collaborative, which benchmarks user experience survey results across its 150 paying members, which includes Epic (price ranges from a one-time $1,250 cost to $60,000 annual membership depending on organization size). As with most of KLAS’s research, the real question is their methodology – who they surveyed, how the questions were worded, who actually responded, and how well the results extend to other organizations. All that aside, my thoughts are:

• I agree with Judy’s point that while doctors often don’t find their EHRs to be empowering and don’t enjoy the time required to feed the beast with their laboriously typed (or dictated) information, surveys don’t always tease out details about the software vs. the rules it enforces that someone else has saddled users with (the “someone else” being insurers, the federal government, and the frequent worst enemy of doctors – their employers).
• Site-specific implementation issues are often involved, primarily setup, training, support, and ongoing communication about why the system works as it does.
• EHRs may well have usability issues, but saying that EHRs specifically cause burnout (rather than being associated with it) is like saying that Word and Outlook burn us out when what we really hate is being overworked and underappreciated, being used short of our potential, being required to provide documentation that does not benefit us, and losing our idealistic view of our profession that turned out to be just another crappy job working for faceless overlords.
• If Epic or another specific EHR were actually causing burnout, it would be reported by nearly every clinician user of those systems, and I haven’t seen that to be the case.
• The VA’s VistA, one of the most antiquated and ugly systems ever built, has high user acceptance and minimal reported contribution to burnout because it has the luxury of focusing on what a doctor needs to deliver care rather than for billing, a situation that exists nearly nowhere else. It will be interesting to see how its replacement with Cerner, which was built around billing and administrative requirements, is perceived by those same doctors.
• The argument that all EHRs cause burnout is also an argument that the software isn’t the problem. Those systems look and work wildly differently, with the only common ground being that they were chosen by organizations who wanted them to work in a certain way. I haven’t seen much evidence that doctors universally love any EHR despite the vendors of those system exploiting every competitive advantage they can find. It’s easy to hate the lawnmower when what you really hate is mowing the lawn.
• EHR design and implementation decisions reflect what the decision-makers want and those aren’t the same people who actually use the EHR.
• Burnout is not consistent across specialties even though many of them use the same EHR to varying degrees.
• Working conditions often require doctors to complete their work after hours at home using the EHR, making it likely they won’t love it.
• Asking Judy her opinion makes for great click-bait for dopey journalists looking for Twitter fodder, but doesn’t otherwise mean a whole lot. She doesn’t have to defend selling the market-leading product or to speak for the entire industry in explaining why the health systems that buy EHRs are somehow wrong.
• The bottom line is that EHRs or not, physicians would be burned out because of the demands made by  those who pay them. All bets are off if you treat them like a monkey that gets fed only after dancing to organ music. Epic can’t fix that.

From Pointed Rejoinder: “Re: doctor empathy via robot. Not possible.” It may be unreasonable to expect skilled doctors, especially those such as surgeons and ED doctors whose services are one-and-done, to also be empathetic in a non-phony way to someone they don’t know. Still, nurses do it well all the time and I’ve seen some of our nastiest surgeons – feared and reviled for their tantrums and intentional hurtfulness toward hospital employees – behaving remarkably tenderly with a deceased patient’s family, which as a hospital employee always made me wonder if we really are incompetent, if the doctor was just using us as a punching bag proxy for our employer, or if they were simply putting on an act for their paying customers. Maybe hospitals should hire “empathists,” otherwise unemployable amateur actors who can pretend to be empathetic, letting them take the doctor’s handoff after delivering bad news in helping patients and families get through those first painful moments of understanding.

Webinars

March 27 (Wednesday) 2:00 ET. “Waiting on interoperability: What can payers and providers do to collaborate?” Sponsored by Casenet. Presenter: Amy Simpson, RN, director of clinical solutions, Casenet. A wealth of data exists to identify at-risk patients and to analyze populations, allowing every payer and provider to operate readmissions intervention and care management programs. Still, payer and provider care managers are challenged to coordinate and collaborate to improve outcomes because of the long road ahead to interoperability. Attend this webinar to learn what payers and providers can do now to share information and to coordinate their efforts to create the best healthcare journey for members and patients.

Previous webinars are on our YouTube channel. Contact Lorre for information.

Acquisitions, Funding, Business, and Stock

Australia-based imaging software vendor Mach7 announces that it will implement a restructuring and cost-cutting program that it hopes will propel its US growth, firing its CEO and eliminating the CTO role in favor of strategic product management. The company has several high-profile US customers including Penn Medicine, UW Medicine, Brigham and Women’s, University of Virginia Health System, Adventist Health, Sentara, and Broward Health.

Business Insider notes that companies such as Hims and Roman that send lifestyle prescriptions directly to the customer’s door often use TruePill, which aspires to the Amazon Web Services of mail-order pharmacy by offering itself as a B2B API and fulfillment service. The technology-focused company can send 100,000 orders per day and allows companies to control the patient experience in the form of custom packaging and shipping options. Co-founder Sid Viswanathan was also a co-founder of a business card scanning company acquired by LinkedIn, while CEO Imar Afridi was working as a CVS pharmacist two years ago.

The Philadelphia paper questions whether Medicaid-heavy Temple Health — the closest thing to a public hospital in the country’s poorest large city — can survive competition from well-funded and growing competitors such as Penn and Jefferson. Temple is considering selling the cancer system it bought seven years ago, which is its most profitable business, to keep afloat. Temple has survived only because the state chips in a non-guaranteed $150 million per year, not only because the health system offers healthcare services, but because it employs many people.

Insurers Cambia Health Solutions and BCBS North Carolina sign a long-term management services agreement in which they will share corporate services and operate in five states under the Cambia Health Solutions name.

Sales

• In Qatar, Alfardan Group and Chicago-based Northwestern Medicine select Allscripts Sunrise Ambulatory, Surgery, Radiology, Clinical Performance Management, Lab, and IPro Anesthesia for their joint project.
• Chapters Health System (FL) will implement hospice and home health EHRs from WellSky.
• DrFirst implements an interoperability gateway to provide medication histories to the Missouri Health Connection HIE.

People

Carol Steltenkemp, MD, MBA, former board chair of HIMSS and the Kentucky EHealth Board, is promoted from CMIO to external chief medical officer of University of Kentucky HealthCare.

Virta Health, which offers type 2 diabetes treatment via virtual health coaches and a ketogenic diet, hires Derek Newell, MPH, MBA as head of commercial. He was previously CEO of digital health benefits technology vendor Jiff and then president of its acquirer Castlight Health for 17 months.

Announcements and Implementations

A new KLAS report on quality improvement software finds a near-revolt of users of the worst-performing Conduent and IBM Watson Health (the former Truven). The top-rated vendors for hospitals are Nuance and Quantros, while the ambulatory-focused vendor list is topped by Mingle Health, SPH Analytics, and Healthmonix.

Government and Politics

HHS’s Office of Inspector General opens a position for Health Information Technology Attorney, looking for someone with expertise in EHR incentive payments, EHR interoperability, and breach notification to represent OIG in civil fraud enforcement and compliance with corporate integrity agreements. Do something wrong in health IT land and maybe you’ll get to meet the successful candidate.

Other

ECRI Institute lists its top patient safety recommendations for 2019:

1. Don’t rely solely on EHR information for diagnostic stewardship and test result management
2. Manage patient expectations around antibiotics
3. Review burnout and listen to provider concerns
4. Deploy mobile health technology wisely by identifying patients who are good candidates, give them training, and monitor the systems for user error and inactivity
5. Provide training and communication to ensure that all providers treat people who have behavioral health needs with dignity and respect
6. Detect changes in a patient’s condition, including using alarms and other technology appropriately
7. Use simulation training to maintain device and procedure skills
8. Recognize the early signs of sepsis in all setting and develop protocols supported by tools for rapid response
9. Increase awareness, surveillance, and reporting around peripheral intravenous catheter infections
10. Standardize patient safety efforts across large systems and leverage the privilege and confidentiality benefits from forming a patient safety organization

An investment analyst thinks Apple will expand the Watch’s medical sensors and then sell the data of wearers to their doctors for $10 per patient per month, claiming that practices that provide services under risk-bearing contracts would be happy to give Apple a cut. I seriously doubt all of this, but mostly the idea that the Watch is collecting information that will allow doctors to deliver better, more cost-effective care to entire populations. 

America’s homeless population is fueling a resurgence of “medieval” diseases such as typhus, shigellosis, hepatitis A, and trench fever caused by living in unsanitary conditions.

A Health Affairs blog post questions whether CMS’s push to give people easier access to their medical provider-managed information will improve outcomes or improve smart shopping, when instead what is known to work is (a) making easily understood information available when they are making a decision; and (b) allowing them to share in any cost savings. The authors are encouraged by apps such as Apple HealthKit that help consumers understand their data and take action on it, but nobody really knows how they will be used.

A man who threatened to sue MIT Technology Review for using his picture to accompany an article explaining why hipsters all look alike – he called it “click-bait” and “a tired cultural trope” — inadvertently proves the article’s conclusion when the editor-in-chief sends him a screen shot of the stock photo (which wasn’t of him) and concludes on Twitter, “All of which just proves the story we ran: Hipsters look so much alike that they can’t even tell themselves apart from each other.”

Sponsor Updates

• Optimum Healthcare IT adds ERP to its service lines.
• AdvancedMD and Aprima will exhibit at the AAOS conference March 12-16 in Las Vegas.
• Arcadia will host Aggregate 2019 April 24-26 in Boston.
• Artifact Health will exhibit at OHIMA 2019 Annual Meeting & Trade Show March 18-20 in Columbus, OH.
• Avaya expands its line of video collaboration solutions with new offerings designed for smaller meeting spaces.
• CompuGroup Medical will exhibit at the Arizona Medical Association Spring Conference March 16 in Phoenix.
• Collective Medical releases a video featuring New Mexico Hospital Association Director of Policy Beth Landon.
• Cumberland Consulting Group will exhibit at the Health Plan Alliance Spring Leadership Meeting March 19-22.
• Diameter Health will exhibit at the Rise Nashville Summit March 17-19.

Blog Posts

• Emotional, psychological & social wellbeing for mental health providers (AdvancedMD)
• Is your CMS star rating wrong? Here’s what hospitals need to know. (Advisory Board)
• Optimizing Care Management with Machine Learning (Apixio)
• Physician Leadership Career Paths (Arcadia)
• GDPR Compliance for Global Managed Service Providers (Atlantic.Net)
• It’s Time to Move Your Huddle Rooms to the Cloud (Avaya)
• Use your revenue reporting tools: A study in the psychology of natural resistance (Bluetree)
• Reflections on Patient Safety Awareness Week (Bernoulli Health)
• Datica is cheering on our customers’ growth (Datica)
• Culbert’s GE-Virence-Athenahealth Practice Update (Culbert Healthcare Solutions)
• Celebrating Patient Safety Awareness Week (Dimensional Insight)
• Catering Your Resume for the Job You Want (Divurgent)

Contacts

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

Morning Headlines 3/12/19

Hill-Rom to acquire Voalte, Inc.

Hill-Rom will acquire Voalte for $180 million and integrate it into its care communications business.

House Veterans Affairs is Having Trouble Hiring Tech Experts

House Veterans Affairs Committee Chairman Mark Takano (D-CA) tells SXSW attendees that the VA is having trouble finding and retaining technology talent for its EHR modernization effort, citing the difficulty of finding candidates with the right mix of health IT experience and policy know-how with salary expectations that fit the VA’s budget.

Aetna Heads A $25 Million Investment Round Into MAP Health Management

Addiction recovery tech company Map Health Management raises $25 million in a Series A round led by Aetna.

Curbside Consult with Dr. Jayne 3/11/19

My HIStalk team mates have already mentioned the sensational news item about a patient being told about a poor prognosis through telemedicine. It was a hot topic in both professional and personal circles this weekend, with reactions from outrage to understanding, so I wanted to weigh in.

Depending on which version of the story you read and who was writing it, the story ranged from “a robot told him he was going to die and they didn’t have any idea before that” to a much better explanation of what actually happened. I’ve seen the video clip, and although certain aspects of it aren’t ideal, it’s often challenging to have these kinds of conversations regardless of how they are held. Some of the challenges we face are unique to current attitudes in the US about technology, medical care, and death.

We’re so used to seeing miraculous recoveries on TV and in the media, whether fictional or not, that we’ve become detached to the realities of what can happen when you go into the hospital. For those of us on the inside, there’s less of a mystery. I’ve seen a healthy, 30-something physician roll onto the labor and delivery unit with her advance directive and healthcare power of attorney in hand, making sure that we understood her wishes because she knew what could happen. The nurses joked about it, but I knew she was serious. It’s not something the average expectant mother thinks about, but it’s a statistical reality, and some of us see the horrors that can happen every day.

I wish more people understood that the hospital is not an episode of “Grey’s Anatomy.” If you wind up in the intensive care unit, there’s a good chance you won’t make it out. And if you do improve, there’s a chance you might not be the same.

We are so focused on being able to do everything and overcome anything that we forget about the realities of age and that fact that you just can’t outrun the statistics no matter how hard you want to. A person of a certain age with underlying chronic conditions who goes into the hospital in respiratory distress has a significant chance of not going home. Our culture is so engrained in “battling” diseases and “the fight” that we push realities to the side. Physicians struggle with being the bearers of bad news, but we don’t do any service to our patients when we are overly optimistic.

For those on the receiving end of bad news, everything is colored by experience. If this is your first time experiencing the impending loss of a family member, you may receive it differently than someone who has been through it before. Whether you’re religious or spiritual and your own beliefs about death influence what you hear. It’s difficult for the care team to know where anyone is in this particular journey, especially with the fragmentation in healthcare today. Often the realities of today don’t include a patient being cared for by their family physician of 30 years at the bedside. There may be emergency physicians, a hospitalist, an intensivist, and multiple specialists. Maybe the patient has that family physician, but they’re hundreds of miles away from home when the unexpected happens. Maybe the patient has a nearby support system, maybe they don’t.

In the first half of the 1900s, people knew what death looked like in real life and they expected it. As an infant, my grandmother almost died of pertussis (whooping cough) and the neighbors who came to give their condolences were shocked that she was still alive. Families often cared for the sick at home and knew what was involved at the end.

In our high-tech age, we’ve medicalized the end of life so much that we forget it’s natural. Atul Gawande’s “Being Mortal: Medicine and What Matters in the End” is a great read in this regard. Different cultures have different feelings about end of life and I have enjoyed learning about different practices. In some communities, the process of dying is addressed with great self-awareness and attention to detail. It’s important for us in the healthcare trenches to remember that no matter how many times we’ve been involved in someone passing, there might not be an easy or obvious way to relate to every patient or family.

I’ve watched dozens of physicians have a similar conversation to what occurred on the video. Essentially, the physician is trying to talk to them about the level of care the patient is receiving and whether they want to focus more on comfort-focused care and symptom relief. Depending on the news account, some family members admit that they “knew this was coming and that he was very sick.” Another said they were just learning that he was gravely ill. One objection was to the technology itself, including the volume of the speaker and its proximity to the patient who had difficulty hearing.

We don’t know the full extent of the situation, whether the family had experience with a video-based consult before, or how the telehealth process was explained to them. We can’t see who else is in the room or at the bedside, but it’s easy for many to pass judgment on it. Even in person there are difficult conversations around this topic, where physicians struggle to find the balance between recommending care that can help and care that might hurt. Families struggle with feelings of giving up versus fighting for life.

This situation creates a tremendous opportunity to have conversations around technology on both professional and personal levels. As someone in healthcare, how did this story make you feel? How does it relate to what your institution might be doing? Are there ways you could be doing things better or otherwise differently? On a personal level, have you talked with family members about their wishes should something happen, whether expected or unexpected? How would you react if a loved one was being cared for by virtual members of the team? How do members of the family value quality vs. quantity of life and how do those beliefs influence medical care choices?

We always talk about assuming positive intent and I don’t think anyone involved in this video consult program intended for a family to be hurt or upset. Sometimes things occur that are out of our control or sometimes mistakes are made, and we can use those experiences to change how we approach things in the future. As “insiders,” we can help educate our families and friends about the realities of what we see day in and day out and how it’s not at all like you see on TV or in the movies. We can start a discussion that will perhaps lead to other conversations that might make it easier on some other family down the line. We can learn about other approaches to death, dying, and intensive medical care and decide whether we want to think about situations in new ways.

As a society, let’s temper our outrage and figure out how we want to do things better.

Email Dr. Jayne.

HIStalk Interviews Guillaume de Zwirek, CEO, Well Health

Guillaume de Zwirek is founder and CEO of Well Health of Santa Barbara, CA.

Tell me about yourself and the company.

I founded Well almost precisely four years ago. My background is not in healthcare. I started my career as a classical musician. Then I worked at Google for four years, then afterward at a big data company that we sold to Amazon. I started a healthcare company because I found myself in a hospital one day and I was just so frustrated with my experience.

Well helps patients and administrators break free of antiquated communication practices. We provide a single command center that connects the many tools they use, transforming everyday interactions between patients and providers.

How can we be sure that hospitals will think about what the patient needs and wants instead of just blasting out self-serving, generic messages that focus on whatever benefits the health system’s bottom line?

I founded this company because I was disturbed by the amount of robo-spam that existed in healthcare. When I was at Google, I saw a transformation from web to mobile apps and then from mobile apps to messaging. That was happening right around the time I was leaving. 

My experience in healthcare in 2015 was precisely what you are describing. Getting four to 17 messages, all saying the same thing that I can’t respond to, with no human on the other end. My only recourse is to call and wait on hold for 17 minutes. That to me is not customer service.

This is an industry that takes up the vast majority of GDP. On average, Americans spend $11,000 a year on their healthcare. A lot of that goes to insurance companies, but you would expect a bare minimum level of support in that environment. One thing I love to tell my team is, pick your favorite retailer — Nordstrom, Lululemon, you name it. Imagine if they were guaranteed $11,000 for every customer that walked in their door. What would they do? How would they treat their customer?

That’s how I like to think about healthcare, because I’m not from this industry. This is my first time in this industry. I encourage healthcare systems to think bigger and to go beyond the status quo. In an era where everyone is talking about AI, machine learning, and automation, we’ve gone in with a totally different approach. You have a phenomenal staff of people at your health system today. They just need the tools to be able to speak to your customers more effectively and make them feel human. It’s really concierge care, but in a way that is much more efficient for both parties involved.

My experience is that providers like to put up self-serving technology walls as a scalable alternative to paying humans to be available, so that if they can make money sending out robo appointment reminders to the potentially unruly masses without hiring people, that’s all they will do. How do you sell them on the idea that it’s OK to allow customers to speak with an actual human?

The problem is that the tools and techniques that are being used today aren’t effective. Look at the portal’s adoption rate across the industry. It’s abysmal. Ask every leading healthcare IT company about their numbers and what engagement looks like with patients. It’s not pretty.

When I was working at Google, my success and failure metric was, will a billion people use this? I was thinking about things on a different scale. I would have gotten fired for having 10 percent of people engaging with a release that I made. That to me is the framework that healthcare should be thinking about when they’re thinking about technology. 

The reality is that you’re only going to engage people when you treat them the way they want to be treated. For texting especially and for messaging, I was seeing a very disturbing pattern. I didn’t want texting to become the new email.

For me, that meant putting humans behind the scenes. An even more important piece was connecting all the pieces. I’m going to divert from your question a little bit, but I’d like to speak to a trend that happened 15 years ago with the EMR and the EHR. This concept where health systems had bought a lot of best-of-breed technologies and all the data was sitting in different silos. The EMR comes around and all the data comes together in one place. Obviously the government fueled this, but there was a deliberate effort by health systems to piece everything together into a central database. Epic and a bunch of others did a great job here.

When I talk to health system executives, I give the same pitch for communications. We’re in a period in time where customer loyalty, customer retention, and building a long-term relationship with patients are critically important. You will never be able to do that if you have 100, 200, 500 different healthcare IT vendors that are all trying to communicate with your patient independently.

I was talking to a health system executive three weeks ago who told me she has 1,000 vendors. One thousand. She did a journey map of her patients, and there was a situation where a patient can get 17 appointment reminders coming from different systems. That’s because the systems aren’t playing nice together.

A big part of this is the educational piece. My pitch to health systems execs is think about communications the same way you thought about data 10 or 15 years ago. Everything needs to be routed centrally. You need to have live agents on the other side to help patients when there’s a need for service recovery.

Health systems like the idea of patient engagement even if they don’t fully understand or embrace what it means. Are they talking to patients about what they want and how they want to receive it?

I’m encouraged by the fact that over the past few years, this position of chief patient experience officer or patient access has become pretty prevalent across health systems. I’m encouraged by the fact that health systems are hiring leaders from outside of healthcare.

Product design and customer research in healthcare is probably lagging behind other industries. A lot of that has to do with the fact that healthcare has acted a lot like a monopoly over time. It’s hyper-local. There might be only a few health systems. The insurance companies control the patients, where you go wherever your insurance company pays. A lot that is changing as patients pay more money out of pocket.

But healthcare for the longest time has had the makeup of a monopoly, just like cable companies and the government. Which is why when you look at customer service ranked by every industry, those are the three worst. They all have monopolistic tendencies.

As someone coming into healthcare from the outside, did it surprise you that unlike in nearly all other industries,  we can’t really define who our customer is?

I’m fortunate that I wasn’t from healthcare and came to the industry with open eyes. I’ve learned a lot. Healthcare is complicated, and for good reasons. There are nuances with patients. A mother with three chronic conditions in a rural area is going be very different than a high-tech Silicon Valley yuppie. There’s a lot of merit to healthcare being more complicated. It is a really, really hard challenge. 

We’re still in the early days of figuring out what a patient engagement strategy means. Health systems are thinking through individual problems. Let me tackle scheduling and registration, eligibility, or telemedicine. We should be taking a step back and thinking about how we can help patients of all these different backgrounds navigate their unique patient journeys. That’s where it comes back to communications for me. That’s where I’ve been laser focused over the past four years.

Is it difficult to get that rational argument heard above all the noise that tends to buzz around healthcare IT?

That’s one part of it that is sad. The most effective way we’ve found to sell is come in and rip and replace legacy systems, the robo-dialers and robo-spammers that every health system has today that send out those appointment reminders that patients love to hate. Then, hopefully, to use that as our Trojan horse to start developing a strategic relationship with the executives and help them understand how they can map out the end-to-end journey, put agents behind this, and offer an unparalleled experience. But that’s the hard part. It’s unfortunate that that’s the way in.

But I’m also pragmatic. I realize that this is a complicated industry with a lot of competing initiatives. Every health system is doing a double Epic upgrade and and CMS is changing their rules left and right. I understand the nuances and the complexities. It was definitely a surprise for me, and one of the sadder things for me, that we have to start there and I can’t start with the full package. I can’t start by implementing this comprehensive, end-to-end solution that would change the way patients experience healthcare. 

It’s baby steps. The jury is out over the next two to three years whether we can get people from that better robo-dialer experience to a truly integrated communications journey for patients.

In the absence of a chief experience officer or chief patient officer, who makes your case internally?

It depends on the health system and where the pain is felt the most. Sometimes it’s IT that is so frustrated with the way that their systems run today. In our world, it’s batch files at night that sometimes go wrong. Patients get the wrong messages and they end up filing support tickets and waiting three weeks. That is when IT feels a lot of pain.

Sometimes it is operations. You’ve acquired health systems, brought on new doctors, exited doctors, and you’re having to manage this entire operational side that is just becoming too time-intensive with existing technologies. That is typically where we are selling.

What is more interesting to me as we move towards risk is thinking about how we could potentially sell on the financial side, to the CFO, to the CMO, to the CNIO. People who realize that keeping patients out of the ED, keeping patients healthy, keeping patients adhering to the protocols that they want them to has long-term impact on their bottom line. That’s where I’d like to see things go. The message will resonate more. But we are still trying to figure out how to sell our message to that group.

How should a startup work with an accelerator or incubator?

You have to go in with a clear goal and objective. We went through an accelerator that was done in partnership with Techstars and Cedar-Sinai. When we accepted the offer to join that accelerator, our goal was to rip and replace their legacy reminder vendor. That was my only goal, my team’s only goal, for the four months that we were there.

We knew that if we succeeded, it would have been worth every minute we spent there. If we failed, we would have learned a lot about how to sell into healthcare, large health systems, and the nuances of workflow. We were successful, but even if we hadn’t been and we had learned those lessons, it would have been time well spent and we wouldn’t have been stuck in this endless pilot phase. I recommend not doing free pilots.

When it comes to accelerators with health systems, I’ve been disappointed to see some of the new accelerators that have come out that try to charge startups money to join. It’s so hard to start a company and be an entrepreneur, especially a first-time entrepreneur like myself, and if we’re going to encourage innovation in healthcare, we need to encourage companies to come to our health systems and spend time with us. We should pay startups if we can. If we want a pilot of their technology, we should pay them, because it costs a startup money to get something running.

The most important thing is that they learn, and they learn quickly, is that the killer of all innovation is time. You can’t buy time. You can’t make time. You have to move as quickly as possible.

We say in health system IT that nobody in the organization is empowered to say yes, but everyone is empowered to say no. Do you find that you need someone to go to bat for you?

It is better to get a quick no than a maybe. I learned this in raising venture capital money. I’ve raised over $14 million and I learned this lesson the hard way many many times. It is way, way better to get a no than it is to wait for months and months and months for a maybe.

The way we did it specifically when we went through the accelerator is that I just asked for meetings. I had a list of 56 practice administrators who had some sort of decision-making authority over the system they had in place. People are normally happy to introduce you to other individuals, especially entrepreneurs and people who are trying to introduce innovative technology. I went into those 56 meetings with an open mind, but a very very clear goal. I got great feedback and refined my pitch, and at the end of the day, I had 50 people who said, I would pay you for this. 

I went to the CIO of this health system and said, I’ve got a bunch of contracts. I think you owe me a few million dollars. What do you think? And I got three pilots out of that. They paid me for the pilots, which was fantastic. But getting to no is sometimes a much harder feat than getting to yes, and it’s just as important.

Silicon Valley types often think they know everything and roll their eyes at any industry that they think is not using technology optimally. How did you develop an ability to avoid talking down to healthcare people in a way that would have made them less likely to want to work with you?

I had my foot in my mouth a few months into starting this company. I was trying to get into this accelerator and they thought we were blowing smoke around integration. I had never integrated before. It sounded really easy. I talked a really strong game around integration. They gave me a second chance to come in and have some humility, be honest about what we knew and what we didn’t know, and where we needed help. I’ve carried that lesson with me every single day since that experience, and that was almost three years ago.

At the core, what keeps me honest is that I’m a patient. All I want is to make things better. I want going to the doctor to be as easy as meeting up with a friend for coffee. I recognize that there is way more complexity than patients ever realize. If I can seek to understand that complexity and partner with health systems to figure out the right solution to making that seam invisible and frictionless to patients, then that’s a win. It doesn’t matter how long it takes. I just need to find the right partners who are willing to get creative and co-develop with us.

That’s where I’m having some of the most fun. Learning with health systems, understanding the challenges, getting curious, and at the end of the day, just trying to make the experience of healthcare something that’s as enjoyable as calling an Uber.

What are the most relevant lessons you learned while working for Google?

There are two lessons that came from the company after Google. I was at a company called Graphiq that now powers a lot of the technology behind Amazon Alexa. The founder there is Kevin O’Connor, a serial entrepreneur. He founded a company called DoubleClick that runs most of the display advertisements on the Internet. 

I learned two concepts from him that I’ve carried with the company. The first is the concept of test-fail-learn, test-fail-learn, test-fail-learn, test-succeed, and then scale the crap out of the things that work. We do a lot of testing. We are very, very focused on analytics. We want data from our customers. We want to give them the data we have. When things aren’t working, we want to pivot.

I’ll give you an example. Early on, we thought that we could launch a health system-to-patient communication solution and also launch a clinician messaging solution at the same time. We failed miserably. I realized within two days of launching a solution that that was such a hard and complicated problem that there needs to be companies dedicated to that solution. Companies like Vocera and TigerConnect do that. That’s just one example of me learning and the test-fail-learn, test-fail-learn mantra.

The other one is this concept of scalable opportunities. Looking at the market, thinking about the things that really excite us but that we don’t really know how to solve yet, and assigning people to those initiatives just so that they become experts in them. As we figure out ways that we might be able to plug into these trends, testing solutions. For us, those are things like the payer landscape and value-based care. There are seven other items that sit on our whiteboard that no one’s actively working on, but we have one person on the team dedicated to thinking about them. One day they might find their way into our product and into our solution. But they are very much pie-in-the-sky ideas, scalable opportunities that we might choose to introduce to our company one day.

As a healthcare newcomer, what did you think of the HIMSS conference?

There was a lot going on. My heart goes out to anybody making purchasing decisions in healthcare. There are so many choices, there is so much noise, there is a lot to make sense of. In my opinion, it doesn’t look like there are clear winners in any category. Walking the, whatever it is, one mile or two miles of the exhibit floor is a clear example of that.

We knew that we had to have a decent presence at HIMSS for people to take us seriously. We went to HIMSS with two goals, to build vendor relationships and to meet with our existing clients and to meet with prospective clients while they’re all under one roof. I was happy with our performance and being able to achieve those goals, but it is a noisy space. I don’t have any solutions around how to make sense of the noise. I guess as a vendor, trying to be louder and trying to prove more value in a way that people hear who are making those buying decisions.

Do you have any final thoughts?

I’m having more fun than I have ever had in my career, and I’m 12 years into my career. I’m sure you’ve heard this from people many times in the years you’ve been writing HIStalk, but I believe that we are at a juncture in healthcare. I believe that patients feel empowered. I am encouraged by many of the new companies coming into healthcare. I am so encouraged by health systems that are opening up their doors to companies like ours, to help them learn and to help them bring new technologies to market. I am hopeful that investors will continue putting money into healthcare IT and that they will see big successes that keep fueling development in healthcare. 

At the end of the day, my personal goal is to flip the status quo, in which healthcare is in the bottom three industries in terms of customer service. In my humble opinion, it should be number one.

We have a long journey ahead, but there’s a lot to be encouraged by and excited about. It’s people like you, investors, health systems, and frankly, companies coming into the space and even competitors of ours. So I really thank you for taking the time to speak with me and for seeking me out. It’s people like you who are helping drive this industry forward the ways it needs to be driven forward. I’m very appreciative.

Morning Headlines 3/11/19

Hidden FDA Reports Detail Harm Caused By Scores Of Medical Devices

FDA has given surgical stapler manufacturers an exemption from publicly reporting problems to its MAUDE database of medical device failures, allowing them to hide widespread problems.

Spokane’s Columbia Surgical Specialists paid nearly $15,000 in a ransomware attack that compromised patient data

Columbia Surgical Specialists (WA) pays $15,000 to regain access to its data following a ransomware attack.

Doctor tells patient he doesn’t have long to live through hospital robot’s video screen

Kaiser Permanente apologizes for one of its doctors telling a 79-year-old inpatient that he was dying via a telemedicine robot.

VA and DOD set to pick health data decider

DoD and VA officials expect to have a lead for their joint EHR efforts named within the next two weeks.

Monday Morning Update 3/11/19

Top News

FDA has given the manufacturers of surgical staplers an exemption from publicly reporting problems to its MAUDE database of medical device failures, allowing them to hide widespread problems by submitting just 100 incidents in 2016 vs. the 10,000 that were actually reported.

FDA’s alternate summary reporting program – created to save FDA employee processing time — allows manufacturers to send a quarterly or annual spreadsheet list of problems instead of detailed reports.

Several experts, including former FDA Commissioner Rob Califf, said they’ve never heard of the program. Companies that use the option tend to keep quiet about it to prevent competitors or prescribers from finding out the true patient impact.

Among the non-reporters are manufacturers of pelvic mesh, the da Vinci surgical robot, and several critical heart devices.

FDA responded to the Kaiser Health News report by saying it will analyze the summary reports, also adding it will make public the 41,000 safety reports it has received that involved surgical staplers. Those reports included 366 deaths, 9,000 serious injuries, and 32,000 malfunctions.

It’s puzzling that FDA received so many patient safety incident reports that it decided its best action was to stop requiring them.

HIStalk Announcements and Requests

Around half of poll respondents say the federal government’s role in interoperability should be to set technical standards, while the distant #2 choice is for the federal government to stay out of it entirely and let the market figure it out.

New poll to your right or here: for provider employees, how much time and energy does your employer devote to planning or delivering value-based care?

Webinars

March 27 (Wednesday) 2:00 ET. “Waiting on interoperability: What can payers and providers do to collaborate?” Sponsored by Casenet. Presenter: Amy Simpson, RN, director of clinical solutions, Casenet. A wealth of data exists to identify at-risk patients and to analyze populations, allowing every payer and provider to operate readmissions intervention and care management programs. Still, payer and provider care managers are challenged to coordinate and collaborate to improve outcomes because of the long road ahead to interoperability. Attend this webinar to learn what payers and providers can do now to share information and to coordinate their efforts to create the best healthcare journey for members and patients.

Previous webinars are on our YouTube channel. Contact Lorre for information.

Sales

• Medway NHS Foundation Trust joins TriNetX’s global health research network to attract more clinical trials and to support research collaboration.

Decisions

• Firelands Regional Medical Center (OH) replaced Aris Radiology with REAL Radiology For teleradiology in fall 2018.
• Braxton County Memorial Hospital (WV) will Implement Epic in June 2019.

These provider-reported updates are supplied by Definitive Healthcare, which offers a free trial of its powerful intelligence on hospitals, physicians, and healthcare providers.

Privacy and Security

Columbia Surgical Specialists (WA) pays $15,000 to regain access to its data following a ransomware attack, explaining, “We received notice from the people that encrypted the files just a few hours before several patients were scheduled for surgeries, and they made it clear we would not have access to patient information until we paid a fee.”

Other

Kaiser Permanente apologizes for one of its doctors telling a 79-year-old inpatient that he is dying via a telemedicine robot. The family says it was hard to hear what the doctor was saying due to the robot’s small speaker, but it was clear when he said, “I don’t know if he’s going to get home” due to the patient’s failing lungs. The man’s daughter recorded the incident on video thinking the family would be receiving care instructions. The patient died two days later. It sounds harsh, but I’m not so sure – not all telemedicine visits will result in good news, the provider isn’t necessarily geographically accessible to the patient, and the idea that empathy requires physical presence may need to be challenged. Or perhaps it’s unreasonable to expect skilled clinicians to be good at comforting patients or consoling their families as much as we as patients would like it. There’s probably no good way to be told – accurately, as it turns out – that you are dying.

23andMe will add type 2 diabetes risk factors to its consumer genetic screening once FDA approves the test, although the science behind it is shaky (it looks at a package of existing genetic traits rather than a specific genetic abnormality and it is known to be super inaccurate for black Americans, for example) and it has not been reviewed in the medical literature. My questions:

• How many people already have known diabetic risk factors, what are they doing about it, and how does this new test benefit anyone other than 23andMe?
• A big percentage of people have known diabetic risk and it’s not clear how many of them take action that are proven effective to avoid moving to active diabetes. What would patients do differently from the results of this test? How does this test change outcomes?
• What is the immediate course of action for someone who tests positive? Call their PCP for an immediate appointment and then be identified for life as “prediabetic” and run up bills for drugs and monitoring? Who’s going to pay? How many of those patients have already been told by their PCP that they are at risk but haven’t done anything?
• Is 23andMe motivated more by its partner agreements that allow those who are identified as being at risk to sign up for paid coaching programs?
• As one expert says, “You might as well just look in a mirror. That’s as good a predictor for diabetes as all your genes put together.”
• Every medical student is taught that you don’t measure something just because you can — the course of action is uncertain; chasing a lab result isn’t necessarily beneficial to the patient; medicalizing a symptom-free patient often doesn’t make sense;  and plenty of people already have diabetes but don’t receive treatment.
• The odds that this test will move the US public health needle is just about zero despite our widespread (and profitable) misperception that we just need to diagnose more stuff.

Sponsor Updates

• US Air Force Reservist Senior Master Sergeant Andrew Branning, director of CloudWave’s project management office and quality and recently returned from overseas deployment, nominates his supervisor Mark Middleton, VP of cloud services and chief quality officer, for the Patriot Award. The award, overseen by the DoD’s Employer Support of the Guard and Reserve, allows citizen soldiers to recognize the supervisors who support their work by offering flexible schedules, time off before and after deployment, and family care.
• Seven hospitals in Mississippi and Alabama form the Mississippi Meditech CIO Collaborative to share common goals, challenges, and a dedication to improving healthcare with EHR technologies.
• Medhost enables integration of National Decision Support Co.’s CareSelect Imaging with its EHR.
• NextGate will exhibit at State Health IT Connect Summit March 18-20 in Baltimore.
• Clinical Computer Systems, developer of the Obix Perinatal Data System, will exhibit at the AWHONN Virginia Section Conference March 17-18 in Charlottesville.
• FlyWire’s global payment and receivables business accelerates into 2019 after integrating OnPlan Health.
• Experian Health will exhibit at the Semi-Annual ACO Leadership Forum March 11-12 in Chicago.
• Sansoro Health releases a new podcast, “The Power of Patient & Family Engagement.”
• Vocera will exhibit at the NYONEL Annual Meeting & Leadership Conference March 17 in Tarrytown.

Blog Posts

• Transforming Health: Health IT and Patient Access (Vyne Medical)
• Let’s celebrate nurses in 2019 (Meditech)
• Top 5 challenges in claim status inquiries – and how to solve them (Waystar)
• Government to private industry: Take the lead in patient records matching (NextGate)
• Customer Success Story: MMR Healthcare — Using Data to Defeat Diabetes (EClinicalWorks)
• Out with the Old: Comprehensive Nursing Systems’ Transition (Netsmart)
• Charge Reconciliation Training, Maintenance, and Accountability (CereCore)
• How AdvantageCare Physicians increased security of patient portals (Experian Health)
• 3 Steps to Amplify Conversion Rates from Print Campaigns for Health System Marketing (PatientBond)
• Is It Time to Upgrade Your Patient Payment Software? (Patientco)
• It’s Time to Simplify Docs’ Docs (PatientKeeper)
• What physicians need to do to change patient behavior (PerfectServe)
• 5 reasons why you shouldn’t do direct-to-database ER integrations (Redox)
• Your Patient Access Management Opportunity (The SSI Group)
• Technology as extra eyes and ears. (Voalte)
• 10 Physical Therapy Marketing Metrics that Matter (WebPT)
• A digital platform for value-based care management (Philips)

Contacts

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

Weekender 3/8/19

Weekly News Recap

• Livongo’s planned Q3 IPO could bring in $1 billion
• Carestream Health sells its health IT business to Philips
• Northwestern Memorial Hospital fires dozens of employees for looking at the EHR records of actor Jussie Smollett
• Amazon, Berkshire Hathaway, and JPMorgan Chase name their healthcare venture Haven
• FDA Commissioner and digital health advocate Scott Gottlieb, MD resigns
• Newly formed Beth Israel Lahey Health says it will eventually consolidate its multiple EHRs into a single product

Best Reader Comments

There is no long road to interoperability. There are data solutions right now that can curate and harmonize all the data that’s out there. FHIR is not going to be a magic bullet either. Healthcare organizations have to stop waiting for Judy to figure it out and invest in an enterprise data strategy and platform. (BK)

A single-payer system that rams real metrics down our throats will engage value-based care as a viable alternative. The original Obamacare bill had a subscription-based expansion of Medicare, i.e. a 25-year-old could pay premiums directly to Medicare for enrollment. Medicare would effectively be setting the floor for premium costs, and commercials would have to come down and offer better services to compete. This absolutely is the way we are trending and will happen at some point. The question is when, and will the healthcare systems/HIT be ready to change to really win the business of patients with VBC. (SinglePayor)

I shouldn’t be, but I am surprised how often I see vendors and providers hyping up value-based care. Upside only arrangements don’t count. Payments based on weak quality metrics aren’t important to consumers. Prices aren’t available to consumers. Where is the value? Most hospitals and health systems have about 5 percent of payments tied to VBC. My opinion is that the only providers who can claim VBC: true IDNs and those that offer a significant number of bundles (Geisinger’s proven care model). If you talk to hospital CEOs and CFOs, it’s very rare to find VBC in their top 10 priorities. My sense is that vendors are driving the hype. (Desperado)

Watercooler Talk Tidbits

Readers funded the DonorsChoose teacher grant request of Ms. D in Massachusetts, who asked for classroom speakers for her elementary school class. She reports, “These speakers have been a lifesaver for my classroom. I use them for all my lessons and for brain breaks for my Littles. For math warm-ups, we often watch videos that help my students learn to count to 100 by 1s, 2s, 5s, and 10s. In reading, I was able to find audio and videos on books that we are reading in the classroom. During indoor recess, I often put on videos of different habitats and they love to just sit on the carpet, listen, and see different worlds. The girls love the speakers on Just Dance Friday, where if the class has earned enough reward points, we turn the classroom into a dance floor. Thank you for the donation to my classroom.”

Median monthly rent for a one-bedroom apartment in San Francisco has risen nine percent in the past year to $3,690. That’s before the upcoming flood of tech IPOs creates thousands of new company millionaires who are anxious to kick off their conspicuous consumption by buying houses, throwing lavish parties, and buying boats even as financial planners warn them that their counterparts at Groupon and Snap did the same until their shares went down in flames. A real estate analytics expert predicts that one-bedroom condos will be worth at least $1 million in five years and single-family homes will average $5 million.

Company swag at Livongo’s first user group meeting included a day’s use of partner company’s continuous glucose monitor patch, reminding everyone about just how big a business diabetes (or the threat of it) is in the US as Livongo barrels toward its $1 billion IPO.

The mainstream press notices that the proposed HHS interoperability rule would also require hospitals to publish the actual prices they have negotiated with insurers. You needn’t wonder where the AHA stands on this issue.

The hospital gown that Kurt Cobain wore in Nirvana’s headlining set in Reading Festival 1992 has been put up for auction by a fan who says Courtney Love gave it to him during a vigil after Cobain’s suicide in 1994. Cobain was pushed onto the stage in a wheelchair while wearing the gown, sang a few lyrics from Bette Midler’s “The Rose,” and then pretended to collapse before springing up to rip through a 25-song set whose bootleg is prized by collectors as one of the band’s best, all to dispel rumors that he wouldn’t make the show because of his drug addiction.

A six-year-old boy whose parents refused to have him vaccinated becomes Oregon’s first pediatric tetanus case in 30 years, with his family refusing to continue the vaccine series that was started during his 57-day hospital stay that cost $800,000.

The parents of a 21-year-old who died in a skiing accident hire a lawyer to force Westchester Medical Center (NY) to save a sample of his sperm with the hope of “preserving some piece of our child that might live on,” but the court will have to decide what happens to the sample since the son didn’t give his permission. He was the only child of the couple, who is from China, and that country’s previous one-child policy has resulted in his having no male cousins to carry on the family lineage. Ethicists say that policies and laws aren’t consistent and there’s the question of who would choose the egg donor and raise the child.

Pop-up, spa-like stores are offering to freeze the eggs of women who worry about the ticking of their biological clocks, hosting champagne parties to convince prospects to pay $5,000 for the procedure and the first year of freezer time. One chain features Dr. Oz on its board, reassuring patients that their medical care will be overseen by someone who has won seven Daytime Emmy Awards.

In Case You Missed It

• News 3/8/19
• EPtalk by Dr. Jayne 3/7/19
• Readers Write: HIMSS, Innovation, and the Infomercial
• HIStalk Interviews Randall, An Anonymous Health System CIO
• News 3/6/19
• Curbside Consult with Dr. Jayne 3/4/19
• HIStalk Interviews Michael Schmidt, Managing Director of Strategic Innovations, Orlando Health
• Monday Morning Update 3/4/19

Get Involved

• Join my Rolodex to provide occasional news reaction or ideas
• Contribute regularly as a provider CIO, IT director, or informatics nurse (anonymous or not)
• Be interviewed (providers)
• Deliver an educational webinar (providers)
• Sponsor
• Report a news item or rumor (anonymous or not)
• Sign up for email updates
• Connect on LinkedIn
• Contact Mr. H 

Morning Headlines 3/8/19

Digital-Health Startup Livongo Eyes 2019 IPO

Chronic disease management-focused digital health company Livongo hires underwriters to prepare a Q3 IPO that’s expected to bring in $1 billion.

Carestream Health To Sell its Healthcare IT Business To Philips

Philips acquires Carestream Health’s imaging IT business for an unspecified amount.

Audit: Bad billing system costs Glens Falls Hospital $38 million in revenue

Auditors blame a 2017 implementation of Cerner’s billing system for the $38 million revenue loss of Glen Falls Hospital in New York.

Dozens Of Northwestern Hospital Workers May Have Been Fired For Improperly Reviewing Jussie Smollett’s Records

Northwestern Memorial Hospital fires dozens of employees for looking at the EHR records of actor Jussie Smollett, who was treated in its ED following his claim of being attacked in a racially motivated incident.

News 3/8/19

Top News

Amazon, Berkshire Hathaway, and JPMorgan Chase decide to call their healthcare venture Haven.

The bare-bones website launched along with the brand is light on concrete details about the company’s plans, though visitors can glean a few details about its goals and structure if they dig deeply enough:

• Haven will focus on offering employees of the founding companies easier access to primary care, easier-to-understand health insurance, and affordable medications.
• It will use data and technology in unspecified ways to meet those goals.
• Haven seeks to become an ally of rather than a competitor to healthcare stakeholders.
• Profits will be reinvested.
• It may one day share its solutions with other interested parties.

Of its nine-member team, only CEO Atul Gawande, MD and Head of Communications Brooke Thurston have health system experience. CTO Serkan Kutan comes from Zocdoc, Head of Measurement Dana Safran from BCBS, and COO Jack Stoddard and Chief of Staff Megan McLean from Comcast.

Reader Comments

From La Vida Loca: “Re: [company CEO name omitted]. Have you seen his arrest record?If I were on the board, which he controls, I would be investigating moral turpitude as a cause. What does that do to the business?” I hadn’t heard that, but Googling turns up a September 2018 arrest and his co-founder wife has since left the company. I’m not naming him because I don’t see that he ever went to trial.

From Cranapple: “Re: CareTrac HIE. Reading between the lines, it is folding because the big Epic hospitals in Minnesota won’t share data.” The forwarded announcement from Southern Prairie Community Care says the HIE doesn’t have a business case because large health systems won’t share their data, adding that HIE’s technology vendor Change Healthcare won’t devote the resources to connecting the HIE to the EHealth Exchange (which the state requires of HIOs) that would have given the smaller players at least some big-hospital data.

From Amy Gleason: “Re: healthcare costs. Check out what my daughter wrote about her monthly infusions. Her newest insurance pays $202K per year more than the last insurance. She is horrified and doesn’t understand why there isn’t an app that would help her.” First off, Amy has moved on from the shuttered CareSync and is now working for the White House’s US Digital Service on HHS/CMS interoperability projects. Her daughter Morgan’s write-up describes the situation – she gets the same infusion every month from the same doctor, same hospital, and same nurses, but the three insurers that have covered her have paid wildly different prices. Like normal humans, she’s wondering exactly how forcing hospitals to publish their chargemasters accomplishes anything when the healthcare world revolves around confidential discounting with each insurance company. I wish I had something encouraging to say, but Morgan has already wisely concluded that “I am thinking that we might really need to just burn the healthcare system to the ground and completely start over,” although I won’t burst her bubble by mentioning that fire trucks – in the form of politicians who are well paid by the profitable status quo – always manage to squelch those flames.

From Odd Bedfellows: “Re: Molina Healthcare. Offering its Washington State Medicaid members a free 90-day subscription to Amazon Prime.” There’s so much wrong here that I don’t know where to start, so I’ll save my snarkiness for this – even after the free subscription ends, the Medicaid members pay just $5.99 per month and that’s a lot less than I pay. You folks in Washington are generous to provide your less-fortunate neighbors with two-day delivery and Prime Video streaming while you’re off working. Still, I’ll table my cynicism temporarily in noting that for those who have transportation issues and who live in food desert neighborhoods, Prime could indirectly improve health and lower costs and I assume that Amazon is footing some or most of the cost in its attempt to get every American on Prime (and 100 million of us have already signed up).

HIStalk Announcements and Requests

Welcome to new HIStalk Platinum Sponsor Artifact Health. The Boulder, CO-based company made headlines this week for its just-announced work with AHIMA to deliver compliant physician query templates (documentation clarification) via its cloud-based platform. Health systems using Artifact reduced their AR days by increasing response rates to nearly 100 percent and reducing average response time by 80 percent. Doctors can respond from their computers or smartphones (often in just three taps) and appreciate receiving the same format for all queries (CDI, inpatient, outpatient, and pro fee). Their responses are recorded directly in Cerner, Epic, or Meditech to become part of the legal medical record with no manual recordkeeping by CDI specialists and coders. Thanks to Artifact Health for supporting HIStalk.

I decided to leave my HIMSS19 burner phone active for a bit longer, just in case you want to text me something interesting.

I’ve received a few reader inquiries lately about not getting my email updates because of spam-blocking or other email filtering on their end. Sign up again if you are among them – you only need to enter your email address and there’s no risk otherwise.

Webinars

March 27 (Wednesday) 2:00 ET. “Waiting on interoperability: What can payers and providers do to collaborate?” Sponsored by Casenet. Presenter: Amy Simpson, RN, director of clinical solutions, Casenet. A wealth of data exists to identify at-risk patients and to analyze populations, allowing every payer and provider to operate readmissions intervention and care management programs. Still, payer and provider care managers are challenged to coordinate and collaborate to improve outcomes because of the long road ahead to interoperability. Attend this webinar to learn what payers and providers can do now to share information and to coordinate their efforts to create the best healthcare journey for members and patients.

Previous webinars are on our YouTube channel. Contact Lorre for information.

Acquisitions, Funding, Business, and Stock

Long-term and post-acute care software vendor PointClickCare acquires LTPAC-focused medication management company QuickMar.

Chronic disease management-focused digital health company Livongo hires underwriters to prepare a Q3 IPO that’s expected to bring in $1 billion. The company has raised $240 million since former Allscripts CEO Glen Tullman started it in 2014.

Philips acquires Carestream Health’s imaging IT solutions business – which includes VNA, diagnostic and enterprise viewers, and clinical, operational, and analytics tools — for an unspecified amount.

People

Impact Advisors hires Jay Backstrom (Schumacher Clinical Partners) to lead its newly expanded telehealth consulting service.

Apixio hires Jennifer Pereur (Hill Physicians Medical Group) as VP of solutions and Terry Ward (Change Healthcare) as SVP of solutions.

Sales

• Allina Health (MN) selects patient engagement software from PatientWisdom.
• In Texas, Arise Austin Medical Center and The Hospital at Westlake Medical Center will adopt Allscripts Sunrise.
• The Escambia County Healthcare Authority in Alabama will implement Cerner Millenium at D.W. McMillan Memorial Hospital, Atmore Community Hospital, and four clinics. Atmore appears to be running Epic under Infirmary Health. The hospitals will also run Cerner RCM, ancillary, and ambulatory as well as outsource its business office to Cerner.
• The University of Kansas Health System chooses Connexient’s MediNav digital wayfinding software.
• WakeMed Health & Hospitals (NC) selects PeraHealth’s Rothman Index predictive analytics.

Government and Politics

VA officials tell members of a House appropriations committee that it will roll out its new Cerner EHR at three facilities in the Pacific Northwest early next year. John Windom, head of the VA’s EHR modernization effort, told lawmakers the pilot had been slowed down to give end users more training time. Also on the VA’s to-do list: finish converting VistA data into a Cerner-friendly format for migration, getting a permanent deputy secretary installed to oversee the roll out, and ensuring VA providers have security clearance to access DoD health records.

This op-ed lays part of the blame for the spectacular rise and self-destructive fall of Theranos at the feet of the US Patent and Trademark Office, which it says has done “a terrible job” of ensuring that whether inventions actually work. The office has admitted to operating on an honor code, a system that worked well for founder Elizabeth Holmes:

Yet more than a decade after Holmes’ first patent application, Theranos had still not managed to build a reliable blood-testing device. By then the USPTO had granted it hundreds of patents. Holmes had been constructing a fantasy world from the minute she started writing her first application, and the agency was perfectly happy to play along.

Privacy and Security

Northwestern Memorial Hospital fires dozens of employees for looking at the EHR records of actor Jussie Smollett, who was treated in its ED following his claim of being attacked in a racially motivated incident. One terminated nurse says that she and co-workers were fired for simply scrolling past the actor’s name on an EHR list while looking for other patients. The real crime in this story is that a grown man named Justin thinks Jussie sounds better.

Medical billing vendor Wolverine Solutions Group notifies hundreds of thousands of patients from an undisclosed number of providers and health plans of a ransomware attack that occurred last September. The company has been sending out notifications on a rolling basis since December, and expects to wrap up messaging by the end of this month, at which point it will have a better idea of how many people were affected.

Other

Auditors blame a 2017 implementation of Cerner’s billing system for the $38 million revenue loss of Glen Falls Hospital (NY), which was forced to lay off employees after losing 12 percent of its annual patient services revenue due to bills that went out late or were never sent.  

A brilliant article in Science looks at how the public relations chief of the American Diabetes Association came up with the term “prediabetes” in trying to scare doctors and their patients to take action to address slightly elevated blood glucose levels, a mostly benign, symptom-free condition that had previously been labeled “impaired glucose tolerance.” ADA rolled out the term on a wide scale and keeps broadening the definition to include more people, now counting one in three Americans as being prediabetic even though studies show that only single-digit percentages of them will ever have diabetes. Since then, billions of dollars have been spent to address the observed blood glucose levels – mostly weight loss and exercise programs that have shown few results – and the now-medicalized “condition” has created a cottage industry of fitness coaches, dietary products, glucose monitors, and prescription drugs that now consume at least $44 billion of US healthcare spending each year and line the coffers of the ADA with up to $27 million annually in drug company contributions. A researcher who advocates wider use of prescription drugs to treat prediabetes has earned $5 million from the companies that sell those drugs and many doctors who wrote the ADA’s standards of care have also made millions. A Mayo diabetes clinician concludes, “The people who lose are the people who go from being a healthy person to being a patient. Now, they have the sick role. They have to go for checkups and tests and treatments … I just don’t think we [prevent diabetes] by making every healthy person a patient.” @EricTopol lauded the article, calling prediabetes “mass, dumbed, down medicine and scaremongering one of three (84 million) adults and 1 billion people worldwide, supported by pharma, propelled by guidelines from trusted organizations … with 80 percent of such individuals at no risk.”

Dear HIMSS Media, I’m confused – is this event in Santa Clara or LA?

In an attempt to prevent hospital readmissions, researchers at the Rochester Institute of Technology in New York develop a sensor-embedded toilet seat they say can detect deteriorating conditions in congestive heart failure patients.

Sponsor Updates

• PMC Regional Hospital (IN) completes its Meditech Expand implementation with help from Engage Consulting.
• EClinicalWorks will exhibit at the AAPM Annual Meeting March 7-9 in Denver.
• Ellkay will exhibit at the ACMG Annual Clinical Genetics Meeting April 2-6 in Seattle.
• EPSi will exhibit at the Metro New York HFMA Chapter’s Joseph A. Levi 60^th Annual Institute March 7-8 in Uniondale.
• Healthfinch publishes the third e-book in its refill optimization series, “Achieving Refill Protocol Consensus.”
• Huntzinger achieves a score of 96.4 in the HIT Advisory Services Category of the “Best in KLAS Software & Services 2019” report.
• Hyland releases a new enterprise search solution as part of OnBase content management platform.
• Imprivata will exhibit at SoCal HIMSS March 12 in Duarte.
• Mobile Heartbeat invites vendors with complementary solutions to integrate with its CURE Connect API Suite via its new CURE Connect Interoperability Program.
• NPR profiles Kentucky Hospital Association, Kentucky Office of Rural Health, and Collective Medical efforts to develop a statewide care coordination network.
• Apixio announces that it has grown its customer base to 36 health plans and provider groups, and has analyzed 11 million documents for Medicare Advantage and private plan beneficiaries.
• Netsmart earns multiple top Black Book awards across behavioral health and post-acute healthcare settings.
• Sansoro Health makes available a cloud-hosted test environment for digital health companies and health IT developers to test application workflows in a real EHR environment.
• PatientPing announces that its national network of ACOs generated over $100 million in shared savings for 2017 under the CMMI Next Generation ACO Program.

Blog Posts

• Enhancing the Patient Experience from Start to Finish (Formativ Health)
• How taking my pup to the vet is like an IT solution health check (Hyland)
• Interoperability and Information Blocking Proposed Rules from CMS & ONC (Impact Advisors)
• Balance for Better: Women in Health IT Talk Success and Inspiration (InterSystems)
• 4 common pitfalls to avoid during your EHR implementation [Executive Summary] (Nordic)
• Taking a Consumer-Centric Approach to Access: Insights from Banner Health (Kyruus)
• International Women’s Day 2019 (Optimum Healthcare IT)
• Sometimes When Things Don’t Go As Planned, It Might Be For The Best (PMD)
• 4 common pitfalls to avoid during your EHR implementation [Executive Summary] (Nordic)

Contacts

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EPtalk by Dr. Jayne 3/7/19

My sci-fi nerd flag was flying high when I heard that the Amazon, Berkshire Hathaway, and JPMorgan Chase venture will be called Haven. That was also the name of a planet featured in “Star Trek: The Next Generation” and one where the Enterprise crew was supposed to have some well-earned rest and relaxation. I’ve perused the website and appreciate the way they’ve spelled out their mission clearly and in a way that most people can understand. It looks like most of the open positions are in their Boston and New York offices. It will be interesting to see what kind of people gravitate there.

Researchers are seeking to use artificial intelligence to help design better vaccines against the influenza virus. Flu is a virus that mutates rapidly. Researchers from two pharmaceutical companies are taking biochemical data from samples of exposed patients and running them through an algorithm in an attempt to understand how an effective immune response forms. Other teams are using machine learning to predict the spread of influenza using training data sets from physician offices, hospitals, and social media. The Centers for Disease Control maps flu trends, but being able to truly forecast flu activity would be an asset. I hope they hurry up and get it right. I’ve avoided flu for most of my medical career, but it hit me this week and with a vengeance.

In Mr. H’s annual reader survey, there were some responses that indicated a desire to see more focus on less-traditional areas of healthcare IT, including telehealth. Since I’ve been doing some of my own explorations in the telehealth realm, I’ll share my observations and findings.

One of the first things I’m finding is that it’s important to understand what you mean when you start talking about telehealth. Is this provider-to-provider, institution-to-institution, or direct-to-consumer? The differences involved in the various approaches are vast.

In talking with physicians, there is good acceptance of the provider to provider offerings, which can help serve rural areas or places that don’t have the specialists needed to care for patients with certain conditions. This typically involves a patient coming in to see their provider, then joining with a subspecialist or other clinician via video call. The provider who is actually with the patient can assist with physical exam findings and vital signs. It doesn’t have to be a physician, but can also be a nurse or other trained member of the care team.

This approach can be huge as far as saving time and money for patients to travel to see subspecialists, understanding that some patients just wouldn’t go because of the burden. I’m seeing this more as academic medical centers partner with outlying organizations and it seems to really be taking flight in the pediatric subspecialist world.

There is also good acceptance of institution to institution telehealth, such as remote ICU monitoring or telestroke management services. This can allow specialists to weigh in on the care of patients at institutions that might not have the level of expertise needed to care for certain conditions. It can also just serve as an extra set of eyes for an already-skilled facility, making sure that nothing is missed in the care of critically ill patients. There are typically deep linkages between the organizations from both contractual and philosophical perspectives, so the level of trust is high.

Telehealth services that are delivered directly to the consumer have variable uptake. Some healthcare organizations have already built robust telehealth programs, allowing their providers to work directly with patients who may have challenges traveling to the office. Devices can be used to report patient-generated data in order to provide better care, such as daily weights for heart failure patients or blood glucose readings for diabetic patients.

Other organizations may be using telehealth strictly for acute visits, allowing physicians to extend their hours, access, and productivity without having staff in the office for an extended session. They may be using a telehealth platform within their EHR or licensing with one of the nationally-known telehealth companies to get this done.

Then there are the independent telehealth organizations that may contract with employers or payers, or may market directly to patients as consumers.

I think providers are skeptical of the independent telehealth organizations. There was recently a raging editorial from one of the leaders of the American Academy of Family Physicians on the topic. However, there’s no question that these services are filling a gap in services that aren’t being provided by brick and mortar clinics or traditional primary care practices. Although there are some direct-to-consumer organizations that seem fairly profit motivated, others have significant interest in measuring clinical quality and patient outcomes along with patient satisfaction and efficiency metrics, just like an in-person practice would. These organizations are doing work to explore how they can fill gaps in care while maintaining antibiotic stewardship and clinical quality. They’re also working to ensure that the loop is closed with reports to primary care physicians so that there is continuity of care.

The challenge for these organizations is the lack of data looking at telehealth care of various conditions. There simply isn’t a body of research (yet) that looks at the effectiveness of a telehealth history and examination vs. an in-person examination. We know that physicians have treated certain conditions over the phone for decades, yet there are challenges when it is a brand-new patient-physician relationship rather than an existing one. Smart organizations are gathering data on their outcomes and their approaches and using it to drive future care pathways.

I think we’re going to see a continued boom in telehealth including expansion into the primary care and chronic care space. There will also be plenty of room for specialized telehealth organizations to flourish. Patients are voting with their pocketbooks on convenience and access and I hope traditional organizations are making note.

The Epic campus has made it into Atlas Obscura,one of my favorite sites for internet time-wasting. I had heard about many of the features, but not the medieval drawbridge, which caught my attention. I’ve never been, but I hear it is something to behold.

Email Dr. Jayne.

Morning Headlines 3/7/19

Health records giant Epic temporarily halts additions to its app store because of privacy concerns

Epic confirms it stopped accepting new apps into its App Orchard last December while it reviewed the security and privacy policies of some third-party developers. We reported and confirmed this with Epic on February 18.

VA to Pilot Health Records System in March 2020

The VA will begin piloting its new Cerner EHR next year at three facilities in the Pacific Northwest.

Amazon-JPMorgan-Berkshire Health-Care Venture to Be Called Haven

Amazon, Berkshire Hathaway, and JPMorgan announce via a new website that their year-old healthcare venture will be called Haven.