Curbside Consult with Dr. Jayne 7/13/20

HIPAA has been a thing for most of my medical career. Although the Health Insurance Portability and Accountability Act was actually enacted on August 21, 1996, it didn’t actually begin to go into effect until April 14, 2003 when the HIPAA Privacy Rule was required. Of the sub-parts of HIPAA, this is the one that most people know the most about.

It is also frequently used to create an inappropriate barrier to information sharing. I can’t count the number of times that hospitals have told me they can’t tell me the status of a patient who I have referred to their emergency department “due to HIPAA.” Apparently they think that HIPAA is a magical force field, and if you’re not part of the hospital’s medical staff, you can’t be allowed in.

Despite the Privacy Rule being in place more than 17 years, I’m working with an IT organization that isn’t doing very well from a Privacy Rule standpoint. They are a mature user of their EHR, having been on the system for at least a decade. However, their use of its features hasn’t kept pace with the evolution of the tool, and they find themselves in a bit of a legal pickle.

I enjoy working on projects like these. It gives me a chance to dust off my database skills and help a group understand its vulnerabilities and how it can improve. Some of these items spill over into the HIPAA Security Rule, circa 2005, with its emphasis on technical safeguards for protecting patient information. In the spirit of sharing some free consulting, I offer you the lessons learned from my client’s situation.

First, have a documented policy and procedure on access to electronic health record systems and other ancillary applications, such as laboratory information systems, radiology information systems, and any other systems where Protected Health Information is stored. These are part of the administrative safeguards in the Security Rule, but beyond that, you can’t claim employees didn’t do the right thing when you never spelled out what actions were right and what actions were wrong. The policy should include a mention of educational resources to be sure that staffers understand the terminology of HIPAA and understand how those elements fit the systems they access.

I remember the health system I was working for when the Privacy Rule went into effect made a series of videos that were themed somewhere in the vicinity of gangsters a la Al Capone, and the fact that they’ve stuck with me this many years later shows that they were memorable. The video linked back to written content that we had to review along with an acknowledgement we had to sign in order to continue being employed. The organization I’m working with at present has an outdated employee handbook with little mention of HIPAA and the obligations of staff to do the right thing.

Second, be sure you have clearly documented job descriptions as well as roles and responsibilities. When you find out that someone administrative was trolling around in EHR charts that have nothing to do with their role in the billing department, you don’t want them to explain that they were “helping Dr. X that day” or that someone was out so they were doing “other duties as assigned” with no way to prove or disprove that what they were doing in the EHR was inappropriate. For those situations where people do have to cross cover, make sure they know where their boundaries are. As an example, someone covering telephone messages for refill requests probably doesn’t need to be accessing the alcohol and tobacco history in patient charts.

Third, make sure you are keeping up with the security features of your EHR. If it allows you to restrict security by job role, make sure you have this set at the most granular level appropriate for the job roles in your organization. Purely clinical employees shouldn’t have access to the billing side of the system, and non-clinical employees who might have to reference clinical information should have their access appropriately controlled. If a billing team member often has to provide copies of office visit notes or test results, give them access to those parts of the system. Do not give them access to document on clinical visit templates or to order medications.

I’ve seen unfettered access more times than I care to recall. If your system allows use of inclusion/exclusion lists to further secure subgroups of patients (such as employees, or professional sports teams, or VIPS) consider using those features.

Fourth, make sure you understand the audit functionalities of your system and that you have a policy in place for regular auditing, even if it is just spot auditing. Of course, if you see high-profile or celebrity patients, you might need to have a more active audit program, but many organizations can get away with spot audits to make sure employees are doing the right thing.

One of the issues facing my client right now is that they didn’t have the right pieces of the audit tool enabled. Although they were tracking access to clinical data, they weren’t properly tracking whether that data was updated, printed, exported, or simply viewed.

Finally, make sure you have a policy that addresses access of patients’ own charts or those of their family members. Even if a staff member is legally permitted access to a patient’s information, whether by being a parent / guardian or through a signed release, it’s probably not a good idea to allow them to access those charts on their own. In my practice, if I want to print a copy of my own lab results for my personal records, I have to work with one of our clinical staff to request the document and have them generate it for me, just like any other patient would. The only difference is that I’m making my request in person rather than over the phone. Our process keeps everyone honest and reduces the risk of inappropriate access.

These are simple things, and you would think organizations would have figured them out by now. Unfortunately, quite a few haven’t.

How does your organization handle similar issues? What’s the wildest HIPAA violation you’ve seen? Leave a message or email me.

Email Dr. Jayne.

Morning Headlines 7/13/20

Top supplier of electronic medical records to pay $2.55M for cybersecurity firm

In Canada, clinic operator and EHR vendor Well Health Technologies will acquire the cybersecurity division of Cycura.

Former Gwinnett healthcare executive pleads guilty to sabotaging medical shipments

A former VP of finance for a medical device packaging company in Atlanta pleads guilty to trashing the company’s computer systems after being fired.

Ahead, a platform that connects psychiatrists with patients, raises $9 million

Mental healthcare startup Ahead raises $9 million in a funding round led by online B2B pharmacy company Truepill.

Monday Morning Update 7/13/20

Top News

A KLAS report on pediatric practice ambulatory EHRs names PCC as the clear leader.

PCC and Athenahealth scored well in product robustness and value.

The report says that PCC significantly outperforms other vendors in relationships with its personal approach, proactive support, and hands-on executive involvement.

Reader Comments

From Livongo and Prosper: “Re: CEOs. In 7.5 years as CEO of Allscripts, Paul Black has taken the stock from $13 to $6.50 per share with a $1B market cap. In one year, Glenn Tullman has Livongo’s stock at $108 with a market cap of $10B. Black helped push Tullman out and now Tullman is laughing all the way to the bank. How does Black still have a job?” I’ll offer these points in resisting the urge to oversimplify the situation:

• Tullman had Allscripts in a complete mess during the last few years of his tenure, including making questionable acquisitions, infighting with Eclipsys loyalists after buying that company, taking a snake oil sales approach to milking the Meaningful Use cow, fumbling clownishly over the MyWay EHR, claiming that the company’s science fair of acquired old products were integrated by definition since they all ran Microsoft SQL, and desperate suing its own customers and prospects that had chosen competing products.
• Black’s performance has been more measured, but not very inspiring or visionary. He, too, was at the helm during some major corporate gaffes, such as making a deal with equally desperate NantHealth, announcing but never actually selling the Avenel EHR, and buying Practice Fusion with the full knowledge that it was waiting for the DOJ hammer to fall for helping drug companies push opioids inappropriately. He’s made some potentially good decisions that have taken the company outside its core EHR business in hoping to avoid getting squashed by the Epic juggernaut and strong ambulatory competitors, but I can’t recall hearing anything all that exciting about TouchWorks and its stablemates in years.
• Livongo is surfing on a sea of employee health hype that it’s hard to see lasting forever, especially given the failure of similar companies to prove their value via unbiased outcomes studies. Tullman has deep experience in working the stock market, having taken Allscripts through a Series J funding round or something like that before going public, so he’s in his element as Livongo board chair.
• Black is better than Tullman was in always announcing something new that makes it hard to judge apples-to-apples quarterly company performance, usually an acquisition that promises fresh opportunities in some hot sector.
• Allscripts wasn’t much of an innovative development shop under either CEO and has exhibited little in the way of vision or passion.
• Tullman mostly stuck to EHRs and related technology during his Allscripts days, while Black favors buying distressed health IT merchandise to wring out a few drops of profit while hoping to sell the customer base something else.
• We don’t know how much of either company’s success is due to its highest-ranking executive. Neither Tullman nor Black were board chair of Allscripts while serving as CEO. Tullman is board chair at Livongo but not CEO. Nor do we know that Allscripts would perform any better under a different CEO who doesn’t control the board. You can do only so much while investors are staring you down quarter by quarter and most of your products are in mature markets that have strong competitors.
• My conclusion is that only some degree of a publicly traded company’s performance can be attributed to the CEO. Tullman was damaged goods after the board put the company out of its misery by firing him, but he has certainly made a better name for himself after founding Livongo, which surprised me.

HIStalk Announcements and Requests

It’s 55-45 on my poll asking whether it’s OK for an employer to fire someone for off-work action or social media posts that don’t result in legal charges. Commenters point out that free speech protection in the First Amendment applies only from the actions of government, not employers, and employers are free to send an employee packing for nearly any reason that doesn’t violate Equal Employment Opportunity requirements. My definition of “OK” was intentionally fuzzy since company reasons for termination can be equally so, but the bottom line is that people lose their livelihoods every day for reasons that may have little to do with job performance.

New poll to your right or here: Which of these activities have you performed on a mobile device in the past year?

Webinars

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

People

Mick Brown (Change Healthcare) joins post-acute telehealth provider Third Eye Health as VP of strategy for health systems and ACOs.

COVID-19

The US has nearly 52,000 people hospitalized with COVID-19, approaching April’s peak of 60,000 and nearly doubling the June 15 count. Texas has 10,000, California 8,000, and Florida 7,000. Florida reported 15,300 new cases on Sunday. Deaths have finally taken a national upturn as expected from the case and hospitalization counts, now standing at 134,000. Nursing homes are once again being hit hard, with some reporting dozens of deaths and residents making up 40% of the COVID-19 deaths in Texas.

America’s push to get students back in school will be a global experiment since no other country has every tried to institute a return to campus during raging coronavirus outbreaks.

The White House reportedly canceled the scheduled media appearances this week of Anthony Fauci, MD after he disputed President Trump’s assertion that a lower death rate shows US progress, which Fauci he called a “false narrative” that could lead to complacency. Fauci says he hasn’t spoken to the President since early June.

Morgues in parts of Texas and Arizona are full and refrigerated trucks are being set up there.

The federal government sends an Army medical task force and HHS disaster response team to Houston.

Atlanta will reactivate a 200-bed COVID-19 field hospital at the Georgia World Congress Center after closing it in May after it had treated just 17 patients. The state has also contracted with Piedmont Healthcare to add 100 ICU and surgical beds to deal with the COVID-surge. Both actions came after health system CEOs urged the governor to help them continue their profitable elective surgeries. 

More than two dozen Mississippi state senators, its lieutenant governor, and its House speaker test positive for coronavirus after weeks of close-quarters meetings in which most or all of them ignored mask recommendations.

Intensivist Nick Mark, MD describes the problems with using the benign term “ICU capacity”:

• Critically ill patients go to the nearest hospital, so statewide figures mean little if the nearest available ICU beds are hundreds of miles away.
• Higher ICU census is associated with worse outcomes.
• ED boarding of patients waiting for ICU beds have an increased risk of death because EDs don’t have the staffing ratios and facilities needed for long-term patient care.
• COVID-19 patients need much longer stays than the ICU average of around three days, tying up beds for a long time and more likely to need ventilator support.
• ICU capacity is often calculated across all types of beds (medical, surgical, cardiac, burn, trauma, and even pediatric) and in some cases count PACU beds as ICU.
• Not all ICUs can provide interventions such as negative pressure rooms, dialysis, and ECMO and other interventions for acute respiratory distress syndrome.
• Step-down rooms can be “upleveled” into an ICU, but skilled staff will be in short supply. ICU staffing is based on an expected occupancy of around 60%.
• Burnout, PPE shortages, and healthcare worker infection are likely with expanded ICUs.

I missed this earlier: hospitalist and CMIO Dirk Stanley, MD, MPH lays out how to determine COVID-19 status from a patient’s EHR. Thanks to @CraigJoseph for tweeting the link.

Other

A former VP of finance for an Atlanta medical device packaging company pleads guilty to trashing the company’s computer systems after being fired, which he accomplished by using a phony logon that he had created beforehand. The company distributes PPE, shipments of which were delayed due to deleted data from its ordering and fulfillment systems.

Sponsor Updates

• Selling Power includes Nuance as a “Best Company to Sell for” on its annual list.
• PatientPing publishes a new e-book, “CMS’s E-Notifications CoP: The Route to Compliance.”
• Black Book Research publishes a new report, “Exploring Physicians’ Perspectives on How COVID-19 Changes Care.”
• Pure Storage publishes a case study, “St. Joseph’s Health achieves speed and reliability with Pure Storage.”
• Redox releases a new podcast, “The Digital Episode of Care with Bronwyn Spira of Force Therapeutics.”
• The Journal of Psychopharmacology publishes an article on a study of comparative rates of delirium of various types of AHTs that used real-world data from TriNetX.
• Vocera releases a new Caring Greatly Podcast, “Physician Suicide and the Impact of COVID-19 – Pamela Wible, MD.”

Blog Posts

• Put contact center technology at the heart of your customer experience (OpenText)
• Hospitals Need Secure Text Messaging-Plus to Support “Mobilized” Clinicians (PatientKeeper)
• Untapped Potential: Telehealth in Rural and Underserved Communities (PMD)
• The Challenge with Scaling Clinical Best Practices During a Pandemic (Premier)
• Overview of Nordic’s Patient Access Solution (Nordic)
• COVID-19 Has Transformed Healthcare – and Exposed Where More Change is Needed (Surescripts)
• CMS Offers MIPS Flexibility in Light of COVID-19 (WebPT)

Contacts

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

Weekender 7/10/20

Weekly News Recap

• Health Catalyst will acquire Healthfinch for $40 million in shares and cash.
• A Health Affairs blog post calls for ONC to start measuring the impact of the interoperability requirements of the 21st Century Cures Act.
• VA seeks robotic process automation to import patient documents from external providers into VistA and Cerner.
• Walgreens will spend $1 billion over the next five years to open VillageMD primary care clinics in up to 700 of its stores.
• Informatics pioneer Octo Barnett, MD dies at 89.

Best Reader Comments

The new interoperability regulations that were promulgated in March are like any other regulations, they are only as good as the enforcement actions that will be taken. Thus, while it is fine to have a wish list of those things ONC should track, more importantly is simply enforcing the regs as they stand. Of course, putting on my cynic hat, I see this article from academics as a lead up to a research grant from ONC to support an academic endeavor to measure these metrics. (John)

Those proposed metrics are a bit confusing to me. Measuring things that aren’t in the rule as a way of implicitly adding the things we all wish were actually in the rule (but aren’t) doesn’t seem right. (Brendan)

The main barrier to telehealth is financial. I work for providers who are using telehealth extensively for med refills and wellness visits, and it has been working well. They and their patients want to continue using it, but the insurers continue to waffle on payment policies and suggest that they will only pay for online visits during the pandemic. Of course practices are preparing to bring patients back in whenever possible under those conditions. (Amanda B)

I work in mental health and much of what we do can be delivered quite well by telehealth and often by phone for patients without the ability or devices to do telehealth. The vast majority of our patients do not want to come into the office and the vast majority of our clinicians do not want to sit in a small poorly ventilated office where there is a risk of COVID transmission. However, our organization is strongly encouraging us to see more patients in person because the rates for phone calls are less than telehealth or face-to-face and because the insurers are already jerking us around on reimbursement with the likelihood of additional payment-related travails from insurers and CMS down the road. (RightOn)

Unfortunately, your assessment of telemedicine is spot on. Absent a significant change in healthcare and healthcare delivery in this country, profits ($) will continue to drive behavior, despite the fact that we have the worst outcomes on a number of measures of health and healthcare in the world (including our management, or lack thereof, of COVID-19. (Michael J. McCoy, MD)

Dr. Jayne, I am so embarrassed and ashamed of our healthcare system as I read what you are experiencing in the trenches. We are about four months into this Coronavirus pandemic. I was a little more forgiving (but not much) in March since supposedly this virus caught us off guard. But now? Really? After working in healthcare since the 1970s, I have no words anymore. Just tears. (JT)

Two ways to do something, the right way and again. Allscripts has showed a willingness to take the second option as a standard practice. So, until that stops, they will lose customers. Remember the business model is to buy startups and then promise to integrate them, while not requiring them to integrate. (AnInteropGuy)

Watercooler Talk Tidbits

Army veteran Richard Rose III of Port Clinton, OH died July 4 of COVID-19 at 37, with his previous Facebook posts in which he disdained wearing masks and checked in at crowded bars and parties now forming his obituary. He said just before he died that he probably caught the virus at the party on the upper right. Meanwhile a 30-year-old man who intentionally exposed himself to the virus by attending a COVID-19 infection party dies of it, telling his hospital nurse, “I think I made a mistake. I thought this was a hoax.”

A Vice article describes how biomedical technicians are buying non-working, 20-year-old ventilators on Ebay, then using a handmade dongle to program around manufacturer protections so they can fix them. They can then sell the repaired device to US hospitals to meet COVID-19 demand. Newer models validate the identity of the repair tech to make sure they’ve paid the manufacturers’ $10,000 to $15,000 fee that allows them to bypass the anti-repair technology, so the market is in older machines that don’t have that protection. Ventilator manufacturers say their machines are complex and they need to limit who can work on them, while hospitals say it’s their own liability if their highly trained technicians make a mistake, which has apparently never resulted in a manufacturer lawsuit. Hospitals also note that manufacturers wouldn’t sent techs onsite in the early days of COVID, so they were stuck with machines they needed that were awaiting repair.

A Nebraska ED nurse renders aid at a two-car accident that she encountered on her way to her daughter’s wedding.

In Case You Missed It

• News 7/10/20
• EPtalk by Dr. Jayne 7/9/20
• News 7/8/20
• Curbside Consult with Dr. Jayne 7/6/20
• Readers Write: Enabling Clinically Intelligent EHRs
• Monday Morning Update 7/6/20

Get Involved

• Sponsor
• Report a news item or rumor (anonymous or not)
• Sign up for email updates
• Connect on LinkedIn
• Contact Mr. H

Morning Headlines 7/10/20

Health Catalyst Announces Agreement to Acquire healthfinch, a Healthcare IT Company that has Helped Define the Clinical Workflow Optimization Space with its Award-Winning Software

Health Catalyst will acquire Healthfinch, a clinical workflow optimization technology vendor headquartered in Madison, WI, for $40 million in cash and shares.

VA Wants to Automate Digitization of its 5-Mile-High Electronic Health Record Backlog

The VA seeks solutions for automating the digitization of old and new patient health records and ensuring they are linked to the correct patients.

Measure The Impact Of The ONC’s New Interoperability Rules Now

Health policy experts call for ONC to start measuring the impact of the interoperability requirements of the 21st Century Cures Act using six initial metrics.

Kindbody Raises $32 Million in Series B Funding to Grow Employer Benefits Solution and Fuel U.S. Expansion

Technology-enabled women’s care company Kindbody raises $32 million in a Series B round led by Perceptive Advisors.

News 7/10/20

Top News

A Health Affairs blog post calls for ONC to start measuring the impact of the interoperability requirements of the 21st Century Cures Act, using these initial metrics:

• The percentage of patients that can gain timely access to their common clinical data set information via an API.
• Whether a given EHR vendor allows patients to write their personally generated data to their systems via an API, as well as the percentage of their provider customers that have enabled at least one of those APIs.
• The percentage of care transitions and referrals in which a summary-of-care record was exchanged via API.
• The number of third-party apps that can connect to each EHR, along with the number of apps that are actually being used by patients and providers.
• The EHR vendor’s availability and provider’s use of an API that supports bulk data transfer.
• The number of information blocking reports on ONC’s website by actor as well as the resulting determination of each complaint

Reader Comments

From Tele Say What?: “Re: telemedicine. The number of visits are dropping, which does not make sense after everyone said COVID experience would make it the standard.” It’s a good time to cynically remind everyone to follow the money since healthcare is not a consumer-driven or even a clinician-driven industry. Stacking up patients in a long hall of always-filled exam rooms is not only more efficient for the provider, it supports upselling opportunities that can’t happen over a video connection. Patients also feel shortchanged if their visit doesn’t result in a prescription or an order for lab or imaging, which presents telehealth with the classic last-mile problem. Yet another issue is that while coronavirus may have temporarily forced bricks-and-mortar providers to send patients to national telemedicine practices who have their own doctors, those providers aren’t about to permanently give up their brand identity and the recurring revenue stream that each patient represents. Buildings, people, and human contact are differentiators that keep patients happy and profitably captive. The pandemic has proven that healthcare, education, and work life can be temporarily shifted online out of necessity, but it has not proven that the virtual alternative is ideal or likely to be sustained.

HIStalk Announcements and Requests

Welcome to new HIStalk Platinum Sponsor eSolutions. The Overland Park, KS company offers best-in-class Medicare and Multi-Payer revenue cycle management, workflow automation, and analytics that help providers get paid quickly and accurately. Its 1,000-plus hospital and health system customers see a 20% reduction in problematic claims in the first 30 days and a 22% reduction of days in A/R within six months. The company processes 164 million claims annually, connects directly to 5,500 payers, and completes 500 million eligibility transactions annually with the fastest response time. It has racked up a 95% customer retention rate over in its 20-year history. ESolutions just announced that its Medicare electronic submission of documentation tool supports CMS’s new requirement for obtaining prior authorization for five types of surgery in hospital outpatient departments. CEO Gerry McCarthy’s first job out of college was in health IT and he’s still here nearly 30 years later with an impressive track record of leadership and company success. Thanks to eSolutions for supporting HIStalk.

I asked some folks to help me put together a media kit for companies that are interested in sponsoring HIStalk and probably think twice after seeing the primitive one I unskillfully cobbled together years ago. There’s a link on the top menu.

Webinars

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

Acquisitions, Funding, Business, and Stock

Analytics vendor Health Catalyst will acquire Healthfinch, which automates physician EHR workflow. SEC filings indicate a purchase price of $40 million in cash and shares.

Doctor on Demand raises $75 million in a Series D investment round that brings its total funding to $236 million.

Truepill a $25 million funding round and the launch of an integrated telemedicine service that will leverage the company’s in-house EHR. The B2B online pharmacy powers fulfillment for brands like GoodRx, Nurx, and Hers.

For-profit Cancer Treatment Centers of America, which operates five hospitals and five outpatient centers, is evaluating buyers who appear willing to acquire the company at a valuation exceeding $1 billion. Six potential bidders are involved, insiders say, and two of them are private equity firms that are teaming up with huge, not-for-profit health systems (that is certainly interesting). The company started out in 1988 by embracing an out-of-network model for out-of-state residents, but has moved to an in-network model with health system partnerships.

Scotland-based charge master and cost management systems vendor Craneware reports $71 million in annual sales, the same as last year even though revenue took a Q4 hit due to COVID-19’s effect on its US customers. EBITDA for the year was up $500,000 to $24.5 million.

Sales

• Peninsula Regional Medical Center (MD) will implement tele-neurology software and services from SOC Telemed.
• SCL Health (CO) selects patient access and provider data management software from Kyruus.
• Philips signs a 10-year, $100 million contract with the VA to expand development of its Tele-Critical Care Program.

People

Silver Cross Hospital (IL) promotes Teresa Andrea, MSHA, RN to VP/CIO.

Bryan Humbarger (AliveCor) joins digital health vendor Eko as SVP, commercial.

Appriss promotes Krishnan Sastry to president and CEO.

The Chartis Group promotes Shawna Schueller to VP of practice operations.

Michele Morton, MS, RN (SCIO Health Analytics) joins HealthMyne as chief marketing officer.

Reimbursement software vendor Alpha II hires Todd Doze, MBA (TransUnion) as CEO.

Announcements and Implementations

The VA launches the Veterans Data Integration and Federation Enterprise Platform using HealthShare data aggregation software from InterSystems.

After a pandemic-induced two-month delay, University Health System in San Antonio will go live on its $170 million Epic project this weekend.

Henry Schein Medical integrates its VisualDx clinical decision support system with Medpod’s telemedicine solutions, for which it is the exclusive distributor.

KLAS looks at bidirectional interoperability between smart IV pumps sold by BD and ICU Medical and EHRs from Cerner and Epic. ICU has 26 organizations live on interoperability and offers strong project guidance, while BD’s 104 live organizations benefit from standardized implementation but don’t always get help with non-standard problems. Epic and Cerner users wish they would make smart pump interoperability a priority with more timely updates, better documentation and verification workflows, and actionable reports, with the sites that are happiest being those who use their own employees to drive improvements and write reports.

Government and Politics

The VA issues an RFI for a robotic process automation tool that can help import external patient documents into its EHRs (both VistA now and Cerner later). The VA has suffered from a huge backlog of external documents since 2014, when veterans were allowed to seek care outside the VA and those external providers often provided only paper copies of the resulting patient records. The VA is looking for a system that can handle internal folders, email, fax, paper, electronic exchange, and API access to its referral management system.

COVID-19

It’s like COVID déjà vu from March, as the country’s many hotspots are one again reporting PPE shortages, lack of testing supplies, long delays in receiving test results, and lack of available ICU beds.

Arizona reported 4,000 cases and a shocking 35% test positivity rate as the US reported more than 60,000 new cases on Wednesday. Florida reported 9,000 new cases, a 19% test positivity rate, and 120 new deaths. Hospitalizations have more than doubled over the past four weeks in several states, including Texas with 4.8 times the previous number and excluding Florida, which does not report hospitalizations. Mississippi says five of the state’s largest hospitals, including University of Mississippi Medical Center, have no available ICU beds.

PPE shortages are forcing neurologists, cardiologists, and oncologists to leave their offices closed and their patients without care. AMA President Susan Bailey urges the White House to invoke the Defense Production Act for PPE and to develop a coordinated national strategy. Caregivers are being ordered to see COVID-19 patients even though no N-95 masks are available and a Houston hospital has told its doctors to reuse single-use masks for up to 15 days.

Sacramento County, CA closes five COVID-19 testing sites because they can’t get basic test supplies. They’ve asked Quest Diagnostics for help, but the company says it is already at capacity. The county says that’s OK anyway since it’s taking 8-9 days to get results back from tests that are perform several days into the suspected illness, making testing pointless – someone with a known positive result would be quarantined for just 14 days, meaning they would complete their isolation (assuming they do it) before seeing their results.

Vice-President Pence says CDC it will soften its just-published school opening guidelines after President Trump scolded CDC on Twitter for being too tough, then threatened to cut off funding for schools that don’t reopen by fall. CDC Director Robert Redfield, MD later clarified, however, that CDC won’t change the recommendations, but instead will provide additional guidance.

Other

We should do this in the US. Volunteers at Glasgow, Scotland’s 50-year-old, donation-supported charity Hospital Broadcasting Service work from home 24 hours per day playing music, offering friendly talk, and dedicating songs to patients that they or their love ones have requested by text message or email. Listen live and you might hear some surprisingly contemporary music as I did. On-demand video streaming, podcasts, and generic satellite radio leave me feeling disconnected with the world, which is nice sometimes but not always, and it must be worse when confined alone in a hospital bed with too much time to assume the worst.

Sponsor Updates

• Arcadia’s population health platform earns HITRUST CSF Certification for data security.
• MobileHelp adds MDLive’s telemedicine service to its personal emergency response system for home-based patients.
• Healthfinch publishes a new case study, “Increasing Centralized Capacity for Prescription Renewal Requests.”
• Swedish software and services vendor TietoEvry extends its collaboration with Hyland Healthcare for a best-in-class solution for digital pathology.
• CareSignal publishes a new case study, “How STRIDE FQHC Increased Engagement and Chronic Condition Self-Management Among Medicaid Patients to Prepare for Value-Based Care.”
• Kyruus obtains recognition from Avia for its enterprise-wide patient access platform.
• Wolters Kluwer Health announces that Clinical Effectiveness CEO Denise Basow, MD has been ranked among the Top 25 Women Leaders in Healthcare Software of 2020.

Blog Posts

• 11 best practices for operational efficiency and cost reduction with Google Cloud (Google Cloud)
• HAS 20 Virtual: Reimagining the Healthcare Conference (Health Catalyst)
• A picture is worth a thousand words: The role of photography in patient care – Part 1 (Hyland)
• Payers: How to Scale SDOH Across Lines of Business and Demographics (Imat Solutions)
• Healthcare Supply Chain: PAR vs. Perpetual Inventory Systems (Impact Advisors)
• How to avoid security breaches and malicious attacks (Infor)
• High-Performing EHR Training Teams: Coaching for Success (Optimum Healthcare IT)
• How Primary and Specialty Care Practices Can Recover from the Financial Burden of COVID-19 (InstaMed)
• Is COVID-19 the Burning Platform We Need to Move to Value-Based Care? (InterSystems)
• Untapped Potential: Telehealth in Rural and Underserved Communities (PMD)
• COVID-19 and Children’s Healthcare: Key Takeaways from Kyruus’ Virtual Access Forum (Kyruus)
• Building Brand Confidence Through Physical Therapy Marketing in 2020 (MWTherapy)
• Difficult Decisions: How Adversity Can Strengthen Identity (Netsmart)

Contacts

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

EPtalk by Dr. Jayne 7/9/20

CMS never misses an opportunity to make its incentive programs more complicated, so they recently posted guidance on how telehealth encounters will fit in for Eligible Professional and Eligible Clinician electronic Clinical Quality Measures for the 2020 and 2021 performance periods. This includes the Quality Payment Program with its Merit-based Incentive Payment System and Advanced Alternative Payment Models (APMs); Comprehensive Primary Care Plus; Primary Care First; and Medicaid Promoting Interoperability Program for Eligible Professionals. Honestly, at this point I’m not sure many of us care any more. My brain is too fatigued at this point to even try to understand this:

There are 42 telehealth-eligible eCQMs for the 2020 performance period. When reviewing this list of eCQMs, please note there may be instances where the quality action cannot be completed during the telehealth encounter by eligible professionals and eligible clinicians. Specifically, telehealth-eligible CPT and HCPCS codes may be included in value sets where the required quality action in the numerator cannot be completed via telehealth. Therefore, it is the eligible professionals’ and eligible clinicians’ responsibility to make sure they can meet all other aspects of the quality action within the measure specification, including other quality actions that cannot be completed by telehealth.

I’m personally going to blame my foggy-headedness on having to wear a mask all the time, since my patients have been telling me they trap carbon dioxide and need work notes so they don’t have to wear masks. As someone who grew up watching M*A*S*H and idolizing Hawkeye Pierce, masks are cool, and I’m not about to make you miss out on the pleasure of wearing one. In all seriousness, there are a couple of good health-related reasons why people shouldn’t wear masks, but I have yet to have a patient request a note for one of those reasons.

I’ve been down on conferences lately, especially after being burned by the HIMSS hotel debacl, the non-event that was HIMSS Digital, the American Telemedicine Association’s sad attempt at a virtual conference. With that in mind, I want to give props to people who are doing it right. The Telehealth Innovation Forum’s initial communications caught my eye, so I signed up. They provided plenty of lead time to allow people to block their schedules for July 21-22, and have been transparent about the sessions.

They sent out an attendee update last week, and I have to say they’re about as close to pulling off the feel of a real conference in a virtual format as I imagine you can get. First, they’re mailing some kind of swag kit to those who request it. Second, they’ve got a volunteer activity with the World Telehealth Initiative. Participants will receive materials to decorate backpacks that will be filled with school supplies and donated to children in need. I’m eagerly awaiting my backpack and have some bedazzling supplies at the ready. I always enjoyed the vendors who had similar activities at HIMSS. Last, they’re offering a virtual “lunch together” with digital GrubHub gift cards sponsored by NTT Data for use on July 21. Kudos to the team at InTouch Health (now part of Teladoc Health) for getting the plan right.

One of our physician assistants called me today to vent about life in the patient care trenches. I feel for her, because she’s early in her career and hasn’t been through a truly terrible flu season yet. As such, she hasn’t learned how to “embrace the suck” or figure out how to arrange her own personal psychology to make it through the crazy practice environment we’re currently in.

Apparently patients were lined up in lawn chairs outside the office today before the clinical team even arrived, and everyone was expecting to be tested. While another provider focused on handling the in-person visits, she had the unenviable task of calling patients whose lab results have finally returned after 10 days (thank you, Quest Diagnostics!) and most of them have already ended their quarantines based on CDC’s time-based strategy. It’s absolutely surreal that professional athletes are getting daily COVID tests and the average person in our city may have to wait more than a week to get results back.

The big hospitals are adding to the problem because they are refusing to test patients unless they are referred to the testing sites by physicians who are on their medical staff. Funny, they were happy to run lab orders and profit on radiology studies from independent physicians previously.

Since Quest Diagnostics and LabCorp understandably won’t perform COVID swabs in the patient service centers, the patients have descended on the urgent cares, where the lab backlogs are crippling. It’s not like we could all work together and serve the community – I guess it’s much better for them to protect their fiefdoms.

For those of you in the trenches, you’ll recognize the four Abbott ID NOW machines in the photo above. We have more than 100 of them at our sites, but we can’t use them because we can’t get supplies. Apparently you don’t get testing supplies unless you’re a hot spot, even though the only way to avoid being a hot spot is to have testing supplies so you can give solid advice to patients other than “everyone just stay home,” which isn’t happening.

I was able to talk my colleague to a semi-happy place, but it’s a shame that providers have been put in this position by ineffective and uncoordinated response over the last four months. It’s bad across the country, not just here. One friend of mine in California told me about how bad things are at local hospitals and having dubious honor of being tied for the most saturated ICU.

Another friend of mine in the Midwest who was furloughed for two months  — unpaid and without the option to use PTO or vacation time because he’s part time and doesn’t have those benefits — learned through a news story that his clinic received more than $5 million in Paycheck Protection Program funds. It’s not like they only furloughed the docs since nearly 50% of their workforce was off without pay. He’s wondering what happened to those funds and why they weren’t used to protect paychecks as intended. Unfortunately, in the current environment with physicians being downsized across the country, he’s reluctant to speak up about it.

Did your organization get PPP funds and how did it use them? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 7/9/20

Doctor On Demand Announces $75M in Series D Financing Led by General Atlantic to Expand Comprehensive Virtual Care

Doctor on Demand raises $75 million in a Series D investment round that brings its total funding to $235.7 million.

Walgreens and VillageMD to Open 500 to 700 Full-Service Doctor Offices within Next Five Years in a Major Industry First

Walgreens will invest $1 billion to open primary care clinics run by VillageMD in 500 to 700 of its stores over the next five years, with the bulk of the investment going towards opening the clinics and combining technologies.

B2B online pharmacy Truepill uses a $25 million funding round to launch an integrated telemedicine service.

VA Selects Philips to Create World’s Largest Tele-Critical Care System, Further Integrating TeleHealth and Delivering Quality Care for Veterans

The VA signs a 10-year, $100 million contract with Philips to expand development of its Tele-Critical Care Program.

Morning Headlines 7/8/20

House appropriators propose $12B increase for VA’s budget, including big IT boost

The White House’s 2021 budget request includes $105 billion for the VA, including $4.9 billion for IT and $2.6 billion (versus $1.5 billion this year) for its Cerner project.

Fastest growing EMR provider Medfar acquires Plexia, expanding reach to Western Canada

In Canada, EHR vendor Medfar Clinical Solutions acquires competitor Plexia for an undisclosed amount.

Google Maps releases new features to help people navigate coronavirus hot spots

Google Maps users in select areas can now receive alerts as they approach COVID-19 border checkpoints and areas that mandate virus protections such as masks and social distancing, as well as virus-related public transit alerts and guidelines from facilities that offer testing.

News 7/8/20

Top News

A new KLAS report that looks at advanced users of clinical communications platforms finds that Epic, Halo, and TigerConnect have the greatest breadth of workflows; PerfectServe and Telmediq have fewer workflows and are more widely used in inpatient settings; and Cerner, Hillrom (Voalte), Mobile Heartbeat, and PatientSafe Solutions focus on inpatient settings and have less use in outpatient.

Cerner and Epic have tight integration with their own EHRs, as Epic Secure Chat provides fully embedded functionality and Cerner offers CareAware Connect Communications as a separate app.

Telmediq, PerfectServe, Halo Health, and Vocera top the list for contacting physicians based on their schedules.

The most commonly achieved outcomes among advanced users are reduced phone calls, improved patient satisfaction or outcomes, more efficient workflows, and replacement of SMS messaging with HIPAA-compliant asynchronous communication.

Users conclude that communications platforms are expensive but worth it; success requires focusing on the patient care team and integrating with the EHR; connecting with the right people requires an enterprise scheduling approach; and health systems should choose a vendor based on their ability to develop rapidly rather than those who claim to have it all today.

Reader Comments

From Smallie Biggs: “Re: sales. Aren’t strategies and desires like this what we are trying to eradicate in this industry? Everyone wants to make money, but why would someone who leads a healthcare practice publish a book that does not align with the focus of delivering solutions to healthcare clients?” John Orton, US healthcare practice leader for Avaya, publishes “Super Seller Secrets Exposed,” in which he explains how he has “been able to collect huge commission checks, but he has also traveled the globe and continues to live a Super Seller lifestyle.” I will generously assume that John is no different than other authors of sales and motivation books who thrust hyperbole in the faces of prospects to convince them to press the “buy” button (he’s a Super Seller, after all). Those of us without sales experience may find healthcare sales unsavory, but I’ve learned to accept that while it’s obviously the salesperson’s job to convince you to buy something, they aren’t necessary unethical connivers who exert their will over health system people using Jedi mind tricks (unless they sell for a drug company, in which they probably are). In fact, having been on the receiving end of endless sales pitches that were made to my health system peers, I was more frustrated by their behavior than that of the salesperson since their gullibility and need to feel important made them an easy mark. John has worked for the same company for 10 years, which suggests that he’s not a wandering gunslinger who is burning bridges behind him. I am fascinated but ignorant of how salespeople move prospects along to contract signing in healthcare, especially with regard to prospect psychology, and the industry richly values those folks who can move iron. Somehow I doubt that reading John’s book will endow marginal salespeople with the superpowers that are required to cavort with John and his Super Seller compadres, but those who are destined for sales success are irrationally optimistic and will thus probably buy a copy in hopes of sharpening their saw.

HIStalk Announcements and Requests

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

Webinars

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

Sales

• OptimizeRx announces two sales of its point-of-care prescription messaging system for patient affordability, adherence, and care management to unnamed clients.

People

Tele-nephrology platform vendor TeleNeph hires Ron Kubit (Sopris Health) as CEO.

Announcements and Implementations

LiveProcess announces the release of Aware, a real-time virtual situation management platform.

Government and Politics

The White House’s 2021 budget request includes $105 billion for the VA, including $4.9 billion for IT and $2.6 billion (versus $1.5 billion this year) for its Cerner project.

COVID-19

The New York Times had to sue CDC under the Freedom of Information Act to force the federal government to provide COVID-19 case data broken out by race, ethnicity, and county of residence, which confirms that Latinos and African-Americans are three times as likely to be infected as their white neighbors and twice as likely to die. These disparities cross state and regional lines. The Times notes that race and ethnicity data are missing from more than half of the 1.5 million cases CDC has documented, its information is current only through the end of May, and it does not included the suspected source of infection. CDC says it has asked state and local agencies to collect and report this data, but cannot force them to do so.

The disconnect between increasing COVID-19 case numbers and decreasing death rates is being attributed by some experts to Simpson’s Paradox, where conclusions that are drawn from big datasets can hide insights that would be visible within smaller data clusters. Trends in COVID case counts, positivity rates, hospitalizations, and death rates may be dramatically observable at the city or county level but can get buried when looking only at counts for a state or the entire US. Expert data review will find insight that computational methods will miss. The common example of Simpson’s Paradox is the batting averages of two baseball players, where Player A has a higher batting average than Player B every month, yet Player B ends up with a higher average for the whole season. The COVID example is that low numbers in the former hotspots in the Northeast are making the US look better as a country when in fact the pandemic is burning out of control in specific areas in the form of regional outbreaks, which will have a strong impact on local resources.

A large seroprevalence study in Spain finds that despite widespread infection there, the country is not even close to herd immunity, if that even matters since nobody knows whether antibody presence indicates protection from reinfection.

Brazil President Jair Bolsonaro, who has downplayed COVID-19 dangers and ignored public health advice, tests positive and starts taking hydroxychloroquine.

People who go to the hospital ED with COVID-19 symptoms are being stuck with huge bills by some insurers if they leave without being tested due to not meeting the hospital’s criteria or not having tests available.

Arizona reports that 3,300 patients are hospitalized with COVID-19 in the state, 870 of them in ICUs that are at 89% capacity. Tucson hospitals are reportedly sending new patients to Phoenix, San Diego, Las Vegas, and Albuquerque. Houston hits a record of COVID-19 hospitalizations for the fifth time in the first seven days of July so far, with 981 in the ICU, Texas Medical Center at 103% of ICU usage, and 47% of ICU patients there due to COVID-19.

Former CMS Administrator Andy Slavitt summarizes his conversations with multiple scientists who have reviewed early data from prospective vaccines:

• Preliminary vaccine data looks good, but early versions may work more like flu vaccine in offering modest protection for some people for some unknown period of time. They expect iterative improvement as new vaccines are brought to market.
• Monoclonal antibody therapy as a COVID treatment may be more promising than vaccines for prevention, and clinical trials for it can be completed easier and and faster.
• The likely future state is that we will see reduced COVID-19 lethality but without eradication as a gradually occurring “new normal” with few big developments along the way.
• Many deaths will occur before a vaccine is available, but even the early versions are likely to be safe and effective to some degree.

The White House notifies Congress and the UN that the US is withdrawing from the World Health Organization, effective July 6, 2021.

HHS Secretary Alex Azar says in a panel discussion about reopening schools that, “Healthcare workers don’t get infected because they take appropriate precautions. They engage in social distancing, wear facial coverings.” He didn’t mention that thousands of healthcare of workers have tested positive for COVID-19 and at least 600 have died.

My young relative still hasn’t received her COVID-19 test results 10 days after being tested after potentially being exposed at work. Her father, who is a doctor, started having symptoms this morning and he is now waiting on his test results while not practicing medicine. I can see why experts say it’s too late to implement contact tracing here since we’ve let our outbreak run wild and we are once again regionally running out of testing supplies, watching lab backlogs grow, and running out of hospital capacity. The virus loves our lack of national planning and coordination. 

Other

A startup in China develops a “pulse fax machine” that sends a user’s pulse reproduction to practitioners of Chinese medicine, who uses pulse palpation to assess health and diagnose problems. The company hopes to sell the system to 50 hospitals in the next year. It also uses it in its own chain of private clinics and distributes it via a hospital systems vendor. The company is Maizhiyu, which means “the language of the pulse.”

Sponsor Updates

• Glytec partners with ThunderCat Technology to make Glytec’s Glucommander insulin management software more widely available to VA facilities.
• CI Security will integrate its Critical Insight Managed Detection and Response offering with solutions from Internet of Things and Internet of Medical Things security vendors Order, Medigate, and Cylera.
• Clinical Computer Systems, developer of the Obix Perinatal Data System, releases a new Clinical Concepts in Obstetrics Podcast, “A Preeclampsia Case Study.”
• Diameter Health will lead a roundtable discussion, “Paper Killers: Innovative Solutions in Digital Health,” during the virtual NCQA Digital Quality Summit July 23.

Blog Posts

• 3 Ways to Optimize Epic Training (314e)
• Best Practices for Building a Telehealth Team Now (Access)
• Hitchhiker’s Guide to Managing a Sustainable Patient Mix (AdvancedMD)
• Enterprise Imaging Goes Live at AdventHealth (Agfa HealthCare)
• A conversation with Tammy Combs and Melissa Potts of the American Health Information Management Association (AHIMA) (Artifact Health)
• The State of Medication Access (CoverMyMeds)
• 8 Most-Asked Questions About Employee Health Screening Tools (Dina)
• ‘The new system:’ How will healthcare organisations navigate COVID-19 and beyond? (Elsevier Clinical Solutions)
• How to Digitize Your Front Office (EClinicalWorks)
• Interoperability Rules are Delayed: Why That’s Good News and Bad News (Ensocare)

Contacts

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

Morning Headlines 7/7/20

NHS England launches coronavirus recovery service

The NHS will launch an after-care service for patients recovering from COVID-19 that will combine an initial in-person assessment with virtual care for up to three months.

COVID-19 leads Greenville healthcare company to new headquarters, new normal

Chronic care management company ChartSpan decides to relocate its headquarters in Greenville, SC, to a smaller space after an overwhelming majority of its employees vote to continue working from home.

2020 Midyear Digital Health Market Update: Unprecedented funding in an unprecedented time

A new report from Rock Health puts digital health funding for the first half of 2020 at $5.4 billion, putting the market well on its way to achieving record-breaking funding for the year.

Curbside Consult with Dr. Jayne 7/6/20

I survived the Independence Day weekend in the emergency department trenches without seeing anyone who had finger or eye injuries, so it was a good one.

I didn’t get to see any fireworks or have popsicles, but the PPE fairy paid me a visit. I’m happy to report that exactly four months after seeing my first positive COVID-19 patient, I finally have an honest-to-goodness actual 3M healthcare N95 respirator, as opposed to a non-medical version from the hardware store. To be precise, I have two of them. Which I’m supposed to rotate indefinitely.

Excuse my cynicism, but I’m not exactly sure what the US has to celebrate today. The actions of our fellow citizens exercising their freedom to not wear masks and their freedom to congregate in large groups is sending patients to the hospital, if not to their graves. Our testing volume is up by about 20%, but our positive case rate is nearly triple what it was recently, so we’re gearing up for a bumpy ride.

Our group has moved into testing entire cohorts of workers from various employers, which is straining resources. The first bolus of patients came from a hair salon, where they are meticulously separating clients with plastic barriers and stylists and clients are all masked. Unfortunately, the 20-somethings who work there all huddle up in a break room together between clients with masks off, or stand outside the door smoking, so close to 80% of them came back positive. No surprises there.

The next set of workers came from a country club, where even though the dining area has been moved outside, servers are still in close contact with patrons. The wait staff also had a communal break area, and frequently took masks off in between runs to the dining area. Now everyone gets to hang out at home for 14 days waiting for tests to come back. Unless something changes with our reference lab, there’s a good chance we’ll be clearing them based on time before their results come back — the lab’s turnaround time has skyrocketed to 10 days.

At this point, I truly wish my EHR had the capability to do a standard visit that could be copied from patient to patient. Although we have some templates for physical exams, everything else has to be keyed from scratch for each patient unless they’re a returning patient. I’d love to be able to bulk-copy these HPIs since they’re essentially the same. “Patient presents for employer-mandated testing, was exposed to a patient over the last two weeks who is now positive. Patient reports non-masked interactions at close range in a common break area and sharing of plates of food by co-workers.”

You might ask why I’m writing an HPI when the patient is just there for testing. Our new reality is that payers have gotten burned by the “sure, we’ll pay for COVID-related visits” policies and are now requiring documentation of medical necessity to support payment for testing. I thought this article from mid-June was over the top until I started experiencing “concern” from payer reps about our testing patterns.

As much as everyone is focusing on the struggles of the hospitals and the potential for overwhelmed ICUs, ambulatory practices (especially independent ones) are really struggling right now. Many are not performing testing because of lack of PPE and we’re still challenged to keep patients safe. Unlike larger facilities, small offices don’t have the luxury of being able to set up dedicated respiratory clinics within their footprint or to offer separate waiting areas for suspected COVID patients. The best they can do is to try to separate patients temporally, bringing in the well patients in the morning and sicker patients as the day progresses.

Many of my colleagues in this situation are using automated screening solutions to try to risk-stratify patients the day before, although the system isn’t perfect. For example, one of my patients who came in for food poisoning recently was actually COVID. It’s hard to triage that without doing a full telehealth visit up front.

I get a lot of direct to doctor emails from tech companies, and I’m surprised by the silence from the companies that have sanitizing technologies. There seemed to be dozens of booths at HIMSS for solutions to sanitize laptops and keyboards and otherwise keep technology clean. If anyone is in that space, I would be interested to see what business looks like right now and if you’re just overwhelmed or how things are going.

The push for telehealth technologies has also slowed. It feels like practices that jumped into the pool with Zoom or other non-healthcare solutions are starting to transition to telehealth solutions that are embedded in their EHR or otherwise integrate. I agree that expecting clinicians to work in two systems is daunting and no one wants to do it for long.

There used to be several players in the hand hygiene market. What’s going on in that space? Are hospitals going high tech to monitor staff compliance, or are they running out of money and worried about taking care of the basics? Any action on expansion of robotic healthcare assistants to reduce the need for humans to go in and out of exam rooms?

It seems like there are so many interesting technologies with potential, but I struggle to keep up with how other organizations might be innovating because I’m simply swamped seeing patients.

I hope that readers had a chance to recharge at least a little this weekend. Many people had Friday off in honor of the holiday or had modified work schedules. In many states where cases are rising, this is just the beginning of a long slog.

How is your organization helping workers recharge their batteries, or making sure they are holding up OK under the stresses of our new normal? Have you instituted new technologies to try to make an impact? What about the addition of recharge zones or stress reduction rooms? Leave a comment or email me.

Email Dr. Jayne.

Readers Write: Enabling Clinically Intelligent EHRs

Enabling Clinically Intelligent EHRs
By David Lareau

David Lareau is CEO of Medicomp Systems of Chantilly, VA.

A key takeaway from John Glaser’s recent article in the Harvard Business Review, “It’s Time for a New Kind of Electronic Health Record,” is that it is time for EHRs to leverage clinical intelligence for analysis of patient data and to address clinicians’ usability concerns.

Current systems were designed to track transactions to generate and justify billable events. They are, in fact, organized as a set of separate “buckets,” with different sections for procedures, medications, therapies, encounters, diagnoses, etc. There is no clinical coherence or correlation between the sections, so providers must search in multiple places to find information relevant to a problem.

Clinicians are highly trained knowledge workers whose expertise in determining what is clinically relevant is acquired through education and experience. They are trained to know what to look for, but current EHRs make it difficult to get a clinically cognitive view of relevant information.

The new kind of EHR advocated by Glaser will require a clinical relevancy engine that can filter a patient record in real time to identify data for any known or suspected condition or diagnosis. This “clinically coherent view” should include medications, lab orders and results, co-morbidities, therapies, symptoms, history, and physical exam findings. Ideally, it should support diagnostic filtering of dictated or free-text notes, as well as coded data such as SNOMED-CT, ICD10, CPT, LOINC, RxNorm, UNII, CVX, CTCAE, DSM5, and others.

It must do so quickly, on demand, with a single click at the point of care.

This new cognitive clinical computing approach requires a radically different method for organizing clinical data. First, data must be organized to support a clinician’s diagnostic thought process. Second, because of the need to process hundreds of thousands of potentially relevant data points and the relationships between them in sub-second times, graph database technologies must be used. Relational databases cannot provide the computational efficiency that is required to support highly trained clinical knowledge workers.

A clinical relevancy engine that is organized around clinical conditions or diagnoses will have millions of potential links between diagnoses and related clinical data points. Relational databases that join tables together were not designed to support data structures with millions of interconnected nodes. Graph database technologies, which are used for complex, connected data, are used by Amazon, Facebook, Google, and others to support large, evolving data structures.

A purpose-built clinical relevancy engine that uses graph database technology will support the clinical thought process by linking clinical concepts (or “nodes”) to each other, with relevancy scoring that enhances clinical decision-making and integrates with systems to maximize physician workflows. This engine enables a clinical user to get an instantaneous view of all information related to any patient presentation in a single view, incorporating both coded data and data points derived from chart notes by using diagnostic natural language processing (NLP) applied to free-text notes.

The old ways of building EHRs to support tracking of transactions for billing will not suffice in the world of value-based care, clinical risk mitigation, and outcomes-oriented reimbursement. Glaser’s proposed new kind of electronic health record must be built on a foundation of clinical intelligence.

Morning Headlines 7/6/20

Health Appointment Booking Platform Chronometriq Acquires Health Myself

Montreal-based patient scheduling and waiting room management software vendor Chronometriq acquires Toronto-based patient portal startup Health Myself.

Missouri announces $50 million program for broadband expansion, including telehealth

Missouri Governor Mike Parson announces a $50 million program for broadband expansion across the state, including $5.25 million for telemedicine services for FQHCs and mental health centers.

Premier Inc. Calls for National Stockpiling Standards to Prevent Redundant Efforts, Next Wave of Product Shortages

Premier calls for national stockpiling standards after its survey finds that 90% of healthcare providers as well as states are amassing masks, gowns, and test kits, creating product shortages and directing supplies away from frontline caregivers.

Monday Morning Update 7/6/20

Top News

Medical informatics pioneer G. Octo Barnett, MD died June 30 at 89, according to colleagues.

Massachusetts General Hospital hired Barnett in 1964 to implement a hospital information system on a time-sharing computer, from which the Laboratory of Computer Science was founded. Barnett was director of the lab until his retirement in 2012.

Barnett, who referred to himself as a “farm boy” and “country doctor” from his upbringing in Alabama, was involved with the development of COSTAR, one of the first ambulatory EHRs, and DXplain, a diagnostic decision support system. He led the LCS group that in the mid-1960s developed early versions of the MUMPS programming language and Cache’ database, which are still used by vendors such as Epic, Meditech, and InterSystems and formed the foundation of the VA’s VistA. He was a founder and original member of AMIA.

Joan Ash and Dean Sittig interviewed Barnett in 2004 as part of a medical informatics oral history project. It is a fascinating read. An excerpt from his advice for informatics fellows:

Get to know the people in the field. Listen and to learn from them. Go to meetings and try to be open to a whole variety of different viewpoints and projects. Don’t get discouraged too easily because there’s going to be some bad times. Hope that in some sense, you’re lucky, that basically things work at the right time and place, because it is very much fortuitous circumstances. It’s very much a time for questioning. I could certainly never have planned my career on any sort of rational, “OK, here’s what I’m going do: Step 1, Step 2, Step 3 … “ You can’t demand a hope for serendipities. That’s the problem, you can’t plan for them. I suppose the best you can do with serendipity is be aware it’s an opportunity when it’s your time.

Reader Comments

From Epic Watcher: “Re: Epic. All these headlines from unfortunate internal emails to pulling employees back to campus. You haven’t provided many thoughts about this.” I’m not an Epic employee, so I’m not all that interested and have no basis on which to opine. They can run the company however they like, and employees and customers are free to act accordingly. My only observation is that Epic has no problems attracting and keeping employees and their industry dominance speaks for itself. I don’t think the company is known for crowdsourcing its strategy and tactics to insight-blessed cheap-seaters .

From HIT CEO: “Re: HIStalk. Thanks for what you’re you’re doing. You have literally changed the industry for better and for good. There aren’t that many people that you can isolate, but what you’ve done with your site, all the way back to the early 2000s, is really fascinating, and seeing the way it has evolved is kind of cool. It hasn’t always been flattering to companies I’ve worked for, but that doesn’t matter because it gives a voice to people.” Thanks.

HIStalk Announcements and Requests

The good news for conference organizers is that most poll respondents think they will return to some semblance of in-person normalcy, but the bad news is that they think it will take years to do so. 

New poll to your right or here: Is it OK to fire an employee for off-work actions or social media posts for which no legal charges are filed?

It has been more than a week since my young relative was tested for COVID-19 after potentially being exposed at work. She still has not received her results and her family (including a doctor) are anxious about how to conduct their lives meanwhile and what will change for them if her results are positive. We aren’t going to make much of a dent in this pandemic if we can’t fix the simple logistics of testing for it and reacting quickly to positive results.

We streamed “Hamilton” on Friday and it was spectacular, right down to playing the Roots over the closing credits. Related to it is the best health IT video ever, Mary Washington Healthcare’s self-introduction to Epic from 2017 that featured “Hamilton” inspired music and costumes that are appropriate to their historical location of Fredericksburg, VA.

Webinars

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

Acquisitions, Funding, Business, and Stock

Montreal-based patient scheduling and waiting room management software vendor Chronometriq acquires Health Myself, a Toronto patient portal startup.

People

Allegheny Health Network names John Lee, MD (Edward-Elmhurst Health) as SVP/CMIO. He replaces Robert White, MD, who is retiring.

COVID-19

COVID-19 test positivity rates continue to increase, especially among young adults, leading to the near certainty of wider spread and increased hospitalization and death weeks down the road. New US cases were at 57,000 on Friday and total deaths are over 132,000.   

North American retail traffic is slowing after weeks of strong gains, suggesting that consumers are choosing to limit their exposure regardless of local, state, and federal government policies. It’s down 50% from this time last year.

The US-Mexico border closes to visitors due to COVID-19 concerns, only this time it is Mexico that is preventing Americans from entering Sonora, which is on the other side of the wall from infection-ravaged Arizona. Meanwhile, England joins the EU in trying to keep visitors from the US out, waiving its mandatory 14-day quarantine for visitors from 50 countries. That policy is still more generous than that of the EU, which banned American travelers entirely last week.

Premier calls for national stockpiling standards after its survey finds that 90% of healthcare providers as well as states are months-long quantities of masks, gowns, and test kits, creating product shortages and directing supplies away from frontline caregivers in the absence of a national strategy.

Houston doctors say hospital EDs are sending patients with obvious COVID-19 symptoms home without testing them, reserving testing for patients who meet the criteria for immediate admission. A Memorial Hermann ED doctor says hundreds of likely cases are sent home from its 17 EDs without testing because of concerns about the availability of supplies.

In India, low-cost ventilator manufacturer AgVa Healthcare is accused by former employees of manipulating its software to show that patients were receiving more oxygen than they actually were. One hospital reported significant differences between the device’s FiO2 display and patient response, with ventilated patients experiencing restlessness, tachypnea, and sweating. Another hospital rejected the company’s ventilators, but eventually accepted them only as backups to their ICU-grade counterparts. AgVa Healthcare says the accusations are misleading, as its ventilators were tested on actual patients in both hospitals following these reports and the hospitals agreed that they worked as expected.

A research institute in South Korea develops a robot that performs COVID-19 nasal swabs as controlled by a remote technician. It includes a live video connection and force feedback for the operator, who is not exposed to the patient during the process.

This is an epidemiologist’s nightmare, as LA residents flee their closed restaurants, bars, and beaches for less-restrictive San Diego in moving a lot of virus around and increasing the chances of another stay-at-home order. Unfettered travel should come with a free tee shirt that says, “My neighbor took a road trip and all I got was this lousy coronavirus.” My suspicions are that viral spread on beaches is minimal, but it’s the bars and restaurants that are involved in beach trips that create a COVID Petri dish.

Other

Chicago’s Roseland Community Hospital loses telephone and Internet service for more than 24 hours when a car crash brings down the connectivity of broadband provider Wow and the hospital’s failover to cell phones didn’t work.

Sponsor Updates

• Spok publishes an e-book titled “The link between the quadruple aim and improved clinical communications.”
• VentureFizz’s Lead(H)er series features PatientPing Chief People Officer Tiffany Mosher.
• RxRevu reaches 100,000 prescribers and exceeds 10 million transactions through its real-time prescription benefit solution in 2020.
• SymphonyRM releases a new video, “HonorHealth’s AVP Healthcare Marketing on Growth and Loyalty.”
• Visage Imaging makes the latest version of its Visage 7 Enterprise Imaging Platform available.

Blog Posts

• Imbio lung AI models support lung disease diagnosis and care via Nuance AI Marketplace (Nuance)
• Plan a Telehealth Strategy for the Long Run (Pivot Point Consulting)
• Designing Scalable Love (PMD)
• Five Years of Redefining the Storage Industry (Pure Storage)
• Three Questions with Sandy Dunn, CISO at a Large Health Insurance Provider in Idaho (SailPoint)
• The link between the quadruple aim and improved clinical communications (Spok)
• EMPI – The Lightweight Solution You’ve Been Looking For? (Summit Healthcare)
• Offering Expertise, Appreciation and Commitment to Those on the Virtual Front Lines (Surescripts)
• Why Cognitive Bias is Ruining Your Clinic’s Outcomes Data Quality – and How to Fix it (WebPT)

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Weekender 7/3/20

Weekly News Recap

• WellSky’s private equity owner considers selling the company at a valuation of up to $3 billion.
• Epic will delay the return of employees to campus by month following a local uptick in COVID-19 cases, but says it is impossible to maintain its culture when employees are working from home.
• UCSF pays ransomware hackers $1.14 million to regain access to its medical school servers.
• A cybersecurity firm reviews Internet traffic of six Fortune 500 healthcare companies and finds significant security exposure and hacks in progress.
• Telehealth visit counts have steadily declined since their mid-April peak, dropping from 14% of all visits to less than 8% as the availability of in-person visits returned.
• Smartphone urinalysis company Healthy.io acquires competitor Inui Health, formerly known as Scanadu, for $9 million.

Best Reader Comments

CMS continues to blast out information like nothing else is going on in the world. Can you spell TONE DEAF???? (JT)

As to definitions, we use these. Telemedicine is doctor to doctor consults, e.g. suspected stroke patient at rural hospital. Telehealth is doctor to patient, omni-channel, asynchronous and synchronous. Virtualcare / health is telehealth combined with remote patient monitoring. (John)

Often the more important distinction is telehealth / medicine vs. virtual care. The former generally implies synchronous communication to replace an in office visit (whether via video, voice, or real-time chat). While the latter brings in asynchronous communication via chat with different care providers, data from connected devices (scales, blood pressure, SpO2, EKG, spirometers) and find a way to present it to the care team and integrate into the EHR that makes care more efficient. (Greg Chittim)

I’ve been using virtual health as the umbrella term that includes (1) telehealth (which involves any modality- video, phone, messaging) between a provider and a patient; (2) eConsult, which is any modality between two providers; and (3) autonomous health, which is any modality between a computer and a patient. My gut is that we will get to a new baseline of 20-30% of telehealth visits assuming reimbursement continues to be at least close to parity in a FFS system. And for healthcare systems in a capitated model, we may see much more. (Lyle Berkowitz)

I am afraid you are too correct in your assessment of the veracity of some state data. We can look at the assertions and testimony of Rebekah Jones, the Florida state chief data scientist who describes the manipulation of data as an example. There are other states that appear to be in similar states of data invalidity for political purposes. This is on top of the problems with data quality that are just inherent to EHR information. I am not sure how to see these trends and infection byproducts in a single EHR, unless that is a combinatorial EHR (acute, ambulatory, ED, etc.) or through a data aggregator. If our testing was both active and historical (covid markers) then we could tag patients then watch their subsequent treatments, Dx, and Rx — maybe through case reporting? But again, if you take that route then you have to trust the health departments to not be influenced by politics. (Brody Brodock)

Watercooler Talk Tidbits

The Alabama Board of Nursing investigates a complaint brought against a nurse who shouted “Heil Hitler” to the Mobile, AL city council meeting and then threatened its members as they approved a mandatory mask-wearing ordinance. A councilman replied nonchalantly, “Good gracious alive. Heil Hitler?”

A newly graduated nurse who had just left her wedding with her new husband “went into nurse mode” when she stopped to render aid at the scene of an auto accident while still wearing her gown.

An unnamed female CEO of a Detroit health IT company pays $3.5 million in cash for a Sarasota, FL condo.

Twitter and JPMorgan Chase will remove the common programming terms “master,” “slave,” and “blacklist” from their source code following complaints from black engineers. Twitter will also replace “grandfathered” and “dummy value.” 

In England, a five-year-old boy who just learned to walk on prosthetic legs following amputation raises $1.5 million so far (versus his goal of $600) in a 10K walking challenge for Evelina London Children’s Hospital, which saved his life as an abused, weeks-old baby. He was inspired and congratulated by 100-year-old World War II veteran Captain Tom, who raised $40 million for NHS charities by walking 100 laps around his garden.

In Case You Missed It

• News 7/3/20
• EPtalk by Dr. Jayne 7/2/20
• News 7/1/20
• Curbside Consult with Dr. Jayne 6/29/20
• HIStalk Interviews Matt Wilson, SVP of Healthcare Strategy, Infor
• Monday Morning Update 6/29/20

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Morning Headlines 7/3/20

Sale process underway for TPG’s WellSky

Private equity firm TPG is considering the sale of post-acute care software vendor WellSky at a potential valuation of $3 billion.

Epic Systems slows reopening plan, calls in-person work its key to success

Epic will delay the phased return of employees to its campus in Verona, WI by one month, citing its culture of on-site collaboration as vital to the success of its customers.

Startup aims AI at clinician scheduling

AI-focused SwitchPoint Ventures and PhyMed Healthcare Group launch Polaris Health, a Nashville-based vendor of analytics for provider scheduling optimization.