News 11/20/19

Top News

The American Medical Association adopts a policy that calls for EHRs to be able to collect the preferred name and clinically relevant, sex-specific anatomy of transgender patients.

AMA’s policy aligns with recommendations that medical documentation contain the patient’s preferred name, gender identity, pronoun preference, and history of medical transition history as well as current anatomy.

Reader Comments

From Creative Juice: “Re: being laid off. I’m thinking about suing. Advice?” Don’t bother. Allow me to list the steps you’ll go through after being laid off, ending with the distant speck of light at the end of the unemployment tunnel:

1. You will experience the ultimate humiliation in coming home early to notify your family that you are no longer employed, threatening your identity in ways you could not have imagined. 
2. For a couple of days after being marched out, you’ll embrace false hope that your former employer will call to explain it was all a big mistake or that they want you to come back in a different role.
3. You will expect an uprising from customers that will never happen, or expect those customers with whom you worked closely to call you cold with job offers, which will also never happen.
4. You will commiserate with former co-workers who also got the axe, convening depressing lunches and not-so-happy hours where the conversation gets louder and faster as you try to convince each other that the company or your former boss will fail without you, which they won’t. 
5. Most of your “work friends” will disappear from your life permanently because (a) they weren’t really your friends, they just shared employer space with you, and (b) nobody wants to hang around former colleagues who were marched out and who are now seeking comforting scuttlebutt about how bad things are at work.
6. You will consider legal action, which is pointless. Even if you are legally right (and you aren’t), it would take years to arrive at a resolution that will not include hiring you back. Not to mention that employment lawyers want their money upfront (they know you won’t win) and it doesn’t really matter anyway because you signed away your right to sue as a condition of receiving severance.
7. You will belatedly update your resume and think about overdue networking as the reality sets in that your income stream is ending. The grim reality of signing up for unemployment will cause endless anguish because you don’t see yourself as one of those pathetic people.
8. Initially you will apply for no positions because of the indignity of the hiring process, then later you will apply for every job in sight because of the indignity of being unemployed.
9. You will struggle with the idea that many of the seemingly good jobs are located in far-away areas where you don’t want to live, requiring uprooting the family with new schools for the kids and a new job for your working spouse (if you have either). You will also rage at the Catch-22 fact that you might get more money later if you move, but you need money now to move.
10. You will eventually find some kind of job, either (a) a short-term one or even a contracting gig that will help pay some bills while you keep looking, or (b) one that is better than your previous one. Then you will rejoice that your incompetent former employer kicked you out of their sorry nest. I’m not one to offer unjustified cheerleading – if you are competent and willing to work, your lot will improve, and if not, then I don’t blame your previous employer for booting you.

From Oingo Bongo: “Re: Allscripts. Heard from a contact that there’s been another round of Paragon staff. Got any info on that?” The company laid people off last week, and while I haven’t heard anything specifically regarding Paragon, I can’t imagine that’s a growth area. Also relevantly not growing is MDRX share price, down 12% in the past year vs. the Nasdaq’s 22% gain.

HIStalk Announcements and Requests

Reader AC made a great suggestion to turn on two-factor authentication for Gmail and other important services that don’t enable it by default, following my story about a hospital employee stealing co-worker logins using a keylogger program. I did it and it was painless. Gmail prompted me to enter a one-time verification code that it sent via SMS message, which it does each time I log in from a new device. Once I did that, it’s business as usual with no further verification unless I (or someone else) logs in from a different device. That means a hacker who has obtained my login credentials still can’t hijack my email account. An extra feature – you can ask Gmail to generate a bank of one-time codes to use when you won’t have your phone. Thanks for that advice. I can’t even imagine the headache and security exposure that would be involved with someone gaining full access to my email account, including all the personal and confidential information it contains.

Listening: the first, eponymous album by The Doors from 1967’s Summer of Love. “The Crystal Ship” alone is worth the ride. Mr. Mojo Risin’ had just turned 23 when the album came out, the beginning of his four-year term as the country’s most dangerous and reckless poet, musician, and performance artist until the unfortunate intersection of drugs and bathwater sent him to “The End” (as it did Whitney Houston and Dolores O’Riordan of the Cranberries). I’m also enjoying new from singer-songwriter JP Saxe, who I think is probably going to be pretty big.

Webinars

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

Sales

• Mary Free Bed Rehabilitation Hospital (MI) will implement Epic in an $8 million, 10-year Community Connect agreement with Covenant HealthCare.
• Cooper University Health Care chooses Phynd for provider management.
• Novant Health will implement KenSci’s AI platform to match workforce demand to capacity and to identify patients who are at risk for longer stays or readmission.
• Visiting Nurse Service of New York selects Netsmart CareManager for care coordination, data reporting, and analytics support for its population health management programs.

People

Ryan Miller (Anthem) joins Change Healthcare as SVP of corporate development.

Medical practice software and services vendor IKS Health hires Kelly Reed, DO (The Iowa Clinic) as SVP of clinical services and outcomes.

Announcements and Implementations

Collective Medical will add HIE CCD data to its care team platform, connected by Kno2.

Virtusa will add EHR data to its VLife life sciences platform from the InterSystems IRIS for Health interoperability solution .

Privacy and Security

National Veterinary Associates, which owns 700 veterinary hospitals and boarding facilities, is struggling to recover from an October 27 ransomware attack that affected 400 of its locations. The company declined to answer questions about the malware or whether it paid a ransom.

Other

American healthcare in a nutshell: the manufacturers of heart stents assure their investors that a widely praised study that proved the less-than-expected value of such procedures won’t hurt their business much. Translation: hospitals, doctors, and device manufacturers aren’t about to let medical evidence get in the way of their profits, meaning your odds of being stented won’t change just because we now know that it doesn’t work any better than a prescription. Meanwhile, a cardiologist whose research helped develop a new drug for a rare type of heart failure criticizes the manufacturer for setting the price of the capsule at $225,000 per year versus the estimated cost-effective price of $17,000.

A Bahamas senator says he “makes no apologies” for his involvement with the 2016 signing of an $18 million contract with Allscripts and Infor that was supposed to transform healthcare there, even through the Public Hospital Authority warned Allscripts in late 2018 that it wasn’t happy that the company hadn’t installed any software anywhere despite having been paid $7 million. The local newspaper speculates that the government will give Allscripts a 60-day cure notice, then terminate the contract with expectation of a full refund. The government blames Allscripts in “a glaring lack of oversight” for “a staggering increase in implementation costs” beyond agreed-on amounts, with consulting firm Avaap billing the government $1.5 million. The paper also notes that the Allscripts proposal was stamped as received 11 days after the tender’s closing, which had already been extended by 14 days. The country’s minister of health declares the project “a bust.”

A free clinic in Syracuse, NY closes after 12 years when the part-time founding doctor found that she was spending more time maintaining its EHR than seeing patients.

Johns Hopkins Bloomberg School of Public Health profiles Assistant Professor Smisha Agarwal, MPH, MBA, PhD in its magazine, which describes her as “the school’s first faculty for digital health” in a sharp contrast between investor-crazed US digital health and public-focused health projects overseas. Snips:

• She says we don’t know how to integrate digital tools with health system, we don’t know if they are cost effective, and we need to be careful not to amplify existing healthcare inequities, such as improving health only in urban areas or for those people who own a mobile phone.
• She hopes mobile clinical decision support tools can help shift caregivers away from triaging low-severity illnesses and providing preventive services, data from which could then be used to apply machine learning algorithms to predict poor outcomes for intervention.
• She says that a downside of digital health is opportunity cost, where resources are moved from established programs to experimental digital programs.
• She worries about gender inequity in countries where the men are the primary phone owners and the effect on needed pregnancy and newborn care.
• She sees the biggest transformational opportunities for digital health being putting real-time data in front of caregivers, using analytics to target high-risk patients, assisting providers who have limited training with education or remote assistance, and counting births and newborn deaths.

Sponsor Updates

• Avaya announces the availability of Google Cloud contact center AI integration with its IX Contact Center solutions.
• Netsmart takes the top spot for the fifth year in a row for customer satisfaction in Black Book Market Research’s annual look at the post-acute health technology market.
• Dimensional Insight will exhibit at the New England HIMSS Maine Conference November 21 in Portland.
• EClinicalWorks posts a podcast titled “Telluride Medical Center: On the Primary Care Frontier.”
• Collective Medical partners with Kno2 to add enhanced clinical data capabilities including continuity of care documents to its clinical insights and analytics software for HIEs.
• Virtusa enhances the health data integration capabilities of its VLife life sciences platform with the integration of the InterSystems IRIS for Health Data technology.
• Woman’s Hospital (LA) will expand its use of Spok solutions.
• Vocera will resell Spectralink Versity smartphones, which has been certified for use with its clinical communication and workflow system.
• Optimum Healthcare IT completes Epic go-lives at several hospitals under Deaconess Health System’s CareConnect program.
• A five-year study finds that a health literacy incentive program using health education content from Healthwise lowered healthcare costs.

Blog Posts

• Watch: How to pick the right tablet and accessories for your hospital (Access)
• Making Telemedicine Seamless (AdvancedMD)
• Better. Faster. More efficient. At RSNA 2019, Agfa HealthCare showcases the latest release of its Enterprise Imaging platform powered by a smart workflow engine (Agfa Healthcare)
• How Improved Interoperability Can Help Healthcare AI Flourish (Apixio)
• Think Good Customer Experience is Obvious? Think Again. (Avaya)
• 4 ways to ensure your Epic system can facilitate timely (and quality) physician documentation (Bluetree)
• Who is HITRUST CSF Certified? (Datica)
• How Choosing the Right EHR Helped Our Practice (EClinicalWorks)
• Trending at the CHIME19 Fall CIO Forum: Humanizing Healthcare Technology (Burwood Group)
• Transitions of Care: The Biggest Challenge for Value-Based and Senior Care Efforts (Collective Medical)
• Be Yourself: Celebrating Individuality in a Big Way (CoverMyMeds)
• Looking into “The Future of HEDIS” (Diameter Health)

Contacts

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

Morning Headlines 11/19/19

Feds charge 3 former Outcome Health staffers

The US Attorney’s office in Chicago charges three former Outcome Health employees with wire fraud and conspiracy to commit wire fraud, all of which are related to a scheme to defraud customers and investors first uncovered in 2017.

Configo Health Launches with Investment from Texas Children’s Hospital and Children’s National Hospital

Pediatric data and analytics company Configo Health launches with an investment from Texas Children’s Hospital and Children’s National Hospital in Washington, DC.

Deloitte Launches ConvergeHEALTH Connect at Dreamforce 2019

Deloitte announces ConvergeHealth, a set of Salesforce-powered engagement products tailored to patients, providers, public health officials, and payers.

CascadeMD Announces Next Generation of Medical AI-Driven Speech-to-Text Solution

Plantation, FL-based CascadeMD debuts with AI-powered, voice-dictation software that populates a patient’s EHR.

Curbside Consult with Dr. Jayne 11/18/19

A former colleague of mine reached out recently, frustrated by a physician in his organization who is demanding that clinical decision support features in some applications be turned off. He was asking for tips to help counter the argument.

It turns out that the physician in question believes that if the application presents you with guidelines that you ignore, you are liable. Fortunately, it’s a pretty easy counterargument. If a guideline exists and you ignore it, regardless of whether it’s in your application, you are liable. In many cases, if a guideline exists and you don’t know about it but a physician would be reasonably expected to know about it, you are liable.

The whole point of clinical decision support is to bring those guidelines  — which you may or may not be familiar with or incorporating into your practice — to the point of care so you can react to them. Of course, this assumes that the clinical decision support in question is accurate and appropriate.

Since crossing into the realm of clinical informatics more than a decade ago, my clinical activities have been limited. This is partly by choice (realizing that I can’t do justice to the traditional primary care paradigm when practicing on a very limited schedule) and partly due to workforce economics. Unless you’re a physician administrator at an academic institution or your CMIO situation includes a specific carve-out for clinical care, it’s unlikely that someone wants to hire you to see patients one day a week.

Since the scope of my practice is relatively limited, one might think it would be easier to keep up with the knowledge base, but it’s still very challenging. I remember a couple of years ago when one widely-used antibiotic fell out of favor for a particular condition. It was a good six months before one of my go-to journals reviewed the primary article and another three months before I actually read it, meaning that I was prescribing a less-than effective medication for a good nine months before I knew any better. What if there could have been clinical decision support at the point of care, which would have alerted me to the fact that the antibiotic selected was no longer recommended for the diagnosis I had entered?

Conventional wisdom is that medical knowledge doubles approximately every eight years. Physicians graduate from medical school and are then trained in residency by physicians who might have been in practice anywhere between one and 60 years. One would expect great variability in those teaching physicians’ knowledge bases as well, which is another plus for clinical decision support.

There are a number of pros and cons around whether clinical decision support should be regulated and how that might impact shifting liability. Others voice concerns about whether this will lead to so-called cookbook medicine or encourage mental laziness among physicians. Regardless of the strength of decision support or whether it’s regulated, physicians still have a duty to determine whether the recommended course of care makes sense or if there are any concerns about the recommendations.

Physicians need to understand where the recommendations found in clinical decision support systems originate. Are they from well-known guideline producers, such as the US Preventive Services Task Force, the Centers for Disease Control and Prevention, the American Cancer Society, or the American College of Obstetricians and Gynecologists? Are they just automated and exposed guidelines that are doing simple checks against diagnosis codes, SNOMED codes, LOINC codes, and medication codes, or are they using artificial intelligence or machine learning?

Rand Corporation blogged about this issue way back in 2012, and the thoughts around it haven’t changed significantly. Straightforward clinical decision support, such as drug-drug interaction checking is great, but alerts have to be at the right level for a physician to highlight the most critical cases while preventing alert fatigue. Users who click through alerts without reading or digesting them will continue to be at risk for increased liability in the case of a poor outcome.

Oregon Health & Sciences University’s Clinical Informatics Wiki covers this issue as well. It notes that, “As long as 25 years ago it was realized that availability of computerized medical databases would likely erode the local or community standard of care.”

Changes to the community standard of care might not be a bad thing. Many of us believe patients should be treated the same whether they live in the city versus rural areas and regardless of differences in income or demographics. However, there have been pockets of the country where physicians were held to a different standard for a variety of reasons.

Take the PSA test for prostate cancer risk. At a time when the US Preventive Services Task Force was specifically recommending against testing (in part because of the number of false positive tests leading to unnecessary biopsies and other downstream consequences) my community performed them across the board because a leading urology researcher at a local academic institution drove expert opinion that they should be done. If you didn’t do a PSA and a patient turned out to have cancer, you were in for a bumpy ride.

OHSU notes correctly that state laws have lagged behind current technology and that the scope of the legal medical record varies from state to state. I’ve worked in organizations that swear that the final signed chart note in the EHR is the legal record, and others who said, “everything in the database is the legal record.” I’ve worked with attorneys going down SQL rabbit holes trying to figure out what a physician knew and when based on various timestamps, user IDs, and other metadata.

The wiki authors also note the need to better understand how clinical decision support systems influence clinician judgment and how their use might impact those who are “not adept at system-user interfaces.” They also note the relative lack of case law in the area, but go on to say that, “Physicians are likely to be held responsible for the appropriate use and application of clinical decision support systems and should have a working knowledge of the purpose, design, and decision rules of the specific decision support systems they use.”

For some EHRs and related systems, this is easier than others. I’ve seen systems where you can quickly drill down to the specific recommendations and understand why a flag was thrown. I’ve also seen systems where alerts don’t seem to make sense and searches of well-known physician resources fail to shed light on the subject (nor do simple Google searches, so a double dead end). The bottom line remains, however, that regardless of the volume of information out there, physicians are expected to know the answers and do the right thing for their patients.

How does your organization address liability for clinical decisions, whether human-created or prompted by technology? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 11/18/19

Trump Administration Announces Historic Price Transparency Requirements to Increase Competition and Lower Healthcare Costs for All Americans

HHS expands its previous plan to require hospitals to publicly post all of their payer-negotiated charges by also requiring insurers to do the same.

Relatient Secures Growth Capital with New Majority Investor Brighton Park Capital

Brighton Park Capital acquires a majority stake in patient engagement platform vendor Relatient and appoints former Siemens USA President Eric Spiegel as the company’s board chair.

Amazon adds new ‘Amazon Pharmacy’ branding to PillPack and promotes its CEO

PillPack CEO TJ Parker becomes an Amazon VP as the company rebrands the online pharmacy it acquired in June 2018.

Former Employee Of Hospital Charged With Compromising Dozens Of Coworkers’ Email Accounts And Stealing Their Confidential Information

The FBI arrests a former IT employee of an unnamed New York City hospital, charging him with installing a keylogger program on dozens of employee PCs to capture their email login credentials so he could steal their photos and tax records.

Monday Morning Update 11/18/19

Top News

HHS, as promised, expands its previous plan to require hospitals to publicly post all of their payer-negotiated charges by also requiring insurers to do the same.

Hospitals would also be required to post the cash payment they are willing to accept for 300 common, shoppable services.

The rule will take effect on January 1, 2021 in the imaginary world where no lawyers live (the American Hospital Association, Association of American Medical Colleges. Children’s Hospital Association, and Federation of American Hospitals immediately said they’re suing for HHS overstepping its bounds).

President Trump said in announcing his executive order:

First, we are finalizing a rule that will compel hospitals to publish prices publicly online for everyone to see and to compare. So you’re able to go online and compare all of the hospitals and the doctors and the prices, and, I assume, get résumés on doctors and see who you like. And the good doctors — like, I assume these two guys are fantastic doctors, otherwise you wouldn’t be here. (Laughter.) And the bad doctors, I guess they have to go and hide someplace. I don’t know. Maybe they don’t do so well, I don’t know. But if they’re not good, we — we are more interested in the good ones. It’s called rewarding talent.

Second, we’re putting forward a proposed rule to require health insurance providers to disclose their pricing information to consumers. We’re giving American families control of their healthcare decisions. And the freedom to choose that care is right before them on the Internet and elsewhere, but on the Internet. Very, very open. Very transparent. That’s why it’s called transparency.

Reader Comments

From Who Diss?: “Re: Who’s Who. This CIO was recognized as a ‘Top Medical Professional’ by a seedy-looking organization’s press release.” A variety of “who’s who” scammers contact people cold, preying on their vanity by advising them that they have been “chosen” by their admiring peers or the company’s editor to be included as a member in a paid online listing. After that, they are hit with the upsell to buy lifetime memberships or vanity crap like wall plaques and hardcopy books. You CIOs, pharmacists, doctors, and nurses who I see listed on this particular one’s site got taken, I’m sorry to tell you. Please don’t list this laughable accomplishment on your resume, which in some LinkedIn examples shares space with bogus educational credentials. Above is the company’s luxurious office suite in Valley Stream, NY, conveniently located above the dumpster in which visitors can pitch their “award” and possibly their careers right out the window.

From Gobsmacked Compliance Professional: “Re: SCL Health and Providence. I was having dinner adjacent to a restaurant’s ‘private’ dining room and was gobsmacked to overhear a detailed discussion about their plan to merge, including proposed timeline, financials, etc. Annual reports are due in December and will be interesting reading.” Unverified. SCL owns eight hospitals in Colorado, Kansas, and Montana that generate $2.5 billion in annual revenue. Providence operates 51 hospitals with annual revenue in the $23 billion range. Maybe this alleged privacy slip is yet another example of hospital people loudly saying things they shouldn’t within earshot of others.

From Register Ringing: “Re: HIMSS20. Look at this page of well over 1,000 things they’re trying to sell to exhibitors.” Vendors can whip out their checkbook to buy nearly every square inch of the convention center or to have HIMSS push their sales message to attendees, including:

• Sponsor pre- or post-conference supplements to “own the conversation” ($20,000).
• Pay HIMSSTV to record a panel discussion in their booth ($20,000).
• Get the impartial, hard-hitting journalists at Healthcare IT News to tweet out links to “one of your thought leadership content pieces” ($20,000, or $22,500 if you want them to just write the piece themselves).

HIStalk Announcements and Requests

Few poll respondents think the Allscripts-Northwell collaboration will result in a commercially successful EHR any time soon.

New poll to your right or here: How would you characterize Ascension’s data analysis agreement with Google? Click the poll’s Comments link after voting to explain.

Webinars

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

Acquisitions, Funding, Business, and Stock

Brighton Park Capital acquires a majority stake in patient engagement platform vendor Relatient and appoints former Siemens USA President Eric Spiegel as the company’s board chair.

Sales

• Amedisys will deploy NVoq’s cloud-based speech recognition solutions for dictation and automation.
• Thomas Health (WV) will add Meditech’s web-based Ambulatory solution to its Expanse system, implemented by CereCore.
• San Gorgonio Memorial Hospital chooses the Azure-hosted Sunrise Community Care from Allscripts. Googling suggests that they are replacing Allscripts Paragon.
• Beebe Healthcare (DE) will improve workflow efficiency and clinician communication using TransformativeMed’s EHR-embedded work management and notification modules to eliminate printed patient lists.

People

CereCore hires Joe Wurzer (Leidos Health) as RVP of sales and business development.

Privacy and Security

The FBI arrests a former IT employee of an unnamed New York City hospital, charging him with installing a keylogger program on dozens of employee PCs to capture their email login credentials so he could steal their photos and tax records. I was thinking that this sort of information shouldn’t have been stored on a work PC in the first place, but then realized that he probably grabbed their logins to Gmail or other web-based personal email services.

Other

The Washington Post covers “rural America’s busiest emergency room,” Avera Health’s telemedicine center in South Dakota that provides remote ED service for 15,000 emergencies each year covering 179 hospitals in 30 states “where the choice is increasingly to have a doctor on screen or no doctor at all.” Rural ED visits have increased 60% in the past 10 years, but hospitals are closing, doctors aren’t willing to move to small towns, and standalone EDs are going broke. One small hospital signed up at a cost of $70,000 per year after it received four critical automobile accident victims with just an single RN working, with no doctors available within an hour’s drive. Fun fact – the virtual service’s doctors wear scrubs and lab coats to their suburban office park location so they will look like real doctors to their TV patients. The virtual ED clinicians must work patiently with local nurses who may have no experience with intubating patients or who need help running a code blue. Avera ECare’s telemedicine network also offers services for ICU, school health, pharmacy, clinics, behavioral health, correctional health, and hospitalist coverage.

The Pittsfield, MA paper covers the $35 million implementation of Meditech Expanse by Berkshire Health Systems. The article focuses on the hospital’s problems with the Allscripts FollowMyHealth patient portal – the inability to share data, uncertainty over how the company might use its data for marketing, low usage in the 30-40% range, and patients who either can’t sign on to FollowMyHealth or who sign up directly with the service instead of through the hospital-provided link. The health system is a longstanding Meditech customer for inpatient and is apparently replacing Allscripts ambulatory with Meditech.

The Wall Street Journal profiles the technology underpinnings of the new $2.1 billion, 368-bed Stanford Hospital that opened this weekend. It was originally scheduled to be open in early 2018, but was delayed because Apple’s spaceship headquarters project sucked up all the Silicon Valley steelworkers. I was curious about Stanford’s financials, which show $4 billion in annual revenue, a profit of nearly $450 million, several executives in the $1-2 million range, and not-unreasonable IT compensation (the CMIO was paid $770K, while the CIO made $500K). Hospital features include:

• Bedside keypads that allow patients to choose entertainment and control temperature, lighting, and window blinds.
• Swisslog robotic dispensing for pharmacy and medication delivery by robots.
• A fleet of automated guided vehicles for delivering laundry and collecting trash.
• Tracking of staff an inventory in real time.
• Remote patient monitoring.

CIOs are expanding their use of “low-code” drag-and-drop automation tools such as Microsoft PowerApps to quickly create applications that automate business processes, which Gartner says will make up 65% of application development in the next five years. St. Luke’s University Health Network (PA) VP/CIO Chad Brisendine says his team has built 20 applications – none of which took more than 20 hours to create – to extract information from hospital systems. A non-programmer needed just eight hours to develop an app that extracts information from its Workday HR system to issue CME reminders to doctors. A Microsoft case study describes how Northwell Health used Dynamics 365 (and its Healthcare Accelerator) and PowerApps to develop a daily rounding app. I admit that the geek in me is aroused.

Several readers forwarded the full text of a just-published article that tried to correlate physician-perceived EHR usability with burnout, with the big conclusion being that EHRs “received a grade of F by physician users.” My critique:

• The sample size was just 870 doctors surveyed out of 31,456 invited, of which the authors used “a deliberate oversampling of non-primary care specialties.”
• Perceived EHR usability was compared to “everyday items” such as Microsoft Excel (which also earned an F), an ATM, and a microwave oven.
• I’m not clear on how the authors expected respondents to answer usability questions about “my EHR,” which would depend on their practice (one or more clinics, one or more hospitals, both, etc.)
• The authors mentioned an “incentivized secondary survey,” which suggests that they paid people to complete it.
• They note that respondents may have been conflating EHR usability with the burden of documentation it supports, with their pushback being against documentation requirements rather than the tool that captures it. 
• A reader says that while one of the authors is an executive of the notoriously EHR-hating AMA, its own JAMA wouldn’t publishing the findings and it ended up in Mayo Clinic Proceedings, probably because of the low response rate.

Sponsor Updates

• OmniSys employees in Greenville, TX collect hundreds of canned goods for those in need.
• The Wharton School’s “Work of Tomorrow” podcast features MDLive CEO Rich Berner.
• The Salt Lake Tribune features Health Catalyst CEO Dan Burton.
• OpenText and Redox will exhibit at Salesforce’s Dreamforce November 19-22 in San Francisco.
• Clinical Computer Systems, developer of the Obix Perinatal Data System, will exhibit at the Perinatal-Neonatal Symposium November 18 in Williamsburg, VA.
• KLAS Research recognizes PatientPing as a high-performing, emerging healthcare IT company.
• Surescripts and TriNetX will exhibit at AMIA’s annual symposium November 17-19 in Washington, DC.
• SymphonyRM publishes a new white paper, “AI Next Best Actions vs. Traditional CRM.”
• T-System adds EvidenceCare’s clinical decision support tool to its emergency department documentation software.

Blog Posts

• OIG Series 6: Addressing Behavioral Needs and Social Determinants of Health (Lightbeam Health Solutions)
• Where’s My Pizza? A Winning New Vision for Transparency in Healthcare (Loyale Healthcare)
• How EHRs can help address patient safety concerns (Meditech)
• APIs, Alerting and Power Users Shine at MHUG 2019 (Mobile Heartbeat)
• Elevating the Role of the Nurse to Support Value-Based Care (PerfectServe)
• 3 Considerations for Choosing a Public Cloud Partner in Healthcare (NextGate)
• Why Hospice Care Matters to Me: April’s Story (Netsmart)
• Health IT leaders answer: What makes a successful Community Connect program? (Nordic)
• 4 real-world examples of how consumer data can transform the patient experience (Experian Health)
• 4 Ways to Engage Baby Boomers Using Healthcare Technology (PatientBond)
• It’s No Secret: The Healthcare Industry Can Improve Lives with Transparent Pricing (Patientco)
• CHIME 2019 Fall CIO Forum: Key Themes and Hot Topics (Pivot Point Consulting)
• 5 big questions still to be answered by the final ONC and CMS healthcare interoperability rules (Redox)
• Balancing Zero Trust with a strong identity strategy and AI (SailPoint)
• Realize Your Potential ROI with an RPA (Robotic Process Automation) Solution (Summit Healthcare)
• Welcome to VUE19 … and the Future of Care Communications! (Voalte)
• Healthcare Safety: The Big Picture (Vocera)
• 5 Strategies for Training Your Clinic Staff on Compliance (WebPT)
• The new healthcare consumer engagement landscape for whole-person health management (ZeOmega)
• How Better Patient Engagement Reduces Avoidable Readmissions (Zynx Health)

Contacts

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

Weekender 11/15/19

Weekly News Recap

• HHS OCR will review the HIPAA compliance of the “Project Nightingale” data-sharing agreement between Ascension and Google.
• NextGen Healthcare announces plans to acquire patient portal vendor Medfusion for $43 million.
• Ontario, Canada announces a Digital First for Health strategy that will give patients more online access.
• Results of the Apple Heart Study find that 0.5% of 400,000 enrolled users received an irregular heartbeat notification, most of whom were found to have atrial fibrillation.
• Premier launches Contigo Health, which will connect participating employers and health systems to optimize employee care using EHR-integrated clinical decision support.
• Kaiser Permanente Chairman and CEO Bernard Tyson dies unexpectedly at 60.
• University of Chicago asks to have its medical center to dismissed from a class action lawsuit that was brought by a patient who says its data-sharing agreement with Google violates his HIPAA rights.

Best Reader Comments

After dozens, maybe hundreds of healthcare organizations have partnered with analytics companies to share data and develop solutions, why are we just now becoming concerned that Google has entered the ring? (SkyNet)

Cerner makes money how? From recent earnings call: “As the acknowledged data source, we plan to develop a monetizable distribution model that provides access to legacy client segments and adjacent market prospects such as biopharma, payers and actuaries, to name a few.” (Vaporware?)

I agree it is patient’s data, but that is not the business model in other industries. What about credit information? Isn’t that consumer’s data, too? But credit agencies hog it and sell it without any explicit approval from the individual to collect / distribute it. (Data Business)

What bothers me is that many hospitals willingly give the data away or sell it to entities such as Google, but when the patient asks for copies of his or her own records, they are charged. (X-Tream Geek)

The letter urges that EHR vendors not create financial burdens for physicians trying to connect to state immunization registries and called on HHS to “hold information technology vendors accountable for creating a national standardized, easily accessible, accurate, robust immunization information system.” That’s a recipe to get some terrible software shoved down physicians throats. (What)

I think Mr. Segert has a surprisingly good handle on the [Athenahealth] business here. He’s right that the ambulatory market is consolidating and that Athena has the best ambulatory-only product. If you accept those facts, it seems that Athena should mop up the rest of the smaller vendors. Athena wasn’t making much progress on that because their focus and execution wasn’t there. They were spending their effort on tiny, low volume/$, rural hospitals who would bail out halfway through implementation and go back to CPSI. That was a great way for Athena to take large piles of investor dollars and set them on fire. Also looks like he has a good grip on the sales channels, which is the hardest and most important thing when selling software to the SMB or smaller enterprise market. (GoodFirstImpression)

Layoffs are almost always painful, but it feels worse during the holidays. As a recruiter, I get to see where the layoff leads. It’s remarkable how often it turns out to be for the best. I’ve seen so many people take layoffs hard, only to look back a few months later with gratitude that it led them to something better. (Jim Gibson)

The best way that most economic development agencies have found to lift families out of generational poverty in under-developed economies is to educate girls and women. Across the board, giving women access to education leads them to start businesses that provide economic stimulus to their entire community. Giving menstrual products to teen girls has proven to do just that. Giving a girl the opportunity to get an education is the fastest method to improving her life and the lives of those who depend on her. It is the same reason that diaper banks have proven to reduce sick baby visits and increase teen mothers’ ability to attend classes and work. A child who is constantly ill due to not being able to have a clean diaper is a drain on their parent. The parent can’t improve their economic situation if they can’t go to school and work. Just because a program is focused at the individual level doesn’t meant that it won’t lift up the community. (MEDITECH Customer)

Watercooler Talk Tidbits

Nike will release the Air Zoom Pulse, a lace-free, protectively coated shoe (“a traditional clog made athletic”) that it designed to combat fatigue in testing at OHSU’s children’s hospital. Six young “patient designers” created their own versions of the shoe, profits from which will be donated to the hospital. I like the above design from 12-year-old Sawyer Miller, whose brain tumor was treated with surgery and 30 rounds of radiation therapy. I bet I could make a HIMSS20 splash walking endless miles in these.

University of Washington students petition the university to prohibit faculty members from requiring a doctor’s note for their absences due to “unavoidable” illnesses, saying that seeing a doctor for that purpose is expensive, requires students to explain their symptoms after the fact, disadvantages low-income and DACA students, and may result in the ordering of risky tests and procedures. The students add that doctors always write the notes anyway, so there’s no impact on their behavior.

Loyola University Medical Center tells a woman who was making inquiries into her mother’s unexpected death that its autopsy camera had been stolen and the photos on it lost. Nine of the 18 cases that had been recorded on the camera hadn’t been uploaded to the electronic files as health department policy requires because the camera didn’t come with a cable and the hospital didn’t have one.

A 26-year-old woman undergoing breast cancer treatment is surprised when her boyfriend proposes to her in front of her Sloan Kettering treatment team on her last scheduled visit, after which they were married in an event donated by a wedding planning company.

The gift shop of Park Nicollet Methodist Hospital (MN) adds a selection of hijabs for patients and employees, saying it’s the first US hospital to do so.

UPMC Magee-Women’s Hospital dresses up newborns for November 13’s World Kindness Day in cardigans like those worn by Mr. Rogers, who spent most of his life and career in Pittsburgh. Other local hospitals and individuals did the same, encouraged by public TV station WQED, which created Cardigan Day in honor of Fred Rogers, who filmed 895 episodes of “Mister Rogers’ Neighborhood” at the station over more than 30 years through 2000. He died of stomach cancer in 2003.

In Case You Missed It

• News 11/15/19
• EPtalk by Dr. Jayne 11/14/19
• News 11/13/19
• Curbside Consult with Dr. Jayne 11/11/19
• HIStalk Interviews Bob Segert, CEO, Athenahealth
• Book Review: It Shouldn’t Be This Hard to Serve Your Country
• Monday Morning Update 11/11/19

Get Involved

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

Morning Headlines 11/15/19

Tyto Care Launches TytoHome Nationwide at Best Buy Stores

Best Buy ups its digital health offerings with the addition of TytoCare’s at-home telemedicine exam device and companion app.

AWS Announces AWS Data Exchange

Amazon Web Services launches AWS Data Exchange, giving users the ability to find, subscribe to, and use third-party data in the cloud.

Ontario Expanding Digital and Virtual Health Care

Ontario health officials announce a Digital First for Health strategy that will give patients the ability to book appointments online, access their medical records, and take advantage of more telemedicine services within the next three to four years.

ECRI Institute and Institute for Safe Medication Practices Join Forces to Enhance Patient Safety

Patient safety groups ECRI Institute and the Institute for Safe Medication Practices will merge, with ISMP becoming an ECRI Institute subsidiary.

Yale study links electronic health record systems to physician burnout, medical errors

The American Medical Association co-sponsors a study that finds that perceived EHR usability is poor and contributes to physician burnout.

News 11/15/19

Top News

The HHS Office for Civil Rights will look into the HIPAA compliance of Google’s data-sharing arrangement with Ascension.

Google has pledged to cooperate with OCR investigators, stressing that its work with Ascension adheres to HIPAA and “comes with strict guidance on data privacy, security, and usage.”

The company added in an amended damage-control blog post that, “Patient data … is not used for any other purpose than servicing the product on behalf of Ascension. Specifically, any Ascension data under this agreement will not be used to sell ads.”

Google Cloud now knows that its parent company has a consumer image problem that, while not on the magnitude of Facebook’s, could still serve as a roadblock for its technical work that has nothing to do with search engine ads.

Perhaps most puzzling is why Google hasn’t enlisted its new high-profile healthcare hires to explain the project or to describe why it’s likely that patient data is more secure within Google’s systems than in those of any hospital or medical practice.

The odds that this deal violates HIPAA are zero. It only violates the data rights that consumers wish they had. 

Reader Comments

From RumorMonger: “Re: Allscripts. Reducing workforce today to cut costs, with a rumored 25-50 people let go.” Unverified, but reported to me by several readers, some of whom said weeks ago that the cutback was scheduled for November 18. Rumored areas impacted are Sunrise, support, and development.

From PizzaSlinger: “Re: Cerner layoffs. A manager apparently sent the layoff script to the associates he was laying off.” I hate that layoffs have become corporate business as usual, with companies unskillfully using them to (a) dump deadwood and high earners while dodging employment law issues; or (b) to quickly juice their financial numbers to arouse some bean counter. I get really worked up when the company cluelessly acknowledges the announcement with a cheery statement that while the valued (to a point) former associates will be missed, the company is hiring wildly otherwise. Maybe the “overall headcount increase” promise encourages investors and customers, but it throws salt in the layoff wound by clearly indicating that the affected “associates” aren’t worth retraining or reassigning. Still, I commend Cerner for sending its executioners a script – which was forwarded to me — to make the employee’s final contact with the company smooth. My summary of it:

• Schedule the appointment ahead of time using an attached link (I assume using the link automatically alerts campus security to be close by at the designated time since that wasn’t emphasized nearly enough in the script otherwise).
• “Anticipate their reaction so you can prepare.” Having laid people off myself, I don’t think you can do this with any degree of accuracy. Most employees are initially stunned, so the idea is to get them off campus without a working access badge before their Kubler-Ross’s “denial” turns to “anger.” I’m surprised that the instructions advised making the appointment ahead of time since that’s a sure sign of impending trouble, although it’s also awkward to have a layoff when some of those affected are on PTO and thus likely to hear from co-workers or a telephoning manager that they are now unemployed. It’s also a good idea to tell the survivors not to let their former co-workers into the building.
• Coordinate with the co-worker who gets the fun job of marching the employee to the “offboarding support area” and then packing up their pitiful personal effects while they are getting the axe.
• Don’t tell people their job has been eliminated while they are at a client site or driving.
• Keep the conversation short, no more than 20 minutes, but book the room for 30-60 minutes so they can compose themselves without being kicked out of the room to make way for the next execution. 
• Have Kleenex on hand.
• Tell them not to return to the office, but advise them that they will remain an active employee through January 14, 2020.

HIStalk Announcements and Requests

The best lesson we can learn from the Ascension-Google controversy is that Americans are naive in thinking that HIPAA gives them broad privacy protection, so perhaps the shock – justified or not – that a company that most Americans know only for searching and serving ads is holding their medical data will open much-needed consumer privacy law discussion. Many people, even media types, seem shocked that HIPAA addresses only providers, or that they get a free pass under “treatment, payment, and operations.” I don’t question the data-sharing deal since it’s really not all that unusual other than consumers react more quickly when it’s Facebook or Google than if they found out that many, many other companies are sifting through their medical information, sometimes paying some other organization for the privilege. Bottom line – Ascension did nothing intentionally wrong, patient data is almost certainly safe, and both Ascension and Google now know they have a public trust issue that isn’t limited to just this tiny aspect of their businesses. I’m waiting to see if Ascension’s interest really is related to clinical outcomes rather than their own financial ones and whether anyone raises the issue of whether Ascension really has 50 million signed Notice of Privacy Practices forms on file (and whether those are valid if they were signed before Ascension acquired the original hospital). All this aside, the issue goes well beyond these two organizations.

Webinars

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

Acquisitions, Funding, Business, and Stock

NextGen will acquire patient intake, scheduling, and payment software company Medfusion for $43 million. Medfusion will spin off its data services business into a separate entity named Greenlight Health. Steven Malik sold Medfusion in 2010 to Intuit for $91 million, then reacquired it in 2013. He owns the North Carolina FC of United Soccer League and North Carolina Courage of National Women’s Soccer League and is working to build a $2 billion entertainment complex in Raleigh.

The planned merger of Sanford Health (SD) and UnityPoint Health (IA) to form one of the country’s largest health systems is called off, with Sanford’s CEO saying that UnityPoint Health’s executives “failed to embrace the vision.”

Sales

• St. Joseph’s/Candler will implement Tabula Rasa Healthcare’s DoseMeRx precision dosing software across its facilities in Savannah, GA.
• Willis-Knighton Health System (LA) selects Meditech Expanse.
• Humana, GuideWell, and Trusted Health Plan will use Healow Insights integrated services from EClinicalWorks for interoperability among their networks.

People

Surgical software vendor Provation Medical hires Daniel Hamburger, MBA, MS (Renaissance Learning) as CEO. He replaces Dave Del Toro, who will join the company’s executive board.

Jamie Trigg (Seattle Children’s) joins Virginia Mason Health System (WA) as CTO.

Announcements and Implementations

The St. Louis Children’s Hospital and Washington University Heart Center (MO) sends high-risk infant cardiac patients home with Locus Health’s remote monitoring app.

Best Buy ups its digital health offerings with the addition of TytoCare’s at-home medical exam device and companion app. The $300 device comes equipped with attachments that can be used during a telemedicine visit with partners from several health systems and telemedicine companies.

CHI Memorial Hospital (TN) implements Epic.

WellSky develops the WellSky IO interoperability framework to help post-acute and community providers connect to patient data exchanges.

The Michiana Health Information Network, Indiana Health Information Exchange, and HealthLinc will merge operations under the IHIE brand in January. IHIE executives believe the consolidation will create new value propositions and help scale services. IHIE has played around with several business models since launching in 2004, including its ThriveHDS clinical data repository services offshoot, which shut down after just nine months. The HIE’s CEO and COO presented “Said the HIE: ‘Reports of Our Death Are Greatly Exaggerated” at HIMSS earlier this year.

Amazon Web Services launches AWS Data Exchange, giving users the ability to find, subscribe to, and use third-party data in the cloud. Healthcare use cases include subscribing to aggregated data from historical clinical trials to accelerate research activities, and subscribing to aggregated and de-identified healthcare claims and transaction data to improve care delivery.

In Canada, Ontario health officials announce a Digital First for Health strategy that will aim to give patients the ability to book appointments online, access their medical records, and take advantage of more telemedicine services within the next three to four years. Providers will be given access to interoperable records, and enhanced data integration and predictive analytics.

A KLAS report on remote patient monitoring finds that nearly all users get measurable outcomes, but the market is changing to demand products that are patient-centric, that engage patients, and that offer patient-provider interaction, all using consumer-based rather than proprietary medical devices. Health Recovery Solutions and Vivify Health are leading the evolution, but the report’s conclusions are incomplete because several vendors refused to participate (Resideo, Care Innovations, Medtronic, and Philips).

Patient safety groups ECRI Institute and the Institute for Safe Medication Practices will merge, with ISMP becoming an ECRI Institute subsidiary.

Privacy and Security

I can’t tell if this is satire or serious: Google’s alleged whistleblower takes to The Guardian to outline why he or she felt compelled to share concerns about “the Nightingale Project” with, presumably, the Wall Street Journal: “After a while I reached a point that I suspect is familiar to most whistleblowers, where what I was witnessing was too important for me to remain silent. Two simple questions kept hounding me: did patients know about the transfer of their data to the tech giant? Should they be informed and given a chance to opt in or out? In short, patients and the public have a right to know what’s happening to their personal health information at every step along the way. To quote one of my role models, Luke Skywalker: ‘May the force be with you.’”

Health Care Cost Institute CEO and former CMS Chief Data Officer Niall Brennan tries to calm the masses.

Other

The American Medical Association co-sponsors a study that finds that perceived EHR usability is poor and contributes to physician burnout. The article is paywalled so I can see only the highlights (except for the graphic above, tweeted out by one of the authors), although I notice that response rates weren’t good. The authors conclude that EHRs scored an F with self-reported doctor scores in the bottom 9% across all industries and then correlated those scores to burnout. The correlation versus causation issue would lead me to question, do EHRs burn doctors out, or do burned-out doctors hate EHRs as a tangible manifestation of their unhappiness? Also, I’m not sure that it’s fair to compare an EHR to Amazon, a Google search, or a microwave oven, especially since those tools are voluntarily chosen for personal benefit. Doctors are frustrated with their EHR, but they’re also frustrated with nearly everything else about their jobs (and many of them must be frustrated with the AMA itself as well, given that only a fraction of US doctors are members, so maybe the EHR vendors should study that phenomenon).

STAT looks at the integral role remote healthcare coaches play in the success of headline-grabbing digital health companies like Omada Health, Livongo, and Fitbit. Omada Health CEO Sean Duffy admits that though he’s a big fan of tech, “It’s hard to recreate human accountability.”

Results of the Apple Heart Study are in, leaving researchers with several solid takeaways regarding the Apple Watch’s ability to alert users to abnormalities. The eight month study of 400,000 users – one of the largest of its kind – found that the device notified two thousand of an irregular pulse; 84% of which were found to have atrial fibrillation. Researchers concluded that passive monitoring can be beneficial, but more work needs to be done for the Watch to be truly useful in helping at-risk, rather than young and healthy, populations. Apple just launched a separate Research app to study heart, movement and hearing issues, and women’s health.

Sponsor Updates

• Apixio celebrates several milestones including its 10^th anniversary, adding 17 new provider and payer customers in 2019, and making Deloitte’s 2019 Technology Fast 500 list of fastest-growing companies in North America.
• Ellkay will exhibit at Momentum 2019 November 22-24 in Orlando.
• Ensocare will exhibit at the 2019 Leadership and Physician Advisor Conference November 15-17 in Miami.
• CarePort Health’s post-acute provider database and patient choice application, CarePort Guide, is now available in the Epic App Orchard marketplace.
• HealthCrowd will present at the Florida Association of Health Plans 2019 Connect Conference November 19 in Orlando.
• In Australia, Hyland integrates Medrefer’s referral technology with its OnBase enterprise information technology.
• InterSystems will exhibit at Healthcare Providers Transformation November 18-20 in Denver.
• Intelligent Medical Objects will exhibit at the AMIA 2019 Annual Symposium November 16-20 in Washington, DC.
• Kyruus CTO Chris Gervais will present at Salesforce’s DreamForce November 20 in San Francisco.
• AMIA inducts Clinical Architecture CIO Shaun Shakib into the 2020 Class of AMIA Fellows.
• Recondo Technology announces that bookings for its automation solution for prior authorization transactions has accelerated in 2019 to 60 health systems, most of them Epic users.
• ZDNet profiles Nuance.
• Health Catalyst appoints Julie Larson-Green (Qualtrics) and S. Dawn Smith (Cologix) to its Board of Directors.
• The Chartis Group publishes a new white paper, “Creating a Successful Physician Enterprise in Academic Health Systems.”

Blog Posts

• How to Improve Your Ob/Gyn with Your EHR (EClinicalWorks)
• How to Narrow Your Post-Acute Care Network – And Why It’s So Important (Ensocare)
• Honoring – and learning from – Google Cloud Veterans (Google Cloud)
• Health IT leaders answer: What makes a successful Community Connect program? (Nordic)
• Harnessing the Power of Chronic Care Management (Greenway Health)
• Anatomy of a Great Prescription Renewal Protocol (Healthfinch)
• 10 ways Hyland Healthcare shined at #CommunityLive (Hyland)
• Interoperability Proposals Push HIEs to Focus on Data Quality (Imat Solutions)
• Meditech Celebrates Digital Health Week in Canada (Meditech)
• Post-Acute Providers Predict Probable Insolvencies Under Value-Based Care Without Basic IT, Data Sharing, and Care Coordination (Black Book Market Research)

Contacts

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

EPtalk by Dr. Jayne 11/14/19

Many EHR aficionados view discrete data as the holy grail of information, but a recent article in the Journal of the American Medical Informatics Association looked specifically at data from unstructured clinical notes. The authors found that such “real world data” was more accurate for use with algorithms to predict coronary artery disease when compared to structured data.

The study looked at data from a six-year time span, gathering a specified set of clinical concepts through structured data gathered from standard query techniques as well as AI-driven analysis of unstructured data. The authors used data from over 10,000 clinical notes and looked at language around existing coronary artery disease, diabetes, and other clinical predictors of coronary artery disease. Food for thought for all those folks who are uncertain about the role that narrative documentation may continue to play as we move forward.

I was glad to see a recent ONC blog that noted that nearly one-third of hospitals can access prescription drug monitoring program (PDMP) data from within the EHR. However, it seems like that number should be much higher if we really want to move the needle on inappropriate prescribing of opioids. If providers aren’t viewing data from within the EHR, that means they have to access a separate system, which in itself adds a barrier to use. The piece didn’t mention rates of integration for ambulatory EHRs, which is where a lot of opioid prescribing happens.

Nearly all states have PDMP registries, with only Missouri lagging behind. (Interestingly, that state was one of the last to have a statewide immunization registry, which makes it look a bit like public health isn’t a priority for the legislators.)  I rarely prescribe opioids, and when I do, it’s usually for 10 or fewer pills, but I still access the PDMP whenever my suspicions are raised about a particular patient. Usually the PDMP confirms my impression, leading to a very direct conversation with the patient.

This hit my radar at the same time as a communication from the American Academy of Family Physicians about its recent vaccine-themed letter to the US Department of Health and Human Services. The letter urges that EHR vendors not create financial burdens for physicians trying to connect to state immunization registries and called on HHS to “hold information technology vendors accountable for creating a national standardized, easily accessible, accurate, robust immunization information system.” It also called for universal payments for vaccinations, which makes sense after my recent experience which I’ll call “A Tale of Two Vaccines.”

One member of my family received their vaccination at their primary physician office. The explanation of benefits statement lists a charge, an adjustment, a payment to the physician, and a patient responsibility of zero since the entire amount was applied to “well care.” I received my vaccination at my clinical employer. Although it’s required as a condition of employment, they bill it to insurance and then absorb any non-covered portion. My explanation of benefits lists a charge, an adjustment, and no payment to the physician since the place of service was “urgent care” and the entire amount was applied to my deductible. If I hadn’t been an employee, I would have paid the entire cost.

Insurance companies should either pay for a vaccine or not, regardless of the place of service, as long as the same CPT codes are being used for billing. Hundreds of patients receive their vaccines from my clinic because we’re fast, friendly, and accessible. I hope they’re not receiving the same rude billing surprises that I did.

I’m skeptical about a new Facebook Preventive Health tool that is supposed to help empower people to seek out vaccines and other preventive services. They plan to use age and gender to identify target populations. My first concern at reading that is that perhaps they don’t understand the difference between sex and gender and how those contribute to the equation. Hopefully that was a lapse on the reporter’s part, since the official Facebook web page notes age and sex as the demographics it’s monitoring.

The official page also notes that it is referring patients to Federally Qualified Health Centers with its “find locations near me” for patients to get checkups and to the HealthMap Vaccine Finder for vaccines. It goes on to say that it “doesn’t verify locations on these lists and the lists may have inaccuracies.”

The feature is available only on the mobile Facebook app and doesn’t give specific sources for all of its recommendations. It did say that a mammogram was recommended for my age and sex and it should be yearly, citing the American Cancer Society as the source. There was no readily visible source for flu vaccination, blood pressure testing, diabetes screening, cholesterol screening, or cervical cancer screening, although they could be found by selecting a details arrow.

It also recommended I have an annual stool blood test for colorectal cancer screening, which is not in harmony with the US Preventive Services Task Force recommendations for my sub-50 age group. It went on to say that “test kits are free with most insurance plans” and I can guarantee that it is not free with my insurance, which covers only what is recommended by the USPSFT. The American Cancer Society (which Facebook cites as its colorectal cancer screening reference) even says clearly that insurers are not required to cover screening for individuals under 50 years of age. Those kinds of discussions will not be enjoyed by physicians when patients roll in with “authoritative” information from Facebook.

The Federal Communications Commission’s Intergovernmental Advisory Committee issued a recommendation last week regarding “State, Local, Tribal, and Territorial Regulatory and Other Barriers and Incentives to Telemedicine.” Not surprisingly, the major issues they cite include broadband access and a patchwork of laws and regulations that impede adoption. Looking at the broadband issue, redundancy is an issue for facility-based telehealth programs.

The report recommends that live video with appropriate image and audio quality be available so providers can accurately assess patients, adding that access to the full patient chart is desirable. They didn’t give much attention to consumer-facing telehealth. They note six policy areas where work needs to happen from a regulatory perspective: reimbursement, licensing, health information exchanges, insurance parity and malpractice overage, privacy-information sharing and HIPAA, and also being able to establish a doctor-patient relationship based on telehealth.

Email Dr. Jayne.

Morning Headlines 11/14/19

HHS to probe whether Google’s ‘Project Nightingale’ followed federal privacy law

The HHS Office for Civil Rights will look into the HIPAA compliance of Google’s data-gathering arrangement with Ascension.

Indiana HIEs Unify to Better Meet the Needs of the State’s Healthcare Community

The Michiana Health Information Network, Indiana Health Information Exchange, and HealthLinc will merge operations in January.

Steve Malik sells Cary firm Medfusion to California firm for $43M

NextGen will acquire patient intake, scheduling, and payment software company Medfusion for $43 million.

Morning Headlines 11/13/19

Cerner lays off 131, but its hiring tops 4,000 in 2019

Cerner lays off 131 employees in a second round of cost-cutting in nearly as many months.

Apervita Secures $22 Million Investment to Fuel Future Growth

Value-based care clinical quality platform vendor Apervita raises $22 million from an incremental investment.

Premier Inc. Forms Contigo Health™ to Help Health Systems and Employers Work Better, Together

Premier launches Contigo Health, a network of member health systems that will use EHR-integrated, evidence-based clinical decision support to optimize care for the employees of its employer members.

UST Global Acquires Contineo Health, a Leading Healthcare Technology Consulting Firm Specializing in EHR Optimization

IT solutions company UST Global acquires EHR optimization vendor Contineo Health to strengthen its appeal to providers and payers.

Health Catalyst Reports Third Quarter 2019 Results

Health Catalyst reports Q3 results: revenue up 20%, with full-year revenue expected to be between $151 million and $154 million.

News 11/13/19

Top News

Google announces Project Nightingale, a partnership with 150-hospital Ascension in which the company will gain access to the identifiable data of potentially all of Ascension’s patients to apply predictive analytics for patient care.

Business Insider reports that the information of 20 million patients has been uploaded to the cloud, with that of another 30 million patients scheduled for transfer in February.

The Wall Street Journal says the data being shared is not de-identified and is essentially the patient’s entire record. It also notes that at least 150 Google employees have access to the data.

The organizations are testing EHR search software and tools that present EHR data graphically to clinicians.

Ascension’s patients and doctors were not notified of the project, except for the 2,000 doctors and nurses who are testing the EHR search function.

Ascension says the deal meets HIPAA requirements because Google has signed a Business Associate Agreement.

Quoted in the announcement was Ascension EVP / Chief Strategy and Innovation Officer Eduardo Conrado, who spent 26 years as a Motorola IT and marketing executive and four years as an Ascension board member before joining the health system’s executive team in September 2018.

Reader Comments

From Laid Off and Up: ”Re: recent layoffs. Why do companies fail to understand how bad they look laying off employees in November and December?” I assume that unrestrained desperation to make Excel cells jump forcibly through hoops to earn a bean counter hurrah outweighs the justified black eye that results from showing previously valued “associates” the door during the two-month holiday window. It’s never a great time to lose your job, but prospects are dim until after New Year’s, long nights invite depressing self-analysis, and it’s an unenviable acting job trying to appear upbeat along with holiday-spirited family and friends. Layoffs are a management failure, but November and December cutbacks suggest a higher level of knee-jerk incompetence. I’ll offer my advice from having served on both sides of the forced march out the door — you don’t want to work for a company that conducts regular layoffs anyway, so they’re doing you a favor by forcing you to choose a better employer.

HIStalk Announcements and Requests

I’m excited that my pre-ordered copy of “Man’s 4th Best Hospital” by Samuel Shem was deposited into my Kindle library upon its release today. I expect that will be the subject of my next book review. Meanwhile, if you think I should read a particular book and report on it, let me know.

Webinars

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

Acquisitions, Funding, Business, and Stock

Cerner lays off 131 employees in its latest round of cost-cutting. 

Value-based care clinical quality platform vendor Apervita raises $22 million from an incremental investment.

Premier launches Contigo Health, a network of member health systems that will use EHR-integrated, evidence-based clinical decision support to optimize care for employees of its employer members. It will also identify available employer health and wellness programs. Premier acquired evidence-based clinical decision support vendor Stanson Health a year ago for $51.5 million, which I would guess forms a key part of this offering. This announcement is a pretty big deal – as big tech companies start trying to figure out this maddeningly complex market, publicly traded Premier knows it inside and out (supply chain, quality improvement, analytics, technology, clinical delivery, etc.) and has now, via Contigo Health, formed relationships with 35 health systems representing 440 hospitals as well as several national employers to address cost and quality issues (also note that health systems are longstanding Premier member-owners). I wrote here several years ago that Premier was the company to watch in terms of disruption and execution and this announcement doesn’t throw water on that prediction. If I were Google or Amazon and was anxious to get a healthcare foothold… well, let’s leave it at that.

Sales

• Mercy will implement Bright.md’s asynchronous virtual care platform to provide online triage, diagnosis, and treatment for patients at any location at any time.
• In Northern Mariana Islands, Commonwealth Healthcare Corporation will upgrade its Medsphere legacy system to CareVue EHR and revenue cycle.

People

Jon Zimmerman (Athenahealth) joins Holon Solutions as CEO.

Datica CTO Travis Good, MD will leave the company’s management team. He will remain a Datica board member and is starting a new venture that is focused on personal data and privacy

Announcements and Implementations

Cricket Health Chief Product Officer Geoffrey Clapp builds VA Care Finder, a free Amazon Alexa skill that allows veterans to provide an address and to be given the closest three VA locations by driving distance (including traffic conditions), powered by the VA’s Facility API. The screenshot above is from an Echo Show device. He’s working on enhancements to use Alexa’s default home location, answer questions about specific facility hours or address, and answer questions about service lines, such as mental health, rather than all locations. Alexa’s limitations don’t allow him to link to external services or to use mapping tools. He’s hoping to explore the VA’s many other APIs to see if appointment scheduling is a possibility. He concludes in his Veterans Day post,

With these APIs — and there is much, much more than just the facilities subset API that I’ve exposed here — the developer community can now get access to data we only dreamed about back in the highly-mentally-scarring VistA integration days of yore. The fact that nearly all the data that is available to internal development teams at the VA or USDS is also available to every hacker, startup, and BigCo means we can do what APIs are meant to — OPEN THE DATA — and build stuff no one ever thought of (or, thought of but didn’t have the budget for…I see you, VA) and there are few populations as deserving of innovation as our Veterans.

A Black Book survey of health information management professionals finds that 93% are optimistic that AI can streamline document creation and capture a holistic patient history to improve outcomes and revenue integrity.

Prepared Health develops an API that users FHIR 4.0 to connect home care agencies and other providers to health plans and hospitals for referrals, care management, and billing.

Government and Politics

Politico reports that CMS Administrator Seema Verma signed a $2.25 million government contract to hire at least 40 consultants to polish her personal brand, several of them former Trump campaign workers who billed taxpayers up to $380 per hour to perform tasks that have always been managed by CMS’s civil servants. HHS cancelled the contract in April 2019 after Politico reported on it, but at least $744,000 had already been spent.

Other

In Israel, Sheba Medical Center says it will create “the first fully VR-based hospital.” That’s certainly a press release stretch, unless the hospital plans to sell off all those buildings in the photo above and instead pass out VR headsets to patients. They calmed down a little further down the page, specifically listing that the hospital will use virtual reality for therapy services and education.

The non-profit Health Care Cost Institute gains access to de-identified Blue Cross Blue Shield claims in a multi-year partnership agreement. UnitedHealthcare stopped sharing its claims data with the group earlier this year, citing privacy concerns about HCCI, which is a non-profit competitor to its claims data-selling Optum subsidiary.

The Environmental Protection agency is proposing to ignore the conclusions of academic studies in its rulemaking unless the authors submit all raw data, including any patient medical records that were reviewed, for public inspection. EPA says outsiders should be able to independently review all study data to verify the conclusions of the researchers. The measure would make it more difficult to pass new environmental laws because the personal health information that was involved is often collected under confidentiality agreements. EPA’s proposed standard would exceed those for published medical studies, which do not require investigators to submit raw data.

A newspaper in India interviews Viren Prasad Shetty, the COO of India-based Narayana Health, which plans to expand from its 30 hospitals and 6,000 beds to 30,000 beds. Interesting points:

• The company plans to create a virtual health network that involves apps rather than buildings in an Uber-like model that will allow it to grow more quickly at a lower cost.
• He says India’s plan to add a new medical school in every three districts of India isn’t adequate because many of the graduates leave the country, noting that the US has more India-graduated nephrologists than India itself.
• He predicts that “the biggest export-earning industry of this country will be our manpower,” specifically medical caregivers as declining populations leave Western countries with no one to care for their senior citizens.
• Narayana’s 20% annual growth in cancer services eclipses that of its primary focus of cardiac services, so “we will want to convert all our hospitals into cancer hospitals.”
• He says the company’s strength is that is led by a core group of doctors – including cardiac surgeon and CEO Devi Shetty, MBBS – instead of business executives, which makes it attractive to doctors.

A man who expected his hernia repair to cost around $10,000 is shocked at the for-profit hospital’s $116,000 bill for the 91-minute outpatient procedure, including $1,700 for a pair of scissors. He had passed on buying real health insurance and instead enrolled in a health-sharing ministry that pools medical bills among self-pay patients outside the purview of insurance regulations. He was approved for up to $50,000, but inadvertently chose the most-expensive area hospital and didn’t realize that patients who are covered by health-sharing ministries are billed at the same rate as uninsured or cash-paying patient without the benefit of heavy insurer-negotiated hospital discounts. The hospital refuses to budge on the $67,000 balance he owes. He’s demanding that Virginia’s consumer protection office force the hospital to write off his balance, but an attorney with Virginia Poverty Law Center says the hospital will probably just sell off his debt to a collection agency for 10 cents on the dollar. 

An American Osteopathic Association survey finds that 75% of Americans feel lonely. My free advice – forget your pretend friends on Facebook and make an effort to interact with actual human beings instead of accidentally trampling them on the sidewalk while staring down in wonderment at your phone’s compelling but imaginary world. The most provocative art I’ve seen recently is by photographer Eric Pickersgill (above), who showed what real life would look like once the “small, cold, illuminated devices” of social media addiction are removed. He describes it as: “This phantom limb is used as a way of signaling busyness and unapproachability to strangers while existing as an addictive force that promotes the splitting of attention between those who are physically with you and those who are not.”

Sponsor Updates

• Apixio will exhibit at the Rise Annual Risk Adjustment Forum November 12-14 in Scottsdale, AZ.
• Clinical Architecture will exhibit at AMIA November 16-20 in Washington, DC.
• Diameter Health will exhibit at the Advent HEDIS 2020 Client Conference November 19 in Scottsdale, AZ.

Blog Posts

• Give your practice the financial breathing room it needs (AdvancedMD)
• You don’t have to list your negotiated rates (yet): Our 3 key takeaways from the HOPPS final rule (Advisory Board)
• Better. Faster. More Efficient. (Agfa Healthcare)
• Keys to a Successful Laboratory System Implementation (Optimum Healthcare IT)
• Analytics for Whole-Person Care: The Rise of the Connected Behavioral Health Network (Arcadia)
• HIPAA Security Rule Checklist: What is the HIPAA Security Rule? (Atlantic.Net)
• The State of AI in 2020: 35 Stats You Need to Know (Avaya)
• HIPAA vs. HITRUST (Datica)
• 6 Reasons to Initiate a Network Assessment Now (Burwood Group)
• nteroperability: Why It Matters So Much to the Current and Future State of Healthcare (ChartLogic)
• Basic Principles That Could Transform Your Practice (EClinicalWorks)
• Recap: ACEP19 Focused Heavily on Workplace Violence (Collective Medical)
• Why a Manufacturer Cash-Price Program Can Be a Better Option for Patients Purchasing Prescriptions (CoverMyMeds)

Contacts

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

Morning Headlines 11/12/19

Our partnership with Ascension

Google clarifies its HIPAA-compliant work with multi-state Ascension after multiple media outlets report that its employees have questionable access to millions of medical records through a secret data-sharing project dubbed “Project Nightingale.”

KKR Makes Formal Approach to Walgreens Boots on Record Buyout

Walgreens shares rise on the news that New York City-based private equity firm KKR has submitted a proposal to take the company private.

Healthcare Leader Jon Zimmerman Named CEO at Holon Solutions

Former Virence Health President Jon Zimmerman joins Holon Solutions as CEO.

Access Physicians Receives Investment to Expand National Acute Care Delivery via Telemedicine

Acute care-focused telemedicine vendor Access Physicians raises $9.3 million in a Series A funding round.

Curbside Consult with Dr. Jayne 11/11/19

My recent conversation with a local university student about how the US looks at public health efforts got me interested into digging in a little more into a local health system’s work to address social determinants of health. I reached out to a former colleague who is now in a leadership role. He asked to remain off the record, since not all of his views fully align with what he is working on as part of the health system’s efforts. I totally understand having to stay off the radar to keep your job, so I was happy to oblige.

One of the major pushes of the health system has been expanding access to care, whether it’s with a mobile unit to visit areas that don’t have providers or whether it’s creation of school-based clinics. They are finding that even those approaches sometimes aren’t enough.

One of the areas where they set up a school-based clinic has a high absenteeism rate, with girls posting higher numbers than boys. Digging deeper, they found that teen girls sometimes aren’t in school due to lack of access to menstrual products. As someone who has worked with a church group to sew reusable menstrual pad kits for girls in developing nations, this doesn’t seem like something we should be seeing in the US. The clinic set out to solicit donations for menstrual products, and guess what? The absentee numbers went down. It’s a great example of how we need to really understand all the factors that are driving health, education, and wellness.

This approach may resonate with practices who help care for high-risk patients by providing transportation or assist with obtaining housing or groceries. If patients aren’t able to meet their most basic needs, they’re not going to be focused on things higher up the hierarchy, like healthcare and medication.

My colleague said this approach is something he actually struggles with philosophically. Some programs focus on those individual social needs, but don’t look at how you need to go about improving the underlying social and economic situation in communities as a whole. The individually-focused interventions are cheaper than delivering more intense medical interventions for sure, but they don’t assist people who haven’t become patients yet or who aren’t in the healthcare system.

He recounted a recent meeting among community health stakeholders, where they spent nearly two hours debating and defining what they mean when they say “social determinants of health.” The phrase was being thrown around and meant different things to different people, and they felt it was important to get everyone on the same page.

Although I don’t doubt that it was probably a painful meeting, it sounds like it was necessary. As he was telling me the story, it reminded me about how people throw around “pop health” and “population health management” and various permutations that may not mean the same thing depending on who is using the phrases and where they’re coming from.

During one of their community-focused initiatives, they actually had quite a bit of resistance from a small segment of community members. Some felt that the hospital’s participation was a way of trying to “medicalize” issues that community activists want to have a much more social and/or services focus. Instead of heaving the health system lead the charge, they want to see it led by community centers, faith-based organizations, and other community-led groups.

In addition to concerns about medicalization, there were also concerns about the hospital staffers not reflecting the community demographic and the optics of having a primarily Caucasian outreach team working with a community whose makeup is predominantly African-American. That’s something that isn’t always thought about, but may certainly be part of how interventions are received.

Patients and community leaders are also skeptical about value-based care. Some see it as rationing by another name, especially when it’s being primarily led by the medical establishment. Others see it as a way for conglomerate health systems to increase their dominance, which can lead to the erosion of community-focused health services.

My colleague mentioned that he struggles a bit going back and forth between the community outreach projects and the health system’s flagship hospital, where he has an office. The hospital’s lobby looks more like a high-end hotel than a healthcare establishment, and executives regularly divvy up the organization’s luxury box tickets for events at the local stadium. When he sees what might be considered excesses, he immediately thinks of how many social services could be delivered using the money spent.

He also has a hard time wrapping his head around the half billion dollars that has been spent on a recent EHR implementation and associated consulting services when his repeated requests to add a social worker to his team have been rejected. He notes that the EHR project hasn’t been all bad since it has made it easier to obtain and use data about different outreach projects they’ve been doing. It’s been useful for clinical reminders and identifying gaps in care to try to optimize health for individual patients. They’ve also been able to use address data to refine locations for community-based health screenings and vaccination clinics. He notes that has been easier since his request for a 0.5 FTE data analyst position was approved.

Apparently there are some ongoing tensions with the local public health organizations, who feel that competing health systems are more about bringing attention to their facilities than about advocating for essential public health needs such as sanitation, preventive services, and immunizations. The health system is having a retreat in a couple of months to talk about its community health efforts and it will be interesting to check in with him and see if there are any major changes to strategic direction or if the plans remain status quo.

I wonder what that retreat would look like if they invited public health leaders, or better yet, also included representatives from the other major healthcare players in town? Maybe that could lead to a more coordinated effort, but I’m just hypothesizing. I wish there were words to describe the eye-roll that resulted when I made that suggestion.

On a side note, I wanted to say thank you to all our readers who are veterans and also to their families and loved ones. We appreciate your service and your sacrifice.

How does your organization integrate with the local public health infrastructure? Is it working, or are there suggestions you would offer? Leave a comment or email me.

Email Dr. Jayne.

HIStalk Interviews Bob Segert, CEO, Athenahealth

Bob Segert is chairman and CEO of Athenahealth of Watertown, MA.

Tell me about yourself and the company.

I’ve been a serial CEO. I have been working in the private equity space for the last 11 or 12 years. This is the fourth company that I have had the privilege to run as CEO. I’ve been largely focused on software and services. This is my first foray into healthcare.

Athenahealth is going through an interesting and fruitful transformation from being publicly held to privately held. This is providing significant opportunity for us to rethink some of the old paradigms and the ways we thought about the business. This allows us to reposition ourselves to ignite against our new vision, which is to create a thriving ecosystem that delivers accessible, high quality, and sustainable healthcare for all.

What do you bring to the table as someone with no healthcare experience?

The real advantage I have is that I can ask all the silly questions and not feel like I should already know the answer. That allows me to get to first principles.

We are all users of healthcare, so we’re all somewhat familiar with some of it, but it’s cursory knowledge. You understand some of the steps. That at least allows you to focus in and have an objective view on the data that you hear.

The value that I bring to this enterprise is that I’ve been a longtime software and services exec and I’ve been in a lot of different industries across the United States and internationally. That allows me to think about this platform business and the apps that we have a different way.

I think about Athenahealth as being a technology company that provides solutions that help doctors be more efficient and effective in what they do. But the underlying core assets that we need to continue to improve and drive value with are, fundamentally, software and services assets. That’s where my strength and background has been in for the last 20-25 years.

What opportunities do you see with the Athenahealth network that connects hundreds of thousands of users on a single platform?

It’s the most powerful asset that Athena has. We believe in an open ecosystem. That’s why our new vision is about creating that thriving ecosystem.

Ecosystems must be dense, resilient, utilized, and open. Think about Athena in that context. We are the only platform out there that has that type of capability. We are fundamentally a SaaS-based application. All our customers are on the same code. We don’t have versions of the code. We update our software every night. Everyone gets it. You don’t have to reinstall it. If you want to get a new code, just refresh your browser and it’s there.

This allows us to powerfully change our rules and change our workflows to be more reactive to changes in the healthcare system and ways to make things better. We don’t have to wait for the next release a year from then. We don’t have to wait another three years for our customer base to adopt it.

The other thing that we’ve invested in, which is an amazing asset, is the data lake. We’ve abstracted all data out of our relational tablespaces that we have for each of our customers into a data lake. We have a full API gateway that is opened up to that. With permission, any person can get into that network of data and provide additional services, whether that’s the hospital system or ambulatory system on their own or whether that’s a third-party provider that has authorization from that practice to access their data. They can now access that seamlessly through the data lake.

Our real advantage comes from the scale of that network and the openness of that network. We have 160,000 providers that are part of our company today. We process over 10 billion transactions every year. It’s a massively scaled platform, open at its core, that fundamentally will continue to be a vanguard and leader in interoperability. Healthcare needs platforms that break down the silos, the information asymmetries, and the incentive asymmetries to enable a fragmented system to thrive.

How does Athenahealth work with vendors that don’t sell EHRs but offer add-on or complimentary products?

We have the Athena Marketplace, with almost 300 partners. Frankly, I think we have underutilized the benefit and the potential of that. I’d like to see 2,500 to 3,000 partners in our marketplace.

We want to make our network open and extensible. We will let anybody come and play in that network and add value to our customers. We think it also adds value to the healthcare system. We think it drives better outcomes, whether it be accessibility, quality, or sustainability.

We are very open to driving that open marketplace and we will continue to invest in that. That’s a key part of our strategy as we think about the business going forward.

We are also committed to driving interoperable solutions at an experiential level, at a physician level. One patient, one chart. The ability to schedule and refer across ambulatory and acute care settings. We want to be able to do that with every single EHR out there that’s willing to connect with us.

Our goal is not to hoard relationships or try to be a closed system. Our goal is to enable better healthcare outcomes. If we can do that, we will prosper, and the American public will benefit.

Do you see a role in helping those companies develop a business?

We have done that in several cases, where we have worked with small businesses that are exclusive partners to Athena to help them gain traction with our customer base. We’ve provided lead referrals. We’ve provided free office space in our main headquarters building in Watertown so people can develop their products and solutions. We’ve been a big proponent of trying to help our partners be successful.

I think we have a lot more that we can do. There are investments we want to make in marketing and onboarding and enablement that will allow us to treat that with a channel support-type mindset so that we can enable the success of those partners.

Of course, there are always opportunities for us to have a broader relationship with the companies that really take off and are doing well within our customer base, for us to have a broader relationship with them. That could be a joint venture, a minority interest investment, or even ultimately an acquisition by Athena.

What is your relationship with Walmart and their use of Athenahealth systems in their Walmart Health pilot in Georgia?

We are doing work with Walmart. We see that as a significant opportunity for us as we move forward. It’s a pilot program right now, but we see that hopefully being able to expand to many more sites over the coming months. We have a lot of other programs in the retail space that will be similar. We think it will be a big growth area for us going forward.

We are seeing demand there because of our SaaS-based platform. People who are trying to use cloud-based technology, SaaS-based technology, to enable outcomes naturally gravitate towards the type of platform that we have. It is dynamic, flexible, configurable, and adaptable.

Competing vendors seem to be addressing a mature EHR market by either expanding into areas that haven’t been big EHR users or cultivating relationships with pharma. Are either of these areas attractive?

We’re not focused on the pharma space. That’s not where our strategic intent lies. You’re not going to see us pivoting into pharma, either from a data standpoint or a broader services standpoint.

Where you will see us focused is on alternative sites of care. You’ll see us increasingly in employer clinics, retail clinics, the ER, and eventually in virtual medicine and telemedicine in the home. We want to be able to meet our patients where they are and help our physicians create a seamless, end-to-end experience across the care continuum as we expand our service offerings and our capabilities in those spaces.

But fundamentally, where you’ll see us double down is investing in our fundamental clinical workflows at the front door of medicine. Peds, OB-GYN, internists, primary care physicians — that’s where we are going to focus. We’re going to focus a lot of dollars on improving that EHR, improving those workflows, and then enabling the exposure of data to help them close care gaps in real time, when the patient is in front of the doctor. That is the key thing that we think we can drive in the industry that others have a hard time matching.

It was a seemingly odd mash-up of cultures to combine the old Athenahealth with the GE business to form the new Athenahealth. How would you characterize the company’s focus and culture now compared to what it was in those previous companies?

I would say it’s evolving. We are leveraging some of the best traits of both businesses.

In Virence, the old GE Centricity business, you had some long-tenured, expert capabilities — specialty workflow experts, anesthesiology, cardiology. You have hospital-related capabilities and RCM. GE had discipline, while Athena was traditionally more freewheeling, with an entrepreneurial, founder-led culture and all those elements that has made Athena such an amazing place to work.

You take that additional expertise and specialty workflow capability and pair that with that front door capabilities that Athena had, where because of its SaaS-based platform, it could succeed with one- and two- doctor practices, because that the delivery model makes so much sense for them, whereas premise-based software doesn’t. It’s a nice mash-up between the two.

We are right in the middle of it since it has been around nine months since the transaction closed. The cultures are coming together nicely and it’s going to continue to evolve over time. You don’t move cultures quickly — cultures evolve. We’re committed to taking the best of both and bringing them together to be even a more dynamic and exciting place to work.

Athenahealth seemed to struggle in its final publicly traded days with a post-Meaningful Use mature market. How does that affect your business strategy?

There’s no doubt that Meaningful Use, the emergence of EHRs, and the incentive to adopt EHRs floated all boats. A lot of companies sprung up because of that. As the Meaningful Use hurdles get higher and higher each year and certification become more and more difficult, I think you’re going to see increasing pressure on some of the smaller EHRs that may not have the engineering wherewithal and financial background to be able to survive.

It is a replacement market. It’s going to be a consolidating market. You’ll see some of the smaller players thrive less than they did in the past. Some specialized small players will continue to do extremely well and grow based upon a focused strategy. You’re going to see some of the bigger players like Athena working to differentiate ourselves in the marketplace, trying to gain relative share as these opportunities come up for replacement.

My view, and what I’ve seen since being inside the tent, is that we have amazing products that people really, really love. We’re not perfect, but people love these products. When we get into a demo environment, when we get a chance to get in with the physicians and show them what Athena can do, we win more times than we lose.

Our big challenge right now is how to get market awareness of the brand, what we’re doing and the favorability around the brand, and to get more at-bats. We know when we get in the batter’s box, we tend to get a base hit or more.

Is it difficult to get the attention of those small practices cost-effectively to earn a sale?

I don’t know if difficult is the right word. Each market segment has a different set of tactics that you need to employ. Small groups, those practices with six doctors or fewer, make up a different market mix. It’s a lot more online advertising. It’s business development resources that are calling and trying to reach doctors and try to set up meetings.

It’s very fast deal cycle. You set up a meeting, have a phone call, set up a meeting two weeks later, and go do a demo. Two weeks after that, you have a signed contract. You literally need two weeks to 30 days to sign a contract. It’s more of a flow business. You must have the resources upfront to canvas the marketplace to make those phone calls. That must be supported with good marketing campaigns that are focused, with real content and intellectual property that gets the doctors to step up and notice.

In our major cities, we just launched the “State of the Smart” campaign. You’ll see a lot of out of home advertising. We just had a full page in the Boston Globe on Sunday. We’ll have another one coming up. You’ll see a lot more Internet-based advertising and print advertising as we continue to position our brand out in the marketplace.

Enterprise is a little bit different. Sales cycles are longer and it’s more of a direct sales relationship sale. But we have a strong engine. I would say almost 40% of our bookings are coming in the small group space. We see that as being increasingly an area of strength for us as we move forward.

Who are your most significant competitors, taking into account the spread of Cerner and Epic into smaller practices and Allscripts saying it will develop a new EHR?

It’s a very competitive market. We compete with all the major players. We compete with all the specialty EHRs when it comes to some specialty practices. We compete on a broader outsourcing model with the companies that are providing broader RCM solutions. It’s a dynamic marketplace for sure.

Everyone is focused on trying to create value for customers. We’re no different. We believe that our core advantage sits around our expertise, the type of people that we have. It sits around our platform and the open interconnectedness into it. It sits around our ability to drive value from data analytics and benchmarking from the real-time execution of our processes. That enables us to differentiate ourselves in the marketplace vis-a-vis some of those other competitors.

Hospital consolidation will continue, there’s no doubt. Hospital bed stays are going down. More and more procedures are moving into the ambulatory care setting. Clinical advances, along with patient experience and preferences, are driving that. We are going to continue to see a robust and valid market in our core segment of ambulatory care. Even if there is some additional hospital consolidation, it’s not going to take the lion’s share of the market. There’s plenty of room for us to continue to grow and thrive.

Are you still planning to release an inpatient hospital system?

We had developed an inpatient EHR platform and sold it to several customers. We will continue to maintain that platform, the rules engine, and certification. We are not actively selling that in the marketplace today. We are redirecting our full focus into core clinical workflows, rev cycle, and the ambulatory care market. But just to be really clear, we will continue to support that hospital product.

We are also strong in hospitals with our Centricity assets. If you look at Virence and the Centricity Business platform, it has a world-class central billing office capability that cuts across both the acute and ambulatory care settings. It is focused on large IDNs and research hospitals. It is one of the gold standard rev cycle products out there in the market today. We are fully committed to Centricity Business. We will continue to invest in that and we see that as being a long-term part of the Athena portfolio going forward.

What about Epocrates?

Epocrates is a part of our business. It’s a relatively small portion of the company today. We see additional opportunity in Epocrates. We believe that there’s more that can be done, more that can be leveraged as we think about how to extend the value of that platform to physicians.

We know that the people who use Epocrates love Epocrates. It’s got a very good brand reputation. We see people using the product and it influences their drug prescribing decisions. It has value in the market. We see that as an asset that can be further invested in and leveraged. Epocrates is part of our family. It’s a smaller part of our family, but we believe there are opportunities there.

Private equity acquisitions often involve cutting costs and selling off non-core businesses to boost profit, then flipping the company or going public three or four years later. How do you see Athenahealth’s future given your background working with companies that grew in different ways?

The right mindset to have with private equity is that they are equity investors. Whether it’s private or whether it’s public equity, equity value and firm value magnifies itself with growth. Every great private equity investor is trying to drive growth. Our investors are no different. This is not about us trying to maximize and take every cost dollar out of the system we can.

We have seen things that we think can be done better. We can be more efficient. We can reprioritize some of our assets and investments outside of areas where we were investing and reprioritize those in other areas. Private equity has a specific focus on value levers and how you drive value creation.

That’s the way you should think about our owners, as being people who want to invest in the business. We made a big, one-time investment in technical debt to improve the platform so that we have a more solid foundation to continue to innovate on. They are very focused on us driving growth. They are very focused on us being innovative.

They have been great partners in the process, and they’re all about creating a great company. They are not about squeezing every last nickel out of the business, because that’s not the way you create long-term value. It needs to be a sustainable enterprise.

My experience with private equity has not been about crash and burn. It’s been about focus, re-prioritizing investment on the things that drive the highest level of growth, and creating the most value for customers. If you create the most value for your customers, then you get to take some of that value yourself.

Do you have any final thoughts?

Athenahealth is an amazing company. It has an amazing heritage. It’s a business that has the right to succeed and the right to thrive. We have a set of unparalleled assets in our employees, our customers, and importantly, the platform and the ecosystem we’ve built. We now have a leadership team in place, a team that’s behind us, and investors who are focused that will allow us to make the smart investments that we need to make to reposition the business for long-term growth and prosperity. That will benefit all the physicians in the United States and the entire system as we create a thriving ecosystem that delivers accessible, high quality, and sustainable healthcare for all.

Book Review: It Shouldn’t Be This Hard to Serve Your Country

David Shulkin, MD, the ninth Secretary of Veterans Affairs, is the latest in the seemingly endless cavalcade of fired President Trump appointees whose tell-all books profitably pay penance for their participation in a divisive administration. The cash registers of websites, TV networks, newspapers, and booksellers everywhere can’t stop ringing from peddling controversy from both sides of the fence.  

I wasn’t going to read “It Shouldn’t Be This Hard to Serve Your Country,” to be honest. I’m wary of whitewashed stories told by humiliated former government officials and politicians who decide to bare their souls in a safe environment where only their own uncontested voice is heard. My experience with that kind of book is that the authors always claim to be misunderstood, selfless saints who just want to set the record straight in clearing their good name (as well as the path to future beneficial endeavors). An HIStalk reader sent me an Amazon gift card to cover the book’s cost and said he wanted to hear my take on it, so that guilted me into buying the Kindle version.

It’s a great title, by the way, referring to both veterans and to the author himself.

Shulkin is an internist who didn’t serve in the military, although much of his family did. He served in several medical school roles, was chief medical officer in an academic medical center, was president and CEO of Mount Sinai’s Beth Israel Medical Center in New York City for four years, and was then president of Morristown Medical Center (NJ) for five years before being tapped by President Obama to be the VA’s under secretary for health in 2015.

I generally believe Shulkin’s contention that he was a selfless advocate for the health of veterans, improving the VA system, and trying to protect the VA from the meddling of limelight-seeking members of Congress. Surely he could have found jobs that weren’t so soul-sucking if his goal was self-aggrandizement or lining his pockets.

Spoiler: Shulkin was fired because of the meddling of political appointees who want to see the VA system dismantled and by a president whose vanity requires him to distance himself from underlings who get bad press that interrupts the mandatory adulation.

The snips Shulkin mentions about President Trump suggest that the President has good intentions, values loyalty above all else, rules by executive order while refusing to talk to the other side, doesn’t have the attention span to analyze issues and relies on subordinates to form opinions for him, and is in far over his head in turning the government over to clueless power-grabbers who wage full-time war against career government workers who actually understand the issues. The Trump administration is dogged by infighting, revolving door cabinet members, and leaks of information that, whether factual or not, are often intended to discredit his legitimacy as President.

It’s also clear that the so-called Mar-a-Lago Three – Marvel Comics chairman Ike Perlmutter, physician Bruce Moskowitz, and lawyer Marc Sherman – had the President’s ear, represented themselves as his personal emissaries, and demanded full participation in all aspects of the VA’s operation. Perlmutter reminded Shulkin constantly that he was meeting with President Trump all the time and summoned Shulkin and others to the President’s Florida resort to tell them what to do, not just with regard to the VA’s EHR project, but in all aspects of the VA’s operation. Shulkin insisted that the three “counsel” him individually rather than as a group since the latter could have been interpreted as an illegally operating “federal advisory committee” that requires public oversight. Shulkin says he wasted a lot of his day dealing with them, with Perlmutter calling him several times a day with one naive idea after another.

Shulkin notes that, like President Trump, none of the three had ever even visited a VA facility and declined opportunities to do so. Only Perlmutter is a military veteran and that was in Israel, not the US.

Shulkin spends a lot of pages defending the travel expense controversy that helped get him fired, providing details that he says prove just how ridiculous the claims were that he was junketing around with his wife on the taxpayer’s dime (which was certainly true of other Cabinet members, but not Shulkin, according to Shulkin). I actually believe him here as well, and while I’m skeptical of the whole “fake news” excuse for unflattering exposes, it seems that the Trump-created 24×7 frantic news cycle where tweets earn headlines has roped even credible media outlets into running poorly vetted stories hoping to wrest eyeballs from equally lurid sites. Once Shulkin got on the wrong side of the headlines, the former Obama-Trump golden boy had to be sacrificed to protect the President’s thin skin, not to mention that cabinet member travel excesses stories were all the rage for newspapers back then thanks to former HHS Secretary and jet-chartering Tom Price.

Shulkin describes some of the improvements he made to the VA, often decisively and with little support – fixing the wait time problems, publishing operational statistics, trying to modernize its HR policies of basically firing nobody regardless of their level of incompetence, and addressing veteran suicide. He observed that the competitive innovation model rolled out by former Undersecretary for Health Ken Kizer, MD, MPH – especially a star ranking system — encouraged VA facilities to hoard best practices to keep other facilities from stealing their stars. Shulkin rolled out five priorities for improvement – care access, employee engagement, care coordination, veteran trust, and best practices sharing.

President Trump’s election brought in a flood of political appointees who knew nothing about their assigned areas of responsibility. The “politicals” ran off career professionals, leaked false information to the press, and stabbed each other in the back. Shulkin notes that not only did the President have zero government background, most of the cabinet secretaries he chose didn’t either, and some of them had spent their careers opposing the agencies they were empowered to oversee. Shulkin said he was told to find jobs for 30 people, which he thought was reasonable given the size of the VA. The person the White House had assigned to dole out the plum jobs was a 24-year-old former Trump campaign intern whose father was a “Fox and Friends” host. Shulkin was told that he had to accept any appointees the White House sent over and was given a direct order not to fire them. 

Shulkin had an obvious problem with some of the appointees who claimed to represent the White House or who wanted to oversee other appointees. One of them followed Shulkin’s staff meetings with his own sessions that included only the politicals, who would then be told to do something else in dividing the department between the “secretary’s team” and the “political team.” He was also getting beaten up by members of Congress who told him privately that he was doing a great job, but warned him that they would be grandstanding with bitterly negative criticism once the cameras started rolling. He assigned one of the politicals – who he names specifically – to serve on a White House committee who then leaked false information, threatened outside groups who didn’t support specific bills, and ran his own agenda in claiming to represent the President.

He also struggled with high-level VA positions that remained unfilled because the White House didn’t like some of his choices, including “a former CEO from one of the country’s largest public health systems” who was rejected because he had once served on a healthcare advisory committee for Hillary Clinton.

It was surprising to me how much influence that veterans service organizations such as American Legion and Disabled American Veterans wield. One of those that had been basically ignored as lobbying group a by the Obama administration – the Koch Brothers-funded Concerned Veterans of America – was welcomed by the White House despite its agenda of privatizing the VA. That issue kept Shulkin in trouble – nobody wants to admit to voting veterans that they want to shut down their healthcare system, so everybody accuses each other of having a hidden privatization agenda.

Shulkin says he made the right choice to replace the VA’s skunk works-developed VistA software. It made the VA paperless and was widely known because two-thirds of doctors trained in the US rotate through the VA, but Shulkin says the VA had made a mistake in allowing each of its 130 medical centers to create their own customized instance of it. He also noted the lack of interoperability with the Department of Defense’s systems, the high cost of maintenance, and the estimated $19 billion the VA would have spent to modernize VistA.

He admits, however, that he was naive in not realizing how his job would be threatened by his decision to bypass traditional contracting and to simply choose Cerner outright because “I was convinced that immediate action was necessary” because of a never-ending lack of DoD interoperability.

The VA engaged with Cerner under a little-used government contracting option called “determination of findings,” which allows a detailed vendor discussion without a formal commitment. He denies New York Times reports that cited a White House leak saying that Jared Kushner was advocating for Cerner. He says he was instead being pushed by former DoD employee John Windom and members of Congress to get moving with Cerner so the VA could align with DoD’s implementation schedule.

Shulkin says his main requirement was interoperability and Cerner wasn’t convincing in that area, offering only minor sharing of administrative data and the dataset used for government reporting. Or as he put it, “The Cerner team was in full sales mode.” He told Cerner’s then-President Zane Burke that he was ending negotiations until Cerner stepped up to the interoperability plate.

Shulkin worked with outside groups and with academic medical center CIOs to make sure the Cerner contract was solid. However, he was getting pushback from the political appointees, some of whom started showing up uninvited to EHR meetings and reporting back to the Mar-a-Lago Three with their concerns about the contract. One of the politicals was telling everyone that Shulkin was rushing to sign a flawed Cerner contract, urging that he be fired before he did so. Which, as it turns out, was exactly what happened.

In the last conversation Shulkin had with President Trump, the President told him, “You’re killing me with all the bad press coming out of the VA” and asked about the Cerner contract, “Can’t you find a cheaper alternative?” Later that afternoon, Shulkin – who had learned he was being hired as VA secretary only when he saw it on TV news — was fired by tweet. Access to government email and phones had already been turned off. He wasn’t allowed to return to the VA to pick up his personal items or to say goodbye to his team. He then was warned by a colleague that the politicals were making up a story that he had walked off with sensitive government information after being fired, so he returned all his electronic devices at 10 at night.

Shulkin notes that seven weeks after he was fired, “The political appointees apparently determined what I had known all along: the options for IT modernization were limited and the Cerner contract was the best option for the VA and for taxpayers. In the end, the right decision was made, and the VA was on its way to gaining a cutting-edge system to propel it into the future.” He also notes that the President took credit for the VA’s accomplishments at a White House event to which no Democrats or VA professionals had been invited. Shulkin was surprised that the press didn’t pick up on a published email in which one of the politicals laid out the firing of Shulkin, his deputy secretary, and his chief of staff, which was to be coordinated by Citizen Perlmutter to happen only after the President was able to take personal credit for completing several VA initiatives.

Shulkin had a lot of problems with the VA’s OIG, a 1,000-employee, much-feared organization that he accuses  of being “secret police” that aren’t always fair or thorough in their investigations.

He says he worries most about the clueless politicals who have run off qualified employees who could have overseen the Cerner project, explaining, “Getting a contract signed is one thing, but carrying out the real work involved is quite another. My years of experience with EHR implementations taught me that doing this well will require participants with real experience and knowledge that is unfortunately in short supply within the VA’s political leadership today.”

I found this book to be interesting, but depressing. Government is even more dysfunctional than we probably all suspect, and the motives of those involved can often be traced back to pettiness and personal gain (and the same can be said of the press, most likely). I don’t have a clue about how to fix that, but I do believe that David Shulkin was doing good for veterans until that opportunity was taken away by partisan politicians who accept incompetence as long as it is cloaked in political loyalty, just like the politicians who came before them and those who will follow.

As a cheap seats observer, I didn’t find Shulkin’s explanation of why he needed to rush into a no-bid Cerner contract to be convincing, but he’s right that he didn’t have any great alternatives. The Coast Guard’s struggle with Epic probably killed its chances, self-development was a non-starter, and not choosing Cerner when the DoD had already done would have been politically risky. He gives himself a convenient excuse should the project fail, warning in advance that incompetent VA politicals aren’t capable of implementing Cerner. 

The book was more interesting than I expected. Glimpses into how government works were fascinating, although not always encouraging. Maybe Shulkin is the self-sacrificing saint he describes in his book or maybe he isn’t, but regardless, I’m left with a more positive impression of him than before (and I was fairly positive about him before). He was unanimously confirmed twice for high-level VA jobs under wildly different administrations, developed consensus that crossed party lines, and as far as I can tell made veteran wellbeing his agency’s top priority. I think veterans were better off when he was in charge.

Morning Headlines 11/11/19

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