Morning Headlines 1/9/20

MTBC Announces Acquisition of CareCloud, Closes its Largest Transaction to Date

Ambulatory health IT and RCM vendor MTBC acquires Miami-based competitor CareCloud.

Komodo Health Secures $50 Million in Series C Funding Led by Andreessen Horowitz, Joined by Oak HC/FT

Analytics company Komodo Health will use a $50 million investment to develop new software and expand its Healthcare Map, which offers a real-time view of patient encounters and outcomes.

Sinai Hospital president to step down, launch telemedicine startup

Sinai Hospital (MD) President Jonathan Ringo, MD will leave the organization in April to launch Verappo, a telemedicine company.

HIStalk Interviews Al Lewis, Workplace Wellness Skeptic

Alfred Lewis, JD is an author of several healthcare outcomes books, operates the website, “They Said What? Because the Wellness Industry’s Pants Are On Fire,” and is founder and CEO of Quizzify of Waltham, MA.

Tell me about yourself and what you do.

I am CEO and quizmeister-in-chief of Quizzify, which is a an employee health literacy company. As we say, wiser employees make healthier decisions. However, I believe we are having this conversation because of my personal blog, which is called, “They Said What?” in which wellness vendors, diabetes vendors, and related vendors are critically analyzed to in fact show that they usually don’t achieve what they claim to achieve.

You’re offering $3 million to any company that can convince an impartial panel that their program can save employers money. Do you have concerns about having to pay up?

None whatsoever. The entry fee is $300,000, and believe me, it’s worth taking a one in a million shot with this impartial panel of five judges, of which I only get to appoint one and the burden of proof is on me. They don’t have a chance, which explains why nobody has tried to take me up on it.

Is it lack of knowledge or intentional deception that motivates wellness companies to sell services to employers without having sound science behind them?

Confucius put it very well. He said, and in those days it was all gender specific, that, “When a man makes a mistake and it’s pointed out to him and he doesn’t correct it, he is telling a lie.” So at this point, these folks know they are lying. They have made the gamble, and it’s a good gamble, that vastly more people are going to read their ads that are going to read my website. So what they do, and they’ve gotten very good at this in the last couple of years, is simply ignore my postings instead of responding to them so as not to create a news cycle and a whole discussion.

Is the available science good enough that they could do it right if they really wanted to?

I would say that for wellness generally, it is mathematically impossible to save money. There are not enough wellness-sensitive medical events. Even if you were to reduce 100% of them, you could not pay for most wellness programs. I’m not going to say it’s impossible, but it has clinically never even gotten close to that 100%. The typical reduction in risk is 0%, somewhere between minus 2% and plus 2%, while you would need a mathematically impossible 100% to 150% reduction to break even.

Most vendors are counting on the fact that most employers have absolutely no idea how many of their employees go to the hospital every year for diabetes. I could tell you if you like, unless you want to take a guess. Out of 1,000 people under the age of 65, how many go to the hospital with a primary diagnosis of diabetes in the insured population?

I’ll say two.

Actually, that’s very close. It’s more like one. Occasionally I run health and wellness trivia contests at conferences. How does the radiation in the CT scan compare to the radiation in an X-ray? But I also throw in that specific question. If you added all the diabetes events and all heart attacks together in a typical employer population, what would the rate be per thousand? In fact, it would be two, if you put both of those together. The guesses that I get are usually somewhere between 20 per thousand and 200 per thousand.

What about the perception of the incidence of chronic disease in general?

It’s not my take, it’s the world’s take. Because I do this show of hands thing, I do these trivia contests all the time. The employer benefits community thinks it is between about 20 and 200 of these events per 1,000 employees. Which of course makes no sense whatsoever. This is just what they say because they get bombarded with information talking about all the people who have diabetes and all the expensive chronic disease. Let’s take those two things one at a time.

A lot of people do have diabetes. They may not even know it. It’s not going to become an issue for them for many years after they find out. If in fact an employer intervenes, they may possibly be able to control it. But what they’re doing is saving Medicare money down the road because virtually nobody goes to the hospital with diabetes before the age of 65. Yet employers want to start paying for medication for these folks, so it’s a net increase in cost.

And then your other point of chronic disease. I’ve written extensively on this fallacy that 86% of cost is chronic disease. If you read it carefully, you’ll find that they are saying that that 50% of adults have chronic disease. Now if you’re defining chronic disease that broadly, you’re including a whole lot more things besides the things that a wellness vendor can get to. You’re including arthritis. You’re including hypertension. Who doesn’t have hypertension?

If you put all that together and say, “Let’s count every dollar that someone with hypertension spends on healthcare.” So someone with hypertension breaks their leg, you count that. You probably don’t even get to 86%, but most of that is also going to be in the over-65 population. In the under 65-population, the major drivers of costs are birth events and musculoskeletal.

The wellness vendors have done a great job of moving the goalposts. It used to be they would say, “You’re going to get a three-to-one financial return.” Then they started saying, “You’ll get a one-to-one return.” Now they’re saying, “There is really no financial return, but the employees will be healthier.”

If you actually look at the health of the employees … I’m not going to name names, except to say that there are a handful of vendors, generally the ones validated by the Validation Institute, that get more than a trivial improvement in health. There are other vendors — and I don’t mind naming names, Interactive Health and Wellsteps come to mind — where employees actually get worse as a result of these programs.

If that’s the case, won’t those companies eventually get fired for failing to deliver?

Some number of them are getting shown the door, but new employers are coming in. The problem is that the vendors have figured out how to measure outcomes fallaciously in such a way that most employers and most consultants aren’t going to catch them. They compare participants to non-participants, for example. It’s been proven up, down, sideways, backwards, forwards, and eight ways to Sunday that every iota, every dollar of savings in a participant versus a non-participant comparison is due to the mindset of the participants versus the non-participants and not to the program.

How do I know that? There are several data points. Studies have benchmarked those things and found exactly that. But the most dramatic one is a company called HealthFitness Corporation that did a wellness program for a company called Eastman Chemical. They separated the groups into participants and non-participants in Year Zero. But due to a whole bunch of incompetence and delays, they didn’t get the program started until Year Two. By the time they started the programs, the participants had already dramatically outperformed non-participants.

The funny part about that is that my nemesis, the Snidely Whiplash to my Dudley Do-Right or the Lex Luthor to my Superman, was stuck with this, so he moved the goalposts. He said, “Oh, we overlooked that. That was our bad. We weren’t competent enough to realize that the program had actually started in Year Zero, not in Year Two. Therefore, you don’t know whether it’s due to the participants or non-participants.”

That turned out to be a big enough lie. And I don’t mind saying, oh, I’ll say on the record, Ron Goetzel is a liar. He can go ahead and sue me. The difference between him and me is that if he calls me a liar, I’ll have him in court the next day.

They put out a graph that shows suddenly that the program started in Year Zero, not Year Two. The people who actually did the program got upset enough with that. If you go back and look at the website now, they have in fact replaced the lie with the truth, which is that the program started in Year Two after dramatic savings had already been found.

You’ve made the case that the simplest way to measure a workplace wellness program’s success is to ask the people who signed up if they participate regularly and see benefit from it. Do most programs fail even that basic test?

There is a tool put out by the Validation Institute that is the most elegant tool for measuring the cost-effectiveness of programs that I’ve ever seen. We are big supporters of it. You ask employees two questions. How much did you use something? You may not even have to ask them that because you already know. Then, did you find it useful? Then you multiply the number of times somebody used something times the usefulness they found. That gives you an engagement score as your Y axis. On the X axis is the cost of the program. You plot the engagement score against the cost of the program and you can tell in a single graph how cost-effective your programs are as viewed by employee use, employee engagement.

You’ve come down hard on Livongo. What concerns would you have as an employer who is considering buying their their program?

I would have two ethical concerns. One is that what they called a study that they point to is essentially a paid ad. The study was done by their employees and their suppliers’ employees. They don’t say anywhere, “We paid thousands of dollars to have this study published.” If they had disclosed that, that would be acceptable. Marginally acceptable. But to essentially take out an ad in this schlock journal disguised as a study, I have an ethical problem with that.

The other thing I have an ethical problem with is that that journal did do a modicum of peer review. Not remotely as much as I’ve done, but a modicum. And they said, “There is no causality here. It is only correlation. There is a correlation between having a Livongo program and having a reduction in costs.” Livongo put out a press release that said, “This study delivered a reduction in cost,” which is a lot different from a correlation. You cannot ethically take the word “correlation” and turn it into the word “delivered.” Those are my two ethical problems.

I have some arithmetic problems as well. The two things that you should measure if you’re trying to figure out if in fact you have reduced the severity and the incidents of diabetes are, number one, what happened to insulin use? Insulin use has actually been declining because the price has gone up so much, so it shouldn’t be a heavy lift to show a reduction in insulin use. Meaning you’re getting some diabetics off of insulin, which is a cost savings, and it also shows that the type 2 diabetics are improving.

Number two, you say, how many fewer diabetics went to the hospital for diabetes than they did previously? That’s a very standard plausibility test that the Validation Institute uses, that Health Affairs has used. It’s in my book, “Why Nobody Believes The Numbers,” which was a trade bestseller when it came out if anybody wants to look at it. It has never been challenged.

Either Livongo did not know enough to measure the two primary outcomes of a diabetes study — which are, did you reduce the use of insulin and did you reduce the hospitalization rate for diabetes – or  they measured them and they did not disclose them. Neither of those gives confidence in Livongo.

The third thing is that their first study said they got a 59% reduction in inpatient, which essentially means that they wiped out every single inpatient admission that did not involve birth events, trauma, cancer, or mental health. Every single one. Their second study made absolutely no reference to inpatient, but said that physician visits and physician expense went down by 26%. So essentially they had two studies, and when they put out the second one, they conveniently forgot about the first, which essentially said the opposite. That’s a red flag.

The other red flag is that every single other wellness vendor in the universe looks at physician visits and physician expense as a good thing. You’re getting people to go to the doctor more. It’s questionable whether that is a good thing, but that’s what everybody looks at. You’re getting people to go to the doctor more, so they’re doing more prevention, et cetera. The idea that you could be titrating all these diabetics’ meds, managing all these diabetics, and somehow have vastly lower physician expense is something they would have to do a great job of explaining to me.

That brings us to the final item, which is that some of what they do appears to be in conflict with other guidelines. This is also in my company Quizzify’s diabetes Q&A, which is reviewed by doctors at Harvard Medical School and carries the Harvard Medical School shield on it as a result. That is, that type 2 diabetics should not obsess with checking their blood sugar. That’s more of a type 1 thing, to check your blood sugar every few hours or every day or something.

It’s quite clear that there is no difference in outcomes between type 2 diabetics who do that and type 2 diabetics who check it vastly less regularly and just have a healthier lifestyle. They don’t have any kind of sentinel events, like a change in their meds or a big change in their weight or some kind of medical event of some type. You just don’t have to check it that often.

But Livongo brags about how many times they get their type 2 diabetics to check their blood sugar. Maybe it’s a coincidence or not, but they are allied with companies that provide medication and other supplies to diabetics. So I would have them explain why they are doing something different from what the literature says.

The manufacturer of Oxycontin pitched their product in referencing a friendly, somewhat obscure research letter that wasn’t peer reviewed. That’s what drug companies do – cite the positive papers in their advertising even if they are scientifically shaky. Is this a healthcare problem beyond just wellness programs, where we aren’t critical enough consumers of literature?

The Oxycontin thing was kind of funny. The doctor was not getting paid to say it and he was actually specifically referring to patients who are already in the ICU. They found something that happened to say what they wanted to say, and like you said, they ran with it.

This one is a little different, because they basically paid a bunch of their employees and they got their suppliers to write this article. Then they paid a journal to publish it. The payments to the journal have never been disclosed to investors. It does say who wrote the article. It does say that the employees and the suppliers wrote the article.

But here’s the thing. Most people, when they see the term “peer reviewed,” that checks the box for them. That says, “Oh, this is legitimate.” But I could give you 15 or 20 peer-reviewed articles in the wellness and the diabetes literature that are essentially incorrect on their face.

Anybody can challenge data. The issue is invalidating data. Can you look at data, and on its face, prove that it’s incorrect? With most wellness data, you can. In fact, I often say in wellness that you don’t have to challenge the data to invalidate it. You merely have to read the data and it will invalidate itself.

Many of those studies are peer reviewed, and many of never should have passed peer review. Oftentimes there are entire journals out there like the Wellness trade journal that have never asked me to peer review anything because they know true peer review would just shoot down everything that they put in it.

Employers talked a lot about coalitions and group purchasing to reduce their healthcare costs, but they haven’t accomplished much. Are wellness programs a half-hearted attempt to rein healthcare costs without addressing provider charges?

Let me take that question and put it into two parts. One is that wellness was very easy to put in place. You could say to your CFO, “Oh, look, we’re doing wellness. This will solve our problems.” Because for wellness, you didn’t have to negotiate with your suppliers or anything like that. You just layered in a new cost item and claimed that it would save money.

A guy by the name of Dave Contorno in our industry, a very capable guy, says the way to save money is to spend less of it, not to add on programs. Like Yogi Berra once said, “We don’t know where we’re going, but we’re making good time.” It was a panacea. There was even a guy — I don’t mind telling you his name, because he said it publicly — by the name of Bruce Sherman, who claimed in a conference that wellness could reduce industrial waste. When you get to that level, you’re just in fantasyland.

The second point that you made is, what should employers do? I would direct you to a book by a guy by the name of Dave Chase. It’s called “CEO’s Guide to Restoring the American Dream: How to deliver world class healthcare to your employees at half the cost.” He points out that, in fact, you can reduce costs by 20 to 40%. It’s been done. It’s not a question of finding solutions — the solutions have been put into place. It’s just a question of putting these proven solutions into place. Things like reference-based pricing and employee education, which is of course what we do. There are new levels of new types of pharmacy benefit managers that don’t have these massively complex contracts with all sorts of rebates that the employers never see, but rather just take wholesale prices and mark them up. All sorts of things have been done. All you have to do is do them and you will see. 

When I work with David Contorno or Dave Chase, I use a little formula with them. Which is, X plus Y equals 20%. X is the reduction in cost and Y is the increase in employee satisfaction with the healthcare program measure, however they want to measure it. Those two figures will add up to a 20% improvement. So if you really want to ratchet your costs, you can do that with no improvement in employee satisfaction. Or at the other extreme, if you feel that a really good program is great for attracting employees, you can keep the cost the same but then basically create low co-pays and  low monthly contributions and get your employees much more satisfied with the program.

Morning Headlines 1/8/20

Healthgrades Acquires Evariant

Physician directory and patient scheduling vendor Healthgrades acquires Evariant, which sells patient and physician relationship management systems.

Pieces Technologies raises $25.7 Million Series B led by Concord Health Partners

Clinical analytics vendor Pieces Technology raises $25.7 million in a Series B funding round, increasing its total to $58 million.

Clearlake Capital-Backed Provation Acquires MD-Reports

Specialty EHR vendor Provation acquires MD-Reports, which offers EHR and practice management systems for ambulatory surgery centers and specialty practices.

HCTec’s HIM Business Line Acquired by GHR

Recruitment agency GHR Healthcare acquires HCTec’s HIM business, leaving its health IT and managed services businesses intact.

News 1/8/20

Top News

Physician directory and patient scheduling vendor Healthgrades acquires Evariant, which sells patient and physician relationship management systems.

Reader Comments

HIStalk Announcements and Requests

I’m thinking a lot lately about a comment Judy Faulkner once made in describing why Epic doesn’t create departmental operating budgets. Instead, she expects the company’s managers to spend money responsibly on what they truly need, subject to some degree of oversight. I’ve always enjoyed creating and managing IT department budgets, challenging the status quo of recurring expenses with zero-based budgeting, and tying budgets to strategic planning and manager goals, so the idea of a $3 billion company tossing those concepts out is intriguing. Maybe budgets are just another form of management laziness (like layoffs and hiring freezes) that encourages undesirable behavior – spending money in the wrong places, always depleting the whole budget to avoid losing funds next year, timing expenses to make the numbers look good, and encouraging managers to upsize their fiefdoms with larger allocations even if that requires some intentional obfuscation. I’m just trying to picture how manager accountability works since budget compliance is usually a top criterion given the hard-walled departmental silos most organizations create.

It’s time to commence the HISsies 2020 process, the first element of which is the nomination form, where you convey your choice for last year’s best and worst vendors, most overused buzzword, and other categories ranging from scandalous to respectful (Lifetime Achievement Award is my favorite, especially since Cerner’s Neal Patterson won it just a few months before he died in July 2017). It’s like the primary election – the most-chosen nominees will move on to the final ballot that will be delivered to the inbox of HIStalk subscribers in a couple of weeks, thereby triggering dozens of folks who skipped the nomination process to complain to me about the poor choices made by their more responsible peers.

I thank my sponsors regularly, but here’s an extra shout-out to the HIStalk Founding Sponsors, Health Catalyst (since 2007, going back to Medicity)  and Medicomp Systems (since 2017). I have just two of those spots available and only one company has ever given theirs up, so I appreciate the support.

Welcome to new HIStalk Platinum Sponsor CI Security. The Bremerton, WA-based company helps healthcare IT people sleep at night by defending their network against cyberthreats 24x7x365. The company’s Managed Detection and Response team of expert security analysts uses best-in-class technology to perform full-cycle threat detection, investigation, response, and recovery, while its consulting services include performing HIPAA risk assessments and penetration testing. For the cost of one employee, organizations get a team of US-based, world-class threat hunters who catch hackers in minutes instead of months to minimize harm. Everybody knows industry long-timer Drex DeFord, who co-presents on  its “2020 Outlook for Healthcare Security” webinar. They’ll be in Booth 413 at HIMSS20 and immediate cybersecurity incidence response is available at 800.604.4810. Thanks to CI Security for supporting HIStalk.

I found this CI Security explainer video on YouTube.

Webinars

January 29 (Wednesday) 2:00 ET. “State of the Health IT Industry 2020.” Sponsor: Medicomp Systems. Presenters from Medicomp Systems: Dave Lareau, CEO; Jay Anders, MD, MS, chief medical officer; Dan Gainer, CTO; James Aita, MBA, director of strategy and business development. Despite widespread adoption of EHRs, healthcare professionals struggle with several unresolved systemic challenges, including the lack of EHR usability, limited interoperability between disparate systems, new quality reporting initiatives that create administrative burdens, and escalating levels of physician burnout. Join the webinar to learn how enterprises can address current industry roadblocks with existing market solutions and fix health IT’s biggest challenges.

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

Acquisitions, Funding, Business, and Stock

Dallas-based clinical analytics vendor Pieces Technology raises $25.7 million in a Series B funding round, increasing its total to $58 million. The founder and CEO of the company, which began as a Parkland Hospital internal program, is informaticist Ruben Amarasingham, MD, MBA.

Ride Health, which offers providers a patient ride coordination service with Uber and other providers, raises $6.2 million in a seed funding round.

The Montreal paper profiles the global ambitions of 65-employee, Montreal-based EHR vendor Medfar, which hopes to grow to a $5 billion valuation by 2030.

Non-profit accreditor URAC acquires the programs of ClearHealth Quality Institute, which offers accreditation for telehealth, mental health and substance use disorder parity, and remote patient monitoring.

Specialty EHR vendor Provation acquires MD-Reports, which offers EHR and practice management systems for ambulatory surgery centers and specialty practices.

Sales

• FastMed Urgent Care, which operates 109 clinics in North Carolina, Arizona, and Texas, will implement Epic, the first independent urgent care company to do so.

People

Cleveland Clinic promotes neurologist Lara Jehi, MD to the newly created position of chief research information officer.

Sumit Nagpal (LumiraDx) becomes co-founder and CEO of healthcare sensor and AI vendor Cherish Health.

Augusta University Health System (GA) hires informatics nurse Mallary Myers, RN, MSN (Baptist Health) as VP and chief innovation officer.

Spok promotes CFO Michael W. Wallace to COO, where he will continue to serve in the CFO role. 

Bluetree hires Julie Walker (Navigant) as SVP of client services.

Announcements and Implementations

A new KLAS report reviews enterprise imaging and how well vendors of universal viewers and vendor-neutral archives support wider image viewing capabilities and increased clinician productivity. KLAS says market leader IBM Watson Health (the former Merge Healthcare) is holding steady, although support and development has lagged since the acquisition. Agfa Healthcare is improving with release of a new platform. while customers of Hyland say the company’s contribution has stalled following its acquisition of Lexmark. GE Healthcare is the most-improved vendor since 2018 but offers limited influence because of its radiology-only focus. Fujifilm “struggles to deliver” because it offers limited guidance beyond using the VNA for disaster recovery.

Philips announces consumer-focused digital health solutions at CES 2020 that include a connected electric toothbrush that shares real-time consumer brushing data with dental insurer Delta Dental in return for free brush heads and coupons. The $280 Sonicare DiamondClean Smart includes sensors and an app that automatically orders replacement brush heads. Philips also offers teledentistry services that include app-based questions and recommendations for $10 and an in-depth assessment for $35.

Also from CES: Omron announces a wearable blood pressure monitor and a device that combines both a blood pressure monitor and EKG. The company will launch a new digital service this summer to offer users heart health coaching and incentives for changing behavior, combining its two existing apps HeartAdvisor and Omron Connect.

Change Healthcare launches an API marketplace through Amazon Web Services.

ROI Healthcare Solutions develops a solution that allows Infor Lawson users to process both just-in-time and traditional orders using a single purchase order vendor record.

Privacy and Security

Aspen Valley Hospital (CO) shares its experience with a Christmas morning ransomware attack that took its systems down until the afternoon of December 26.

Other

Nurses top Gallup’s annual list of most honest and ethical professions by far, with doctors coming it at #3, pharmacists at #4, and dentists at #5. Finishing last were advertising people, insurance salespeople, Senators, Representatives, and car salespeople. Big losers over time are journalists and clergy members.

Former National Coordinator Vindell Washington, MD, MS has apparently been hired by Google as chief clinical officer on the Verily Health Platforms team, given this tweet by recent Google hire and former National Coordinator Karen DeSalvo, MD, MSc, MPH.

Sheba Medical Center, Israel’s largest hospital, expands its chat service to Facebook’s WhatsApp messaging platform, allowing digital phone callers to also receive information and documents during the their call. The hospital says 20% of all calls to its call center are already coming from WhatsApp, which was implemented in a pilot project in September. Facebook bought WhatsApp in 2014 for $22 billion.

Weird News Andy assures us that there’s a kernel of truth somewhere in this story from England. A 41-year-old firefighter who tried over several days to dislodge a piece of popcorn stuck between his teeth using a pen cap, a toothpick, a piece of wire, and finally a metal nail gets a toothache as a precursor to life-threatening infective endocarditis, repair of which required open heart surgery. The patient says he should have gone to the dentist, adding, “I won’t be going near popcorn again.”

Sponsor Updates

• Pivot Point Consulting creates an advisory board that includes Aspen Advisors founder Dan Herman and former MaxIT Healthcare President and CEO Mike Sweeney.
• Central Logic opens a call for speakers (due January 17) for its Patient Flow Summit, to be held September 21-14 in Las Vegas. 
• Health Catalyst and Bluetree will present at the JP Morgan Health Conference January 13-16 in San Francisco.
• Impact Advisors announces a strategic partnership with Chicago Pacific Founders.
• Bluetree will present at the Relatient Customer Panel January 9 in Nashville.
• Clinical Architecture releases a new podcast focused on SNOMED.
• CompuGroup Medical streamlines its laboratory software.

Blog Posts

• How to Prevent Tablets From Spreading Infection in Your Hospital (Access)
• MIPS Highlights for Year 4 (AdvancedMD)
• Increasing Accountability and System-wide Adoption of Value-Based Care in Maryland (Audacious Inquiry)
• Optimum’s Top 5 Blog Posts of 2019 (Optimum Healthcare IT)
• KLAS Research: Arcadia’s Care Management Solution Scores Highly for Identifying and Closing Care Gaps (Arcadia)
• The 2020 trends shaping Epic healthcare denials management (Bluetree)
• How to Comply When You Receive a HIPAA Breach Notification (Datica)
• How to Create a Technology Adoption Strategy That Works (Burwood Group)
• The Future of Interoperability as 2020 Dawns (ChartLogic)
• 5 Biggest Healthcare Policy Changes in 2019 (Collective Medical)
• Senate Upholds Ban on Funding of NPI System – What it All Means (ChartLogic)
• 2020 Formulary Changes Expected to Increase Number of Prior Authorization Requests (CoverMyMeds)
• What We Were Thinking – 5 Bold Statements on Clinical Interoperability circa 2019 (Diameter Health)
• Physician Burnout: Using Data to Find Possible Causes and Solutions (Dimensional Insight)

Contacts

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

Morning Headlines 1/7/20

Walgreens names new chief medical officer

Former Athenahealth CMO Kevin Ban, MD takes on a similar role at Walgreens.

Perficient Announces Acquisition of MedTouch

Perficient adds to its healthcare marketing and technology consulting capabilities with the acquisition of MedTouch.

Philadelphia health tech firm raises $1.75M, plans to double headcount

Hospital discharge planning software startup Repisodic raises $1.75 million.

Curbside Consult with Dr. Jayne 1/6/20

An issue that is often cited as a cause of increased healthcare expenditures in the US is our fascination with technology. This is readily apparent as I see patients. They don’t want me to tell them that it’s highly unlikely that they have strep throat due to a well-validated clinical decision support rule. Instead, they demand an in-office strep test. They have been conditioned to expect technology to provide answers, even if it involves radiating a pair of totally clear lungs because the patient is concerned that they have pneumonia. The increased reliance on patient satisfaction scores as a marker of quality care certainly hasn’t done anything to improve this situation.

Earlier this week, I received a scathing review from a patient that triggered a phone call from the COO. She was upset that I suggested that she be sure to contact her primary care physician when she is ill. I had noticed that she is a member of a notoriously restrictive HMO and I wanted to spare her the denials and her physician the penalties. Instead, she took this as a statement that I “didn’t want her business” and that she was “not welcome at urgent care.”

Being interrogated by the COO about the patient encounter  — which was unusual enough at the time that I put several interesting details in the chart — was the last thing I needed during a busy clinic day when we literally had patients trying to die in the office. When I’ve talked to the emergency department charge nurse at the local Level 1 trauma center three times in the same day, that’s a bad sign for sure.

I would love to have bureaucrats and politicians in the room with me when I have to explain to a patient with a critical illness that they absolutely need to go to the hospital by ambulance and that no, you cannot go by private vehicle when you are actively having a heart attack. I had three different versions of this conversation during my last shift: one for the heart attack, one for a patient with multiple blood clots in the lung who was short of breath, and one for a patient with what appeared to be an evolving stroke. The fact that these patients were at an urgent care center and not the actual emergency department is a result of many factors.

In my anecdotal experience, the first reason is convenience. Patients want to be seen in their neighborhood by someone who can care for them quickly. They don’t want to deal with an office that can’t fit them in or a crowded clinic.

Second is cost. They don’t want a surprise bill from going to the hospital or a denial if their care isn’t deemed emergent after a hindsight review.

Third is a complicated health literacy issue. Patients often don’t understand what can be cared for at home, what needs to be at a retail clinic, what needs an urgent care center, and what needs to go to the emergency department or even a specialized emergency department. As an urgent care physician, I think sometimes we’re victims of our own successful marketing, but that doesn’t help your stress level when you’re urgently transferring a child with a coin in their airway or telling a patient they have advanced cancer that was blown off by their primary care physician.

Many forecasters thought that high-dollar deductible insurance plans would make patients savvier consumers and wiser spenders of their dollars. What we see in practice is that patients are paying so much for their insurance that regardless of the deductible, they want more and more services to get their money’s worth. I never thought I’d see patients coming in saying, “I think I’m OK, but I just want a CT scan to be sure.” They’re shocked when they say that we don’t have enough cause to order it, or that the insurance might not pay for it.

I try to use technology in some of those situations as a teaching aid, pulling up websites and providing information about why the patient is going to be just fine. Somehow it’s more believable when they see it on a website than when the doctor in front of them is saying it. I try not to take it personally.

There are also the times though that technology fails us. Recently, some patients who had undergone preventive mastectomies after concerning genetic testing results learned that the BRCA gene test may have been inaccurate. That was earth shaking for many patients, who have come to trust high-tech answers to their questions. I saw that article on the same day that I saw the Google blog piece about using artificial intelligence to improve breast cancer screening using digital mammography. Another win for technology after a stunning loss.

I was also heartened by the ultimate telemedicine encounter that occurred recently. Apparently one of the astronauts on the International Space Station developed a deep vein thrombosis (blood clot) in their neck, which was evaluated and treated remotely. The astronaut patient performed ultrasounds with guidance from an Earth-bound care team in order to monitor the clot. A pretty cool story, but difficult when you transpose it with the reality of many patients on the ground who can’t get an ultrasound for a suspected clot on two of every seven days, simply because they’re classified as “weekends” and facilities don’t have ultrasonographers readily available.

Being at the forefront of healthcare delivery is like being on a roller coaster. There are amazing highs (identifying the blood clot in the lung before it killed an otherwise healthy 25 year old) and devastating lows that are sometimes too horrific to put into words.

In my informatics practice, I work with people every single day who are committed to trying to solve the problems that we all are facing every time we, or those we care about, interact with the healthcare system. It’s a new year and hopefully a new opportunity for healthcare technology to really make a difference for patients around the world.

I’m excited to be a part of the future of healthcare. Who’s with me?

Email Dr. Jayne.

HIStalk Interviews Joe Petro, CTO, Nuance

Joe Petro, MSME is CTO and EVP of research and development with Nuance of Burlington, MA.

Tell me about yourself and the company.

I got into health information technology about 15 years ago. I started with Eclipsys, on the executive team running R&D. About three years after I was at Eclipsys, I got a call from Nuance. They had a smallish healthcare division and they were looking to go much deeper. I joined as healthcare senior vice-president of R&D. We’ve grown this business over time to about a billion dollars.

Nuance has two divisions. Two-thirds of the company is basically healthcare, while the remaining one-third is enterprise. About 18 months ago, I took over as a chief technology officer for everything. I do all of the products, the technology, and the research as well.

What progress has been made on ambient clinical intelligence and the exam room of the future as conceptually demonstrated at HIMSS19?

Ambient clinical intelligence is super exciting. Five or six years ago, Carl Dvorak at Epic was having a conversation with us and floated the notion of a room being able to listen. At the time, we didn’t have any necessarily tangible connection with how we were actually going to accomplish that. As conversational AI and other technologies developed, we started to get a firmer notion around what the exam room of the future could look like.

A lot has happened over the last 12 to 18 months. We have a number of clients now in beta, so we are learning from real feedback from real physicians. We have made a number of advances in terms of the state of the art and in terms of that summarized document that is produced by the conversation. From a tech point of view, that’s an intergalactic space travel problem in terms of how hard that problem actually is. We are jumping from a broad, basic, human-to-human interaction to a finely-tuned clinical document. From a tech point of view, we have advanced the state of the art.

We have also come up with the second generation of the ambient listening device that sits in the room. That second generation is being rolled out soon.

We definitely do not have a demand problem. Just about everybody in the industry has reached out to us, either as a potential partner or as a client. It’s a super exciting time.

A research article addressed the difficulty of turning an exam room conversation, especially in primary care where it might include social elements and cover multiple diagnoses, into clinical documentation. What are the technology challenges?

In the basic inside-the-tech, Russian doll part of it — getting inside and inside and inside – you are layering together accuracy levels on the entire problem. The first thing you have to do is diarize the speech, separating the multiple speech streams in the room. It might not just be the physician and the patient speaking — it might be the physician, nurse, patient, and the patient’s family.There’s a signal processing and a signal enhancement problem associated with that. That in and of itself has its own accuracy challenges. Then you have to turn that into text, and casual conversation is different from the more controlled clinical conversation.

We have 500,000 physicians on our Dragon Medical One product. That formal conversation has accuracy rates of something like 95, 96, or 97%. When it becomes more casual and conversational, it’s a different kind of a challenge because the text and the concepts aren’t necessarily well formed.

The next step is to extract facts and evidence, so you apply something like natural language processing, AI, and neural nets. You extract things like diagnoses and the active medication list. You try to associate things with the patient’s history versus the current issues that are going on with the patient. 

Finally, you jump to the summarized document. That’s a big jump, because if a patient is talking about the fact that they hurt their back changing a tire, that may or may not end up in the clinical documentation at all. Based on the data we collect, we decide which things to include in the documentation and which shouldn’t be there.

The flow I just went through involves, from a Nuance point of view, the last 20 years of technology that we’ve developed. Each one of the problems alone is hard, but all the problems together are even harder.

Is the technical challenge of multiple voices and accents less of an issue than when systems needed to be trained on individual voices and users had to speak closely into a microphone?

With the introduction of artificial intelligence, a lot of things have yielded. But it’s not just the AI on the software side of things. Inside that device that hangs on the wall is a linear microphone array. There is something on the order of 17 microphones in there, lined up and separated by a small distance. When you think about the capability of each one of those microphones, think about a cone that is emitting into space from each one. The software and the signal enhancement technology behind the scenes, which is AI based as well, figures out who is in the room and who is actually talking. Then with voice biometrics, we can identify that person and keep a lock on them even if they’re moving around inside the room.

That’s one of the breakthroughs that we’ve brought to this space. We have been in multiple industries for a long time. This has been going on in the automobile industry, as an example, for quite a long time. We actually just spun out our auto business and that has had speaker diarization in it for quite some time, where you’re identifying the person in the driver’s seat versus the passenger versus the variety of children and family members who might be in the back seat. That problem was cracked some time ago and we brought that battle-hardened technology over to the healthcare space.

Wouldn’t there be easily harvested clinical value in simply capturing the full room conversation and storing it as text to support searching, either within a specific patient or across all patients?

Yes, for sure. When I’m talking to the executives here or the executives at EMR companies or even physician or hospital execs, one of the things I always try to explain is that as we get deeper into this problem, opportunities are going to reveal themselves and present themselves to us for augmenting present-day solutions with things that we learn during the ambient clinical intelligence process. We have already had discussions about making the transcript available.

There are pluses and minuses to this. You always have compliance issues and whether physicians and hospitals want this thing hanging around as part of the record. But I think we’ll get through that and figure that out with everybody. But for sure there are things that we’re going to introduce, such as making that conversation available, making the diarized speech available, making the facts and evidence that are intermediate results available. We are having these conversations in an ongoing way with all the electronic medical record vendors, just to figure out what intermediate artifacts we might be able to produce along the way that have high value.

It’s one of the things that makes this exciting because it’s almost like gold mining. You are constantly discovering these things that have tangible value and you can introduce them as part of the product offering.

The excitement over extraction of concepts and discrete data from voice in the room overshadowed the ability to control systems hands free. Is it widely accepted that voice-powered software commands could improve usability?

It’s a little lumpy, to be honest with you. From a Dragon point of view we’ve had what we call Command and Control, Select and Say, voice macros, and these types of things for quite some time. Now we’re evolving this to what we call conversational AI, which allows you to do what you just described in a more conversational way. You can say something like, “Dragon, show me the abnormal lab values,” or “Dragon, let’s pull up the latest imaging study,” or “Dragon, let’s send something to the nursing pool.” It’s more conversational and it could potentially be interactive.

Whereas in the old days, and actually in the present day for the most part, with Command and Control, you’re using a voice command to trigger some kind of a keyboard accelerator that might be available through one of the EMRs. You’re trying to execute a rigid macro that checks off a bunch of boxes. The rigidity of all that, and the brittleness of that, is evolving to something that’s quite flexible. 

We’re at a tipping point now where, as you say, is there wide recognition that this could be really good? A certain segment of the population, like the advanced users of Dragon, have always been using this and think of it as rote. They’ve been using it, see the power in it, and realize how it can affect their lives.

I think what’s going to happen now is that we’re going to get past that early adopter phase that we’ve been stuck in for quite some time. There will be broader acceptance the more natural that experience becomes. It’s breathtaking how natural conversational AI can be now. Again, we’re bringing over technology from our auto business and our enterprise business that has been doing this for huge companies for a very long time. All that conversational AI expertise is coming over.

You’re going to see some really big advances here. I’m personally super excited about what’s going to happen over the next couple of years in terms of what we call virtual agents. That’s a very exciting territory.

Will consumer acceptance of voice assistants make it easier to get EHR users to use something similar?

It lowers that barrier, where someone might feel awkward interacting with artificial intelligence and doing it on a day-to-day basis in a natural way. The more that speech becomes ubiquitous as a primary modality that folks interact with, either artificial intelligence or some kind of behind-the-scenes systems, the more the barrier is lowered for us.

I was at a physician’s office the other day and someone had their phone turned up to their mouth and was dictating. The insertion of punctuation into dictation is so unnatural and awkward, but it’s amazing that the person was just sitting there doing the dictation. That type of thing creates relief on our side because it doesn’t feel so awkward for the physician to do it. It also doesn’t feel awkward for the patient to observe the physician doing it. It lowers those artificial barriers that used to be there. I think you’re right — that does create a certain luxury for us.

How do you see speech recognition and synthesized speech being used for population health management?

It can come from both sides. Voice-enabled systems allow folks who are interacting with those systems to to pull information out of them by telling the system what they want. You have a knowledge worker on one end and then the patient side, the reporting, and the things that we could capture from a social point of view that could end up in systems like this. You’re going to see a lot of territory covered in terms of what is actually available to patients.

We’re going to have to address PHI and all of that stuff in terms of what ends up in these systems, how it ends up, and how the patient opts in. But once we get through that phase of it, you will see a lot more entry points that are voice controlled. They will be on both sides of it. You’re going to get the speech side, which is pushing things in in a natural way or trying to extract something with a natural expression of a query. Then you’re going to have the interactions from the patient’s side, which are also voice enabled, but it’s all going to be conversational AI based. You’re going to be talking to a system that asks you questions.

An example of that might be if you ask the system to query something, and it’s an incomplete thought, the system can ask you using voice synthesis — what we call text-to-speech – for whatever it needs to complete the thought so that it can get the appropriate level of information. You’re going to see that all over the place. It’s a bunch of tech that sits around the periphery that will be involved as well.

What impact do you see with EHR vendors signing deals with cloud-based services from Amazon, Google, and Microsoft that give them access to development tools, and I’m thinking specifically of Amazon Transcribe Medical?

It’s another entrant. We keep track of everybody that’s out there. Google has their version of that, Microsoft has their version of that. It’s a good thing to see all the cloud players getting involved. It allows us to create clear differentiation between what we do and how we do it, the accuracy and the fidelity of the experience.

We think about the speech problem as being much bigger than just providing speech to text, and that’s what a lot of these SDKs do. In Dragon, there are literally hundreds of features that sit above the speech dial tone.

The more entrants, the better. That competition is a good thing, but it’s just another competitor type of a response from us.

What opportunities does AI create in going beyond transcription and voice commands to extracting information?

The Comprehend piece, the natural language processing piece — the ability to reach into a stream or a blob of text or documentation or whatever and extract facts and evidence — has been around for a long time. It’s not a new concept. But it allows you to make intelligence part of that natural interaction, which is so important.

For example, we’ve been generating queries to physicians in what we call Computerized Physician Documentation. That’s based on AI. It’s based on natural language processing and it’s also based on speech. It allows us to put intelligence into what we call the speech dial tone, so that as you are speaking, we are aware of the context of what is going on with the patient because we have access to that information through our EMR partners.

But we also know what you are saying. If you’re doing a progress note and you make a statement about some condition, we can connect the dots. If there is specificity missing, if a hierarchical condition category got triggered in the ambulatory setting, if there’s some piece of information missing that could lead to a different diagnosis, we can present that information to the physician in real time. This is making the experience both natural and very, very rich, because the more data we bring into it, the more it takes the burden off the physician.

Physicians are under massive cognitive overload every single day. If we can relieve that a little bit through these mechanisms, it will be a really good thing. Things like Comprehend Medical, the stuff that Microsoft has, Google, the stuff that we have — I think it will all move things in that direction.

Do you have any final thoughts?

We are really excited about the future. I’ve been doing this for a long time now, and I’ve never been more excited about what we’re doing. Ambient clinical intelligence definitely provides an opportunity for Nuance, working with EMR partners, to advance the state of the art in terms of the patient and the physician experience. We are all about the healthcare mission and we are all about relieving burden. What we’re doing here will improve life for all of us as patients, and the partnership with Microsoft and so forth definitely advances that. It will definitely accelerate our mission to get there as quickly as we possibly can. We are jazzed about it and we are really excited about the next few years.

Morning Headlines 1/6/20

AMIA Announces Departure of President and CEO, Douglas B. Fridsma

The American Medical Informatics Association fires President and CEO Doug Fridsma, MD, PhD after five years.

Alphabet-backed One Medical files for IPO as money-losing tech companies struggle on public market

Membership-based primary care company One Medical files for a $100 million IPO.

NHS gets £40m to cut login times on its IT systems

England’s NHS will receive $50 million to implement single sign-on technology across its facilities.

Monday Morning Update 1/6/20

Top News

The American Medical Informatics Association fires President and CEO Doug Fridsma, MD, PhD after five years.

Fridsma says the organization’s board wants “to move in a new direction,” adding that he respects that decision.

AMIA EVP/COO Karen Greenwood is serving as interim CEO during a search for Fridsma’s replacement.

AMIA’s most recent tax filings indicate that Fridsma was paid $376,000 per year.

Reader Comments

From Sunny Jim: “Re: your favorite Epic kiosk, helpfully labeled ‘kiosk.’ This reflects the health of the healthcare industry.” Saint Luke’s has ironically retreated further from paperless – the last photo I ran of the health system’s kiosk had the “undergoing maintenance” electronic message that has now been replaced by a paper sign that directs patients toward even more paper, i.e. the ubiquitous, HIPAA-violating sign-in sheet. I guess it’s too much work to remove non-functioning equipment from the customer’s view.

From Digital Insertion: “Re: HIMSS digital influencers. Odd list, yes?” HIMSS pruned its previous cadre of self-promoting, lightly-experienced tweeters for this year’s batch of unpaid promoters, although nine of the newly named 10 work for what seem to be for-profit employers. They must be influencing someone even if it’s not me. They’re on the hook to participate in videos and roundtables, write thought leadership articles, create “snackable” content (use of that word tells you it’s the marketing people in charge), and run Twitter polls.

From Departmental Division: “Re: hospital IT department enemies. Clinical areas, would you say?” The finance department was been the worst IT opponent in my experience. Clinicians don’t present a unified front and are too busy doing their jobs to dabble in IT politics, but finance people always seem to fancy themselves as enterprise IT experts because they learned to write Excel macros. The best thing I ever did to quiet them down about the IT budget was to have all my directors decompose our organizational cost to the application level (allocated by workstation or network connection for infrastructure) to prove, not surprisingly, that finance-related apps consumed the biggest part of our budget. The nice but meek CFO let his Type A directors run roughshod over everything, including one who ran his own data center and networking and programming teams since he could intimidate his boss to fund his shadow IT operation in proclaiming ours as unresponsive (since we dared niggle about trivial points such as budget, staffing, integration, and infrastructure requirements). Another of the directors wrote an enterprise budgeting application that was used by hundreds of managers in Excel, where it ran from a server tucked away in the kneehole of his desk. I admired their self-sufficiency, but it wasn’t really strategically sound to fund an operation outside of the IT budget allocation process and to write admittedly useful apps that, when they invariably broke, became IT’s problem to fix. You learn quickly that hospital finance people never run short on money to pay for their pet projects and personal technology yearnings.

From In The City: “Re: Y2K. A similar, current New York City example.” Parking meters in New York City and other cities start rejecting credit and prepaid parking cards on January 1 when a software vendor forgets to update its payment software to work in 2020. Would-be parkers were forced to find and install the city’s parking app since even a fistful of quarters would cover just a few minutes of NYC parking time. The vendor provided a fix that requires the city to send workers out on the street to manually reconfigure its 14,000 parking meters.

HIStalk Announcements and Requests

Amazon is the main technology supplier for poll respondents, although Best Buy earns a respectable but distant second place when you combine its online and in-store sales. I realize as I write this that some of the sites that I formerly used have fallen off my radar – Newegg, EBay, the old Buy.com (now Rakuten), and office supply stores. I’m also mostly skipping Amazon these days because third-party seller fraud and phony reviews are rampant, not to mention the big secret of Amazon — many products cost the same or less elsewhere, often being sold by the same company that paid to list its wares on Amazon and with the same free shipping. I ordered a new $15 IPad case last week from Best Buy online to replace a highly rated but crappy Amazon one that was falling apart after just over a year and I had it in my hands via UPS barely 24 hours later. 

New poll to your right or here, for hospital IT management: Has a vendor/consulting firm gone to your peers or bosses without your knowledge to influence an IT decision or to put your job at risk? Please click the poll’s “Comments’ link after voting and tell us the story. I’ve seen it happen in various forms in my own job:

• A vendor who wasn’t selected for our health system’s clinical system replacement appealed to the board and C-suite, knowing that the IT bridges he was burning didn’t matter since he was going to lose the sale anyway.
• A conglomerate – which strategically donated to our health system foundation in a noble-appearing form of palm-greasing — appealed to the foundation’s SVP to intervene in an imaging procurement, which he did (unsuccessfully) in representing his own interests first in demanding to know why we hadn’t chosen that vendor. That particular vendor had burned the hospital more than once, was bottom-rated in KLAS, and had finished dead least in our evaluations even after sending whole teams of people off on foreign junkets.
• Vendors who provided IT outsourcing were always calling up executives to make the case that IT’s reluctance to send work (like help desk) offshore was self-serving. They knew which of our execs thought they were experts on modern business and disruptive technology and were thus receptive to a sales pitch in which a company claimed they could do it for less while still returning an investor-pleasing profit.
• My CIO boss early in my career assigned me to share everything about our department with the CEO of a recruiting firm, who the CIO’s peers had suggested as a good person to review our organization. I was wary but complied, and not long after, the CIO was canned by those same peers and the recruiting firm’s CEO got the lucrative contract to find a replacement.
• On a more positive note, the hospital had a longstanding contract with a big-name firm to do IT department and security audits and to serve as our technology and policy resource when needed. They did an excellent job and were always respectful of IT’s role, avoiding selling us out and instead making sound recommendations for improvement that were shared with IT leadership in advance to make sure we weren’t blindsided. We did a “state of IT” executive retreat with their help in recruiting experts to explain the landscape to the entire C-level team and it was very well received with their added stamp of national credibility that we knew what we were doing. That firm made a lot of money from us and their tenure was never threatened because they delivered and the partner-level folks they assigned to our account understood our culture.

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

Long-time reader M made a generation donation to my Donors Choose project, whose impact was multiplied by matching money from my Anonymous Vendor Executive and other sources that allowed me to fully fund these teacher projects:

• Headphones for Ms. C’s kindergarten class in Kinston, NC.
• An Apple TV for math problem projection for Ms. F’s eighth grade mass class in Houston, TX.
• Programmable robots for Ms. K’s elementary school class in Racine, WI.
• Programmable drones for Mr. K’s elementary school class in Pleasantville, NJ.
• A design and engineering center for Ms. F’s science classes in Roseville, MI.
• Headphones for Ms. K’s elementary school class in Gautier, MS.
• 24 math books for the library of Mr. S in Yonkers, NY.
• A Circletime Around the World carpet and a lounger to create a quiet exploration space for Ms. B’s elementary school class in Tarboro, NC.
• A field trip to the National Museum of Mathematics for the special needs / special abilities elementary school class of Ms. K in Bronx, NY.

I accidentally ran across a recap of my HIMSS16 Donors Choose CIO lunch at Maggiano’s in Las Vegas, where vendor folks could attend in return for a $1,000 tax-deductible donation. I’m wondering if there’s interest in a repeat of that event? My Anonymous Vendor Executive has generously replenished my matching funds kitty and I think that particular activity raised more money than anything I’ve done. 

I also accidentally ran across the splashy August 2015 announcement in which North Shore-LIJ (now Northwell) planned to commercialize a population health management platform that had been developed by Newport Health, which seemed to have one employee, under the Health Connect Technology name. The company’s website has gone dark and I can’t find anything current on investment banker and CEO Sophia Teng. It would be fun to revisit old HIStalk posts to see how big news announcements turned out, although I’ve done it before and readers seemed indifferent.

We’re just over 60 days from HIMSS20 and everybody is back to work this week, so those lazy hours spent ordering last-minute gifts and planning holiday potlucks are over. I just realized that since I don’t listen to live radio, I didn’t hear “Grandma Got Run Over By a Reindeer” even once.

Webinars

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

Acquisitions, Funding, Business, and Stock

Alphabet-backed, tech-powered primary care chain One Medical announces IPO plans, reporting revenue of nearly $200 million and losses of $33 million in the first nine months of 2019.

Privacy and Security

Enloe Medical Center (CA) reschedules elective procedures after ransomware takes down its systems, which it says were restored within three days.

Other

A dentist complains to Boston Children’s Hospital that Marc Ackerman, DMD, MBA, its director of orthodontics, violated ethical standards in his favorable journal review of SmileDirectClub, which offers clear teeth aligners prescribed by teledentistry that the American Association of Orthodontists claims are unsafe. He says he isn’t paid by SmileDirectCompany and has no financial interest in it, but the Boston Globe says he acknowledges that the company pays him for both expert testimony and patient treatment and the company has also donated $176,000 to the American Teledentistry Association, which he runs from his home. SmileDirectClub shares have slide 50% since the company’s September IPO, taking the two 30-year-old co-founders and the father of one of them off the country’s list of billionaires as the money-losing company’s valuation drops to just over $3 billion. 

England’s NHS will receive $50 million to implement single sign-on, with Health Secretary Matt Hancock saying, “It is frankly ridiculous how much time our doctors and nurses waste logging on to multiple systems. As I visit hospitals and GP practices around the country, I’ve lost count of the amount of times staff complain about this. It’s no good in the 21st century having 20th-century technology at work.”

India’s Kashmir region remains under a government-imposed Internet blackout that has lasted five months, ending Save Heart Kashmir’s WhatsApp-powered cardiac emergency network. The program is run by an interventional cardiologist to diagnose cardiac events and to initiate thrombolytic therapy when indicated in the “golden hour” in a region where few residents have health insurance and financial assets. The group had analyzed nearly 40,000 EKGs and 20,000 cases. The Internet shutdown, the longest ever imposed in a democracy, was intended to eliminate “provocative and instigating material” by invoking an 1885 telegraph law. Service was restored this week to 80 government hospitals, but 1,000 private hospitals and clinics still can’t connect, programmers can’t work, online sellers have no market, young people are moving out, and whatever tourists had planned to visit are heading elsewhere. 

Humana apologizes for a computer mistake that left thousands of Medicare Advantage members in Florida and Texas without coverage with the rollover to the 2020 plan year.

In England, an investigation of the NHS111 emergency telephone service finds that at least five toddlers died when staff or the triage software they use failed to identify significant medical issues. A 2016 report found that three children had died of sepsis because the computer script used by staffers wasn’t programmed to identify it.

Contacts

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

Morning Headlines 1/3/20

Changes in Quality of Care after Hospital Mergers and Acquisitions

NEJM-published research finds that not only does hospital quality usually not improve after a merger, it sometimes gets worse as lower-rated hospitals acquire those with better quality scores.

Liberty IT Solutions Awarded $95M Management Consulting Services and Healthcare Revenue Workflow Management and Business Information Technology Tools Task Order

The government consulting firm expands its VA contract portfolio to over $800 million with more Cerner-related work.  

It Looks Like Health Insurance, but It’s Not. ‘Just Trust God,’ Buyers Are Told.

One million Americans have chosen unregulated cost-sharing health ministry plans to save money over traditional insurance, even though the companies issuing them are not obligated to pay claims, they don’t cover pre-existing conditions, they have a fixed limit on payouts, and they require adherence to a Christian lifestyle.

News 1/3/20

Top News

Professors of nursing and medicine write in a New York Times opinion piece that the professions should overcome their traditional hostility toward each other and unite in protesting the excessive documentation required by billing and regulatory requirements that are enforced via the EHR.

The authors recommend that hospitals regularly review their EHR setup to strip away requirements that are not related to patient care.

They also observe that while doctors make more money and are often dismissive of nurses, the latter have done a better job of supporting unions.

The piece concludes by saying that doctors and nurses want the best for patients, but are prevented from delivering it because of “profiteering and gross inefficiency.”

Reader Comments

From Moon Shot: “Re: sponsors. I used Internet Wayback to compare your sponsor list three years ago to today. I’m surprised at those that have disappeared for reasons other than being acquired.” I never though of using Internet Wayback for that, but it does indeed work. The end of the Meaningful Use-fueled buying frenzy has caused quite a few companies to scale back in various ways that I assume aren’t limited to HIStalk sponsorship. Several sponsors tell us they are cutting back or don’t have any senior people remaining in marketing or other departments. I expect that trend to continue and I predict that the HIMSS conference exhibit hall will be more Spartan than in the gold rush years. We will find out if companies can downsize their way to competitive success, but in any case, I appreciate those companies that keep HIStalk running and the readers who keep coming back in numbers that haven’t diminished.

From Corporate Brand Expert: “Re: our company name. You omitted our trademark designation – please fix.” Companies use trademark symbols in their own communications. Third parties and journalists, except for the clueless ones, do not. 

From Robert D. Lafsky, MD: “Re: New York Times opinion piece on EHRs. How did paperless systems become ‘paperwork?’” Dr. Lafsky — the only grammarian I know who is even less forgiving than I – correctly notes that the Times article’s headline refers to performing low-value EHR activities as “paperwork.” I blame the headline writer of the “paper” (pun intended) since the authors don’t use that term in the actual article. I’m not appalled because I don’t know any word that conveys the concept better, although I am annoyed at its omission of the Oxford comma that makes the headline harder to read (no one is ever confused by its inclusion, but some are confused by its omission).   

From Going Commando: “Re: Calvary Hospital (NY). Sacked the CIO and the analysts they hired after a successful Meditech Expanse rollout. Navin Haffty is now ruling the roost.” Unverified, although Kathleen Parker’s bio has been removed from the hospital’s web page. Either way, it’s always interesting to me how frequently CIOs are deposed by the vendors they manage.

From Please Provide a Correction: “Re: Health Catalyst share price. Up 30% from its IPO price, not down 8%.” Share performance is based on price at the market’s close. Health Catalyst shares were priced at $26 for its first day of trading on July 25, 2019, but opened for trading at $37.37 and closed at $39.17. They are now at $34.76, down nearly 12% from that first-day close in valuing the company at $1.3 billion. Their all-time high was $48.47 on August 12, while the all-time low of $26.44 occurred on October 9. HCAT shares are traded on the Nasdaq, which is up close to 10% since July 25.

From Health Tech Stocks: “Re: hospital patient survey vendor NRC Health. Shares were up 74% in 2019, valuing the company at over $1.5 billion.” Shares of NRC – headquartered in Lincoln, NE — are up nearly 400% in five years. The company was founded in 1981 by Mike Hays, who remains CEO. He holds $10 million worth after selling $300 million worth from the trust fund of his grandchildren last year.

From COBOL Been Berry Good to Me: “Re: Y2K. Thanks for that look back, which as someone involved in the remediation, made me smile.” People forget that Y2K was the ransomware of its day, a non-event only because programmers who were forced to dig into ugly, old code made it so. Anyone who thinks the issue was a made-up problem is ignorant of the facts, conveniently benefitting – as do people who refuse to be vaccinated – by the more responsible behavior of others. I think we’ll do better in fixing well in advance the Year 2038 problem, the “Unix Y2K’ in which systems that represent time as the number of seconds elapsed since January 1, 1970 will stop working when the storage variable runs out of space on January 19, 2038.

From Get Thee to Conferences: “Re: health IT conferences. I see other sites attend dozens of conferences each year. Why don’t you?” I think the lack of return is obvious given the continuingly inexpert content of those sites. Racking up exhibit hall miles is no substitute for running a hospital IT department, practicing as a clinician, performing informatics research, or all those other activities that go beneath self-important conference meet-ups and selfies. I admit that I sometimes develop useful perceptions about vendors and trends at the HIMSS conference since it covers just about everything important, but I’m not too tempted beyond that. Technology education requires cross-country flights and overpriced hotels only because that’s where the exhibit hall cash register is ringing. I always savor the irony of the American Telemedicine Association holding an-person conference in New Orleans to pitch seeing a doctor by video with the argument that those sessions are cheaper, more efficient, and more convenient.

HIStalk Announcements and Requests

Welcome to the new year, when the high deductibles and out-of-pocket maximum costs of many expensive health insurance plans reset, most likely giving providers a break as the patients who need their services can’t afford them.

Webinars

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

Announcements and Implementations

The World Health Organization designates 2020 as the “Year of the Nurse and the Midwife” in calling for 9 million more nurses and midwives that are needed to achieve universal health coverage by 2030.

Government and Politics

The VA awards Liberty IT Solutions a three-year, $95 million task order to integrate the VA’s Consolidated Patient Account Centers with its Cerner system, adding to the $434 million contract Liberty won in November to modernize the VA’s systems under Cerner. The company had previously won $700 million in VA IT contracts in a single quarter of 2019.

Other

Hospital mergers and acquisitions haven’t improved quality and in some cases have made it worse, researchers find. While prices nearly always increase after a merger, quality rarely does. Sometimes the acquired hospital saw its quality scores dragged down by the lower ones of its acquirer.

An Australian insurer says doctors there appear to be choosing medical device implants based on their personal profit rather than medical evidence, to the point that sales reps are scrubbed in to advise surgeons during procedures (it’s exactly the same in the US, in case you haven’t worked in a hospital). The company recommends creating an independent organization that reviews prices and clinical efficacy similar to a program that reviews drugs, also noting that the federal government sets medical device payments for public hospitals but private hospitals pay a lot more. The medical device trade group says the campaign is a smokescreen for increasing health insurance premiums and that it’s not the government’s job to decide which products provide the most value.

In England, politicians call for the resignation of the Imperial College Healthcare Trust Chair Paula Vennells after the country’s Post Office – which she headed as CEO from 2012 through 2019 – agrees to pay $75 million in lawsuit damages to sub-postmasters who were blamed for accounting shortfalls that were actually caused by the Post Office’s Horizon computer system. Some of the sub-postmasters had been fired, fined, or imprisoned while the Post Office was spending millions defending Horizon, which the presiding lawsuit judge called “institutional obstinacy.”

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
Get HIStalk updates.
Send news or rumors.
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EPtalk by Dr. Jayne 1/2/20

Regardless of what holidays you celebrate, everyone is impacted by medical offices that are closed and healthcare facilities that are running on modified schedules this time of year.

I’m in the middle of a streak of clinical shifts that have at times reduced me to a mound of quivering jelly. Influenza is definitely on the rise and I’m starting to feel like my mask is permanently attached to my face. Our urgent care group saw nearly 2,000 patients on December 26, breaking our city-wide record. Many patients reported trying to get in touch with their primary care physician only to find the office closed, with some offices being closed until after the new year.

Seeing a 20% bump in volumes, the IT side of my brain always wonders about scalability of the solutions we use. I’m happy to report that the EHR held up like a champ, but viewing radiology images in the PACS was another story entirely. Load times were running up to two minutes, which seems like an eternity when you’ve got a full house and need to know what’s going on with your patients’ films.

One of my patients happened to be an imaging rep, who asked how we were holding up this time of year. It was nice to see someone who understands that there are many factors behind keeping an office running, although he was less than amused that we couldn’t send his records to his primary physician.

As an independent organization, the large health systems in town aren’t too keen on sharing data with us even though it would mean they receive our work product as well. Just another example of information blocking that isn’t a vendor’s fault. In the meantime, I take full advantage of the features within Epic that allow me to access patients’ charts for a short time with their permission.

My operations brain is always challenged by these high-volume days. They make me wonder what “the system” could do differently to better manage these patients. Although many of those we saw had acute conditions that needed urgent treatment, like influenza or pneumonia or lacerations, many of them could have been handled by a nurse triage line or other lower-acuity situation.

Quite a few patients hadn’t tried any self-care, not so much as a decongestant or an over-the-counter cough medication, even though they were relatively young and healthy and didn’t have any reason to be concerned about medication interactions or worsening of chronic conditions. Several had been sick for less than a day. My favorite presenting issue of the day was, “My throat started with a tickle a couple of hours ago and I just wanted to see what it was.” This shows a lack of health literacy, even in the relatively affluent area in which I was working. What could we as a healthcare system do to serve these patients better?

I’ve also been able to put my telehealth hat on this week, due to a spike in volumes in my state. I only do telehealth visits sporadically since I don’t hold a lot of different state licenses. I was pleasantly surprised by the number of patients who weren’t specifically seeking antibiotics – who just wanted to make sure they were doing everything possible to treat their condition, or wanted validation of their treatment plan because they were making slower than expected improvement.

Back in the clinic the next day, I also saw the dark side of some virtual visit care as patients came in for face-to-face visits after having been prescribed medications that seemed unrelated to their symptoms. I saw three patients from the same physician who were each a bit concerning. It sounds like her practice has recently started using functionality within Epic that allows for patients to have billable asynchronous visits, and perhaps she isn’t in the swing with the fact that just because a visit is virtual doesn’t mean you don’t have to follow the standard of care. Maybe she doesn’t know the antibiotics she is prescribing aren’t indicated for the condition being treated, but there’s no good way to try to address that professionally when we see it.

Our volumes continued throughout the weekend, with record-breaking numbers of visits at several of our locations. I encountered a couple of primary physicians and one psychiatrist whose offices were not only closed during the holiday weekend, but also who had no after-hours coverage. Even other physicians received no response when trying to reach them. In my state, that’s tantamount to patient abandonment, and I hope those patients have some difficult conversations with their physicians (or perhaps soon-to-be-former physicians) about being left hanging.

I also heard some complaints from patients who just don’t feel like their physicians listen to them. It’s not only complaints about looking at the computer instead of the patient, but also complaints about physicians pushing additional procedures that are unrelated to their care plans. One patient showed me the brochure from her pulmonologist who was offering cosmetic Botox injections. These are just a small sample of the patients who wind up in the urgent care, where they’re trying to make up for whatever they’re not receiving in their usual setting of care, if they have one.

Santa must have been very good to a couple of patients, who presented with ICD codes in the F12 series: cannabis-related disorders. Cannabis-induced palpitations was one of the conditions, and I would have loved to have simply typed “lay off the weed” in my care plan. Somehow “reduce or eliminate cannabis use until cleared by cardiology” just doesn’t seem as festive. Nor does “your risk of recurrent vomiting would be lower if you stopped using marijuana.” These are the things they don’t tell you about in medical school, that one day you might find yourself dealing with in an exam room.

On days like these, I long for the relative lack of excitement found in a good lab interface build or some of the other work I do in my informatics practice.

For those of you who worked around the holidays, what kinds of adventures did you have? Any great stories? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 1/2/20

Doctors, Nurses and the Paperwork Crisis That Could Unite Them

Professors of nursing and medicine urge the professions to come together to reduce the documentation requirements enforced by the “bureaucratic nightmare” of EHRs.  

Using AI to improve breast cancer screening

A study in UK hospitals with the participation of Google Health finds that an AI model that supports radiologists in detecting breast cancer produced a modest reduction in false negatives and positives even though the model did not have access to patient histories and prior mammograms.  

The Family Wanted a Do Not Resuscitate Order. The Doctors Didn’t.

A ProPublica report finds that transplant doctors sometimes talk families out of asking for DNR or withdrawing life support within 30 days to avoid skewing the survival statistics of their programs. 

Social media hosted a lot of fake health news this year. Here’s what went most viral.

The most widely shared health misinformation on social media in 2019, much of it originating with anti-vaccination groups, include the US government conspiring with drug companies to hide cancer cures, herbs and homeopathy that cure cancer and chronic conditions more effectively than medical treatments, and the injuries and deaths caused by vaccines.

Woman wrongly told she had cancer when software misheard doctor

A hospital in England apologizes to an endoscopy patient for telling her doctor that her exam revealed “cancer,” which it says was an unnoticed mistake made by its speech recognition software that misunderstood the word “candida” that relates to the patient’s yeast infection.

Morning Headlines 12/31/19

FDA Failed to Ensure Safe Prescribing of Opioids, Documents Show

Johns Hopkins Bloomberg School of Public Health researchers find that FDA was lax in failing to require opioid manufacturers to collect data to prove that their physician prescribing training was effective in reducing addiction, overdoses, and deaths and instead allowed those companies, in the absence of such data, to regulate themselves.

I tracked my sleep with an Oura ring — here’s what I learned

CNBC’s Chrissy Farr says Oura’s sleep tracking ring provided a lot of sleep quality data over a two-week period, but the 15 minutes she spent with a sleep coach – which the company does not offer – provided more value.

What’s Next for Health: Leading Through Change with a Strategic Direction

HIMSS touts its “new strategic direction and brand re-alignment” that includes a reorganization to remove silos, an emphasis on its value beyond the annual conference, and its intention to become “a catalyzer to transform the global health ecosystem through the power of information and technology.”

The Big Change Coming to Just About Every Website on New Year’s Day

The California Consumer Privacy Act, which takes effect January 1, requires the websites of large companies to provide ways – including web buttons saying “Do Not Sell My Personal Information” – to their websites, which will be available to all US citizens since the sites can’t target Californians specifically.

Morning Headlines 12/30/19

DCH Health System patients file federal suit over ransomware attack

Four patients of the Alabama-based health system claim their care was disrupted by an October ransomware attack.

Verily Partners with Emory Healthcare to Analyze Medication and Lab Ordering Patterns for Improved Cost-Effectiveness and Operational Efficiency

The health system hires Alphabet-owned Verily to use analytics to find value opportunities.

Just what the doctor ordered: How AI will change medicine in the 2020s

Eric Topol, MD again calls for technology to give doctors “the gift of time” that will allow them to develop deeper relationships with their patients.

New York doctor sues Apple over irregular heartbeat detection

NYU Langone Health cardiologist Joseph Wiesel, MD says Apple violated his patented method for detecting atrial fibrillation after he shared details with the company in September 2017.

Monday Morning Update 12/30/19

Top News

Four patients of DCH Health System file a class action lawsuit that claims their medical care was disrupted because of a ransomware attack in October.

One of the plaintiffs says she couldn’t get post-op meds, another complains that she was told her daughter would have to wait 4-5 hours to be seen for an allergic reaction, a third says her orthopedist couldn’t see her in a scheduled follow-up, and a fourth patient makes no specific claim except to say that her care was disrupted.

Reader Comments

From Gilligan’s Paragon Island: “Re: Allscripts. Its Atlanta Paragon hosting center suffered an outage at 6 a.m. on December 21 and didn’t come back up until 30 hours later. They were not forthcoming about what caused the outage or what they were doing to fix the issue. How can hospitals provide quality patient care without access to their EMR and core ancillary systems for more than a day?” Unverified.

From Oneida Platter: “Re: CoverMyMeds. It’s actually a phishing attack. If you search in a browser, it advertises a CoverMyMeds link that actually takes the user to a rogue site.” That’s what I assumed since the “contact Microsoft immediately at this number” scam is always delivered via browser. It has nothing to do with the systems of CoverMyMeds.

From Joey Cheesesteak: “Re: Optum layoffs. You reported the rumor of a January 3 layoff – I’m one of 24 consultants (of 90) in Optum Advisory Services who was laid off effective January 2. HIStalk is still a daily read – thanks and keep up the great reporting with a humorous spin.” I’m sorry to hear that and angry with Optum in laying people off over the holidays. Optum generates more half of the $260 billion in annual revenue of parent company UnitedHealth Group, which is tracking at $20 billion in annual earnings. I’m trying to decide which is most despicable: (a) laying off employees over Christmas; (b) laying off employees at all from a division that brings in $112 billion per year; or (c) having a parent company in UnitedHealth Group that is making $20 billion in annual profit on $260 billion in annual revenue, all of it coming from people who are either sick or who are trying to fund the future cost of becoming sick. Your $10,000 investment in UHG 10 years ago would be worth more than $100,000 today, and the CEO (who has been around only a couple of years) holds something like $300 million worth. Buying shares of healthcare’s profiteers might have been the best hedge against rising healthcare costs, but you need money to make money.

HIStalk Announcements and Requests

Christmas is the most commonly celebrated winter holiday among poll respondents, but I’m interested that 18% don’t really care about any of them. Cosmos suggests that employers provide “religious vacation” instead of limiting paid holidays to those that are Christian-centered. That’s why I love the paid time off system, although even then some employers mandate using PTO for holidays like Christmas where there’s not much work to get done.

New poll to your right or here: Where did you buy your most recently purchased technology item? I subscribe to the New York Times, of which reader comments are the most interesting part, and today it featured a furious debate over Amazon’s role as both a supporter and competitor to small businesses and whether having a huge company fulfillment center in your town is good for business and residents. We heard the same thing about shopping malls and Walmart before Amazon, of course, and regular retail disruption is pretty much a given unless Amazon’s size, analytics capabilities, and political influence have made it immune. I noticed that some NYT commenters also called out Amazon’s possible Achilles heel being its tolerance of scammy sellers offering counterfeit goods backed by fake reviews.

Today I learned that all Chromebooks are shipped with a hard-coded expiration date, after which they will no longer receive Chrome OS updates. That education was delivered to me via a pop-up message on my four-year-old Asus that gives June 2020 as its final connection to the Google mother ship. The hardware manufacturer sets the date based on when the configuration is first locked down, not when the Chromebook is manufactured or sold, so even a new copy of an older model could be short dated. I’ll have to decide whether to replace mine or just use it without updates, but at least I paid only $200 for it and it’s still my favorite computing device. Most important to me is the 11.6” screen that makes it barely bigger than a tablet, but with a good keyboard.

Happy 20th birthday, Y2K. Thank a remediation programmer — quite possibly a paunchy, gray-haired COBOL coder who was dragged out of retirement — for making it a non-event and thus rendering Y2K survival kits worthless when humankind survived after all. The nail-biting Y2K teams were sitting in war rooms listening to “Smooth,” “Back At One,” “Hot Boyz,” and “Blue,” or more likely, watching TV news to see what was happening in countries whose rollover midnight came hours before ours.

Webinars

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

Acquisitions, Funding, Business, and Stock

I checked 2019 share price performance of the publicly traded health IT companies I could think of, of which just four beat the Nasdaq composite index percentage increase:

1. NantHealth (up 91%)
2. Teladoc (up 68%)
3. Nuance (up 56%)
4. Cerner (up 40%)
5. Nasdaq composite (up 36%)
6. Change Healthcare (up 34% from mid-2019 IPO)
7. Inovalon (up 32%)
8. S&P 500 (up 29%)
9. McKesson (up 26%)
10. Dow Jones Industrial Average (up 23%)
11. CPSI (up 8%)
12. NextGen Healthcare (up 8%)
13. Premier (up 3%)
14. Allscripts (up 3%)
15. Health Catalyst (down 8% from mid-2019 IPO)
16. Livongo (down 33% from mid-2019 IPO)
17. Castlight Health (down 40%)
18. Vocera (down 47%)
19. Evolent Health (down 56%)

Announcements and Implementations

Emory Healthcare (GA) engages Alphabet’s Verily for medication and lab ordering analytics to identify value opportunities.

RSNA and Carequality publish “Imaging Data Exchange Implementation Guide Supplement,” expanding Carequality’s medical image exchange capabilities. It was presented at RSNA on December 2.

Other

The New York Times cites a study that proves what we all know – healthcare services in the US cost way, way more than any other country (basically double), with one example being an angioplasty that runs around $7,000 elsewhere costs $32,000 here. The employer survey looked only at private insurance, meaning that the spread is probably even larger since public health programs pay less elsewhere. The Times concludes that those high prices finance a politically powerful healthcare industry that is likely to repel any efforts to reduce prices.

Experts warn that terrorists could create “dirty bombs” that could contaminate several square miles by extracting Caesium-137 from blood irradiators used in hospitals and blood banks. A 2008 government panel wanted the devices withdrawn in favor of equally effective but safer alternatives, but hospitals complained that the panel was “regulating the practice of medicine” and the number of devices in use has grown since. A GAO report noted that a hospital left an irradiator on an unsecured cart on its loading dock, while another stored the device behind a combination-locked door upon which someone had helpfully written the combination.

Contacts

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

Morning Headlines 12/27/19

The Watch Is Smart, but It Can’t Replace Your Doctor

A physician author says in a New York Times article that the public health value of the Apple Watch’s atrial fibrillation detection capability is overhyped and that even study participants mostly ignored its guidance.

Artificial Intelligence Is Rushing Into Patient Care – And Could Raise Risks

AI systems have already made significant healthcare mistakes as technology companies their rush products to market without the benefit of peer-reviewed studies and with minimal FDA oversight.

Mayo Clinic names chief digital officer to lead transformative digital strategy, create Center for Digital Health

Mayo Clinic hires Rita Khan (United HealthCare, Best Buy, Macy’s) as chief digital officer.

Augmedics Announces FDA 510K Clearance and U.S. Launch of xvision, the First Augmented Reality Guidance System for Surgery

Chicago-based Augmedics earns FDA’s F10(k) clearance for its augmented reality system that allows surgeons to visualize 3D spinal anatomy and track instruments and implants while looking directly at the patient.