Curbside Consult with Dr. Jayne 3/25/19

Back in November 2017, the Epic-using world was abuzz about Share Everywhere, which was supposed to let the rest of us who are using other systems have one-time access to key patient information such as medication lists, problem lists, test results, allergies, and possibly physician notes. I remember from the announcements that the feature was version-dependent and figured it would take some time for the most current general release version to roll out to the various health systems that surround our independent urgent care.

Share Everywhere allows patients to generate an access code that allows the patient to give access to a provider, home health worker, therapist, or other member of the care team who doesn’t already have access to the patient’s Epic chart. It’s supposed to be accessible through MyChart. Since anyone in my city who has been hospitalized in the last year has been cared for on an Epic system, I figured a year would be enough for the hospitals to roll out the latest and greatest so that patients could let our urgent care providers peek behind the curtain at their records.

Now that flu season is starting to abate and I have a little more time to breathe while I’m talking with patients, I decided to make a concerted effort to ask patients about their use of MyChart in general and Share Everywhere in particular.

Patients frequently pull up information on medications, whether it’s from MyChart, the Walgreens app, or their CVS profiles. Some even access their pharmacy benefit manager, such as LDI or Express Scripts. Many patients still carry a paper copy of their medication list in their wallet, often with strike-outs and additions.

Today, I had four patients offer to pull up their account in MyChart. None of them had any knowledge about Share Everywhere or how to access it. I decided to go digging for it myself once I got home, accessing my account at Big University Hospital. Once I found the link at the bottom of a little-used tools menu, I generated a code for myself.

Despite having an accurate problem list in my patient-side account, the “share” version of my chart was lacking a problem list of any kind. It’s basically blank. The medication list contained a list of items that didn’t show any date of prescription or the name of the prescribing provider, only the person documenting it whose name I didn’t recognize. Only the items documented pre-Epic that came in with a conversion had start dates. Allergies were up to date (fortunately) but immunizations were blank. I found some useless test results that all said “see scanned report.” The family history information was clearly entered by the clinical geneticist I saw a while back, based on its specificity. There wasn’t any kind of a list of providers, which might be useful for patients that see a few more providers than the two I see each year.

Going back to MyChart, I also found a “Wallet Card” feature I had never seen before, which was supposed to have a “convenient, printable summary” of my medical information. The diagnosis list was blank, the medication list was blank, the allergies were blank, and it included a work phone number where I was last seen in 2007. I’m not sure how it’s even in the chart since I make sure to review the updates every time I’m seen at a practice, but it’s in there nevertheless. I found a handy way to print my eyeglasses and contact lens prescriptions, but unfortunately it doesn’t have my name on it or the name of the provider, so it’s not useful to try to get lenses dispensed. Good idea, poorly executed.

I’m a curious person and I was on a mission, but I wonder how many other people know these features are available to them or how to use them? Certainly Big University isn’t sending out an email telling patients that if they wind up at another place’s emergency department or an outside urgent care, here’s the best way for that competitor to access their records.

Now that I know how to tell patients how to find the Share Everywhere code generator, I’m at least able to go back to my desk and peruse their records without having to try to read them on a phone in the exam room. I’m not due to go back to Big University as a patient until at least July, so I’ll have to try to clean up the phone number issue at that point. I’ve learned from battling the billing team through the patient portal that it’s not worth trying to deal with it remotely. It hasn’t been effective in the past and I ultimately have to call a physical office.

We’re still a long was from patients being able to truly hold their records in the palms of their hands, but at least we’re taking baby steps. Maybe I’ll start a grassroots movement to have patients actually review their records and inundate the health systems with correction requests where needed. Depending on the volume, it might spur some changes in documentation habits or help providers understand that there are people outside their own system that are seeing what they are putting into charts. I’ll have to follow up with some of the more senior members of my family that have more extensive records and see what resemblance theirs bear to reality.

I’d be interested to hear from non-Epic providers whether they’ve had much utility with Share Everywhere and whether other hospitals and health systems are doing a better job keeping it accurate than mine is apparently doing. And from patients, are you aware how to generate a token for your providers to access your information? It’s only good for five minutes, so you have to do it right there, but in the right circumstances it would be useful. I’m also curious whether the other major software players have similar access for outside providers. If you can point me in the right direction, I’ll start polling patients. It’s got to be easier than watching people try to populate an intake form from memory.

When’s the last time you shared your record? Leave a comment or email me.

Email Dr. Jayne.

HIStalk Interviews Grahame Grieve, FHIR Architect and Interoperability Consultant

Grahame Grieve is a principal with Health Intersections of Melbourne, Australia and was the architect-developer of HL7’s Fast Healthcare Interoperability Resources (FHIR, pronounced “fire”) specification that allows EHRs to exchange information.

Was it weird to see FHIR as the only universal topic of HIMSS19?

Not so much weird. Obviously it was gratifying for us to see the community investment that so many people have made becoming justified. It’s definitely worth saying that we really value HIMSS’s active participation in driving the conference in that direction. There was an organicness to the fact that FHIR became the big issue given the way the industry overall is, but HIMSS definitely actively drove that and that was an important part of the picture. I thank Hal for pushing that.

I thought there was maturity at the HIMSS meeting this year. You and I talked about bad FHIR puns and expected to see them all over the place, but we didn’t actually see anything like that. We saw instead quite a lot of maturity around the discourse and the challenges of sharing data. I thought that was really good.

I always call you the father of FHIR without asking you if you accept that title. Is it fair or unfair to call you that?

I did initially draft it and propose it and I’ve curated the passionate community input over the years. If that makes someone the father, then I guess I am. The community is the real father. I get undue attention as if it was some magic that I achieved, where actually it’s just thousands of people passionately contributing to the common values that we hold.

I’ll repeat a question that I asked you last time we spoke. Are you worried that non-experts mistakenly believe that we’ve figured out interoperability because they keep hearing about FHIR and APIs?

That definitely happens. People assume that since FHIR is now the designated answer, it is the answer to all of the problems faced. But it’s not.

As HL7, we can only take on and mandate solutions that everybody completely agrees to. This is healthcare, so there’s a very limited set of things that everyone completely agrees to. Additional agreements are required. The scope and scale of the agreements required are beyond any single organization. We’re spending increasing amounts of our time investing in collaboration with other organizations to get a seamless process around scaling up agreements and consistency across multiple organizations like IHE that are helping out with the problem.

As long as hospitals buy an EHR and then spend a $100 million customizing it to their workflows, then interoperability is going to be a challenge. On the other hand, the fact that hospitals make those kinds of investments indicates the complexity of healthcare. There is no easy win. There is no easy victory to get interoperability with some kind of tick mark against it. It’s an ongoing process that we’ll be going through for a long time yet.

It seems like every EHR vendor has at least some customers exchanging information with the EHRs of other vendors and now CommonWell and Carequality are connected. Can product shortcomings still be given as an excuse for lack of interoperability?

The vendors work really hard, and from my perspective, the vendors are committed to making patient data as easy to move as possible. On the other hand, the vendors basically fight with their old legacy code bases that are extensively customized and very had to work with. That’s the nature of any mature software product. I think that if I was a consumer, I would be unhappy with where they are, rather than if I’m an engineer looking at their problem. It’s kind of a challenge for the vendors.

But increasingly, as I observe the space, the challenges are with the providers. To what degree do the providers want to share information? To what degree are the providers prepared to standardize their record-keeping practices and their clinical practices to make it easier to exchange data and to transfer patients seamlessly? Not many of the colleges really understand that problem. I would like to call out the American College of Obstetricians and Gynecologists, which understands the problem very well and has very standardized record-keeping practices on paper. That puts them in good stead to get interoperable.

A lot of doctors I talk to think about this as a technology problem, but it’s not a technology problem. It’s an information problem, and so technology can’t solve it. It needs clinicians to make clinical agreements in order to get clinical interoperability.

There’s one more thing I’ll say, which is that interoperability is not a binary thing. We get a degree of interoperability. We can routinely exchange patient summary information. But seamless transfer of care will require a deeper agreement. We’re not there yet. We’re working on those as a community. But I believe that increasingly the load will move away from the IT side or the technical side to the clinical side as time progresses.

Efficiently accepting patient information from an outside source requires placing it into the receiving clinician’s workflow and being willing to use information that was entered elsewhere. Not that we need another interoperability frontier, but is figuring those issues out the next one?

The trust issue is really important. I’m glad you brought it up, because increasingly as I look at projects around the world, the question, is who trusts who and why? A lot of the complaints I hear from patients about poor record-keeping actually comes down to no established trust framework. If the patient provides you with a written statement concerning their medical history and you read that, are you liable for not asking them verbally? Can you rely on that written statement? If you get a written statement from another institution, can you rely on that? The interplay between trust and liability is something that we’ll have to revisit as a community and make that a fundamental part of our interoperability considerations.

What could I do as Provider A if I find that I’m regularly receiving incorrect or unreliable patient information from Provider B?

Looking around the world, I routinely hear that more than half of patient records contain wrong information about the treatment history. Some of those are really, really wrong, and you can easily find examples of that in the media. Surveys that I’ve seen show that it’s more than half the records contains something wrong, and yet we make those available to the patient without any consideration for what a patient should do if they look at it and say, that’s not right, I’m a guy, so I don’t think that a pregnancy test was actually performed. Life’s a bit more complicated than that, but what do they do?

You asked the same question about providers with each other. There’s one organization working on the policies and technologies associated with this, which is Carin Health. But we should start moving towards a culture where it’s a professional obligation that if you share your records with somebody, you have an obligation to have some sort of error detection and correction process running so that your records can be corrected. But in today’s environment, we’re a long way away from thinking like that.

What has been the impact of Apple exchanging information with EHRs using FHIR?

There’s certainly discussion happening around Apple in particular, but more generally patient access to information and what kind of difference that will make. Obviously that was a subject of the keynote at HIMSS. Apple brings a particular sharpness to that debate because of its global consumer reach, the style of its consumer reach, and the potential for Apple to disrupt health in the way they’ve disrupted other industries. I certainly hear discussion about that. Some people are wildly in favor of any disruption. Other people are very much not in favor of any disruption. Some people are concerned about what a consumer company like Apple might do.

My perspective is that getting patients their data doesn’t really make much difference to patient satisfaction or behavior, because it’s all historical data. What makes a difference to a patient is the services that you provide. You need data to support the services, but it’s the services that matter. As long as healthcare services are fundamentally delivered in the flesh in the physical world, there’s a limited degree to which the consumer electronics companies can disrupt health.

In order to provide substantial healthcare services, you have to put people on the ground. That raises all of the classic “how do you manage healthcare” problems, for which I don’t think there’s any magic bullet. I think that their impact will be significant, but ultimately limited by real-world constraints.

Joe Biden and Seema Verma have recently expressed disgust that they, even as high-ranking government officials at the time, were unable to get the medical records of their relatives, and Verma in particular seems outraged. Do you think the government sees its role now differently than it did originally?

It has become more clear across the industry that what we have is not a technology problem. We have a business and an information problem. The government laid down a whole lot of money as far as stimulus, partly to spend money — which it did effectively — and partly to move past the technology barrier to the information barrier. Aneesh Chopra has told me that what happened was relatively predictable. We’ve now solved the technology problem. We can focus on the business and the information problems, and here we are doing that. The NPRM focuses on cleaning out the technology problems and moving the business and information problems to front and center.

But as the government, the levers that you can pull have limited effectiveness. That’s even true in autocratic countries. I was in one country where they showed me that certain things were happening in a particular way. The next day, I would meet with the programmers. They would say, “This is how we do it, but don’t tell the bosses, because they’re not allowed to know.” The levers that you can pull as a policymaker and a money-spender are a lot more limited than people believe. At least the US government is acutely aware of that, much more so than other governments I deal with.

Nothing leaps out at me as any quick solution here, so since the NPRM is marginal improvements being made over time, we can look for improvements. I’m particularly hopeful that we can solve the access to healthcare records problem through thoughtful change. I already saw that happen with vendors. When I started dealing with health information exchange, vendors were suspicious about exchanging patient data. They saw that as a business threat. Now when I deal with C-level people at the vendors, they’re all like, “Well, why wouldn’t we do that? We can’t not do that. It’s part of our business. It’s a business opportunity.” Whereas if I talk to providers, I see providers very much being, “Why would we do that? Why would we spend money doing that? Isn’t that a business threat?” It’s about making that same cultural adaptation to their thinking.

That’s the key thing that we need to chase — the understanding that exchanging patient data with the patients is a business opportunity, not a business threat. But it’s a cultural transition that needs to be bedded deeply through the provider before the provider is ready to see healthcare as a different kind of business model. There are a number of institutions around the USA that are pushing that as hard as they can. Hospital in the home, seeing the hospital as part of a wider network, the whole ACO thing is pushing that. There’s a bunch of things happening, so I’m not particularly pessimistic about it.

Does anybody still care about Blue Button?

There’s a really active community around the new Blue Button work that CMS is doing with FHIR. The FHIR community is picking up and processing the data. There certainly is interest in cross-correlating data from Blue Button with data from the Argonaut interfaces that patients can get, and creating a market in that space. The White House is interested in that. It makes a lot of sense to try and leverage some efficiencies out of the system by cross-correlating payment data and payment efficiency data with individual healthcare data.

That’s the logical place to look for where you, as a funder, could seek to provide more efficiencies in the healthcare system. In the end, the providers of healthcare are not motivated to perform systemic repair to healthcare. It’s the funders who are motivated to perform systemic repair. That’s an important part of the overall picture.

Morning Headlines 3/25/19

FDA Chief Calls For Stricter Scrutiny Of Electronic Health Records

Departing FDA Commissioner Scott Gottlieb says FDA oversight of EHRs would be appropriate “when they’re doing things that could create risk for patients” in turning into a medical device.

Healthcare Analytics Leaders Clinigence and QualMetrix Merge to Accelerate Value-Based Care and Population Health Management

Population health analytics company QualMetrix becomes a subsidiary of quality reporting software vendor Clinigence.

Wolters Kluwer provides NASA astronauts in outer space access to UpToDate clinical decision support resource

Wolters Kluwer is providing International Space Station astronauts with access to its UpToDate medical information resource.

UCLA Health System Settlement

UCLA Health System (CA) will spend $5.5 million on cybersecurity defense as part of a proposed settlement stemming from a 2015 data breach that left patient data exposed for nearly a year.

Monday Morning Update 3/25/19

Top News

Departing FDA Commissioner Scott Gottlieb — reacting to the “Death By 1,000 Clicks” article — says FDA oversight of EHRs would be appropriate “when they’re doing things that could create risk for patients” in turning into a medical device.

Gottlieb added, however, that Congress would need to define those conditions. He doesn’t expect any changes in the next several years.  

Reader Comments

From Captive Cursor: “Re: Beth Israel Lahey Health. Named former Dartmouth-Hitchcock CIO Peter Johnson as interim CEO of the new entity. He would be an interesting interview.” Johnson’s LinkedIn says he’s been an independent consultant since leaving Dartmouth-Hitchcock in 2011 after 26 years and I know he has covered CIO roles since. I agree that it might be fun to interview him.

From From Athena With Love: “Re: Athenahealth. Post-acquisition layoffs are about to happen (April) according to rumors.” I’m pretty sure you can count on layoffs, especially when combining two companies that must have quite a bit of corporate overlap. The real question is how they handle the product portfolio, especially the GE Healthcare part. That’s compounded by the fact that healthcare experience, especially that obtained from somewhere other than Athenahealth, is hard to find among the executive team members.The corporate raider script, especially with hedge funds like Elliott Management, seldom wavers from: (a) create distress by criticizing the targeted company publicly and maybe applying some dirty tricks; (b) use the resulting share price drop to bully the board into selling the company at a discount; (c) cut costs mercilessly to shore up the financials while the company is sequestered away from investor oversight as a private entity; and (d) either find another willing buyer, or as is more likely with Athenahealth, expand into sexy-sounding areas with big potential, take it public again, and transport wheelbarrows of cash to the bank before the company’s long-term prospects turn out to be less impressive than the juiced numbers and creative story suggested. Vertitas Capital’s big healthcare IT score was selling the healthcare database business of Thomson Reuters, renaming it Truven Health Analytics, and then selling it to IBM for more than double the $1.25 billion it had paid just four years earlier. Athenahealth’s prospects are probably less rosy in the absence of a likely buyer (especially one as desperate as IBM), the overall sagging of the EHR market, having product that were run into the ground by GE Healthcare in its mix, and the significantly inflated company value that was purely due to Jonathan Bush’s involvement.

From Randall N’Jobu: “Re: doctors. I saw an article wondering how many people call their doctor by first name. Survey your readers?” Take a few seconds to answer and I’ll share the results. I’ve noticed than I’ve changed my practice of always calling my PCP “Dr. XXX” changed when I moved to a concierge doctor, where it’s more personal, less formal, and in my mind more appropriate to use first names since he’s working directly for me. Oddly enough, however, both concierge docs I’ve seen call me “Mr. XXX” even as I called them by their first names, so maybe I’m either faux-pas’ing or something about the situation has turned the tables (they are also younger than I, so that may play a part, as I included in the poll). Physician readers, are you put off when patients call you by your first name, do you invite it, or what do you really prefer? I remember cringing in my early hospital days with a 20-something nurse would address an 80-year-old patient as “Mildred,” but that perhaps was a signal that informality was moving from society in general to medicine in particular.

From Dollar Cost Averaging: “Re: healthcare IPOs. Are they suddenly a thing again?” I’m no expert, but it seems to me that companies see the recessionary writing on the wall and figure they need to either move now or wait years for the cycle to turn back around.

HIStalk Announcements and Requests

A third of not very many poll respondents say they saw something at HIMSS19 worth following up on. They left us to guess what that was.

New poll to your right or here: How much doctor burnout is caused by EHR design (workflows, screens, clicks, etc.)?

Webinars

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

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

Sales

• Iowa Health Information Network will provide real-time patient notifications to its provider members using PatientPing, replacing Iowa’s Statewide Alert Notification system. 
• University of Vermont Medical Center will use solutions from Loopback Analytics to identify at-risk patients and improve outcomes related to specialty medications.

People

Two ROI Healthcare Solutions executives – Founding Partner / CFO Kathy London and Managing Partner / President Jim Jancik – announce their retirement.

Other

The VA struggles with documenting care for veterans who have undergone gender reassignment surgery, as one advocate wants all EHR mentions of surgery and previous gender removed to protect them from violence, while others say providers need to know the patient’s full history.

A “Madison Magazine” columnist says the local airport should be renamed from Dane County Airport to Judith Faulkner Airport as Epic has remade the area’s economy from its Oscar Mayer heritage of making “wieners and pimento luncheon meats” (the company bailed to Chicago in 2015) and Epic saved the area from “one of the most forlorn demographics in all the world.” He notes that Epic makes it possible to take direct flights to Phoenix, San Francisco, and Los Angeles and has fueled the growth of hip venues that cater to its campus full of young adults with significant incomes.

Wolters Kluwer is providing International Space Station astronauts with access to its UpToDate medical information resource. I admit that I don’t follow low-orbit type projects, especially now that they sell seats to space tourists, but this announcement made me wonder what will happen if an occupant has a stroke, heart attack, or even appendicitis. I assume it would be like in the remote parts of the world, where doctors on the ground instruct crew members who have undergone the most basic of medical training to perform diagnostic tests or minor treatments in sort of a celestial MinuteClinic, but without the option to call an ambulance to take them to a better equipped hospital.

Warner Music Group signs a startup’s AI-powered algorithm to release 20 albums in the next year. Endel creates custom soundscapes such as “Sunny Afternoon” and “Rainy Night” that embed custom frequencies that are tailored to a particular listener’s mood, location, and heart rate. Endel’s engineers said their songs are intended to serve as tailored background music rather than album tracks, but agreed since all 20 albums can be “made just by pressing one button.” They had to hire an entertainment lawyer to figure out who to list as artists for collecting royalties, finally settling to just listing all the engineers as songwriters.

A woman sues Olive Garden for up to $1 million for failing to warn her that her “defective” stuffed mushrooms were “extremely hot,” claiming that after the first bite she staggered through the restaurant with it stuck in her throat, vomited in the restaurant’s kitchen, headed off to the ED, then called 911 on the way because she thought “death was imminent.” She was taken to the hospital, then airlifted to Parkland Hospital’s burn unit. Personally, I would be more tempted to snoop in her medical records than those of Jussie Smollet.

Sponsor Updates

• Lightbeam Health Solutions, Experian Health, and PerfectServe will exhibit at the AMGA 2019 Annual Conference March 27-30 in National Harbor, MD.
• MDLive and Redox will exhibit at ATA19 April 14-16 in New Orleans.
• Meditech will host the 2019 Home Care Optimization Symposium March 26-27 in Atlanta.
• NextGate achieves advanced technology partner status in the AWS Partner Network.
• OmniSys will exhibit at the Computer-Rx T.H.E Conference March 28-30 in St. Louis.
• QuadraMed’s EMPI partners with LexisNexis Risk Solutions Partners to prevent patient identification errors.
• Surescripts will exhibit and present at the 2019 AMCP Managed Care & Specialty Pharmacy Annual Meeting March 25-28 in San Diego.

Blog Posts

• Best Practices for Communication and Coordination in Long-Term Care (LiveProcess)
• Using the cloud to ‘untether’ medicine from wired tech (Meditech)
• Improving Healthcare’s $6 Billion Patient Matching Problem (NextGate)
• The IT Service Management Series – Part 2: Information Security Management – Beyond Compliance (CloudWave)
• How Schneck Medical Center manages denials promptly and with ease (Experian Health)
• The AHA Health Motivation Platform is More Important for Your Reactive Cardiac Patients Than You Think (PatientBond)
• Don’t Implement a New Patient Billing System without This Checklist (Patientco)
• The Net Impact of Poor Patient-to-Provider Communication (PerfectServe)
• How to Use Generated Forms Inside PV’s EMR (Practice Velocity)
• ONC & CMS Proposed Rules Part 2: Interoperability (Sansoro Health)
• A complete solution from smart bed to smartphone. (Voalte)
• 10 Emails You Should be Sending Your Patients (WebPT)

Contacts

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

Reader Survey Results: How I Would Change EHRs

I asked readers how they would change EHRs to improve outcomes and reduce costs while still meeting the requirements imposed by the US healthcare system. That’s the basic question EHR vendors face every day. Some of the excerpted answers I received are as follows. Non-clinician responses are indicated with an asterisk.

* Keep them headed in the direction they’re on: platforms supporting standardized open APIs. The Fortune article was hysteria-feeding bias by writers who don’t understand economics, technology, or healthcare. Chopra had the best take in the article: MU was a messy process but it was a necessary down payment that will yield benefits to patients for years to come.

Create true app store-type environment being opened up by the recent mandate for FHIR APIs,  a way to totally separate the data entry issue from the clutches of current vendors. The most practical complementary situation in the interoperability realm would be a timeline approach to presenting links to patient specific information for the caregiving team. There are many candidates whose product offerings could be customized to fulfill this.

* Allow doctors to create/buy their own EHRs with no regulatory restrictions on interoperability other than summary reports, lab interfaces, and pharmacy interfaces. This puts agency back into the hands of the frontline clinicians themselves and allows us to cut the complexity out of entrenched vendor products and brings e-health back to the basics, where it belongs.

* I would move EHR interoperability to something more similar to the SWIFT financial network. A cooperative would operate a set of datacenters and network. Transactions on this network would be defined by a set of standards (HL7+X12 but with a strong opinion on what that actually means.) Messages would be routed from the providers to the cooperative then onward to other providers or insurers or wherever. Failure to reply to requests with the appropriate clinical information would result in an increase in the transaction fee that the networks charge for submitted claims.

Say you don’t return a request for patient data promptly or fail to submit an HL7 ADT message when a trigger happens — some percentage of your claims for the next year will be put into a general fund that supports the network. Awards are given from the general funds to whistleblowers who point out failure and non-compliance. Additional failures or non-compliance will result in a steadily increasing withholding from each payment your org receives. Failure to join the network or repeated non compliance with the requirements will lead to loss of Medicare and other government payments. US digital service and some CMS lawyers form the initial public committee that organizations go before to submit complaints against each other, appeal decisions, etc.

* All big systems were designed around billing, and the visit is the hub. That should be tossed out and redesigned so patient is the hub.

* Phase out Meaningful Use. Halt any usability mandate initiatives (let free market decide). Pass legislation that makes it much more difficult to sue for patent infringement. For EHR software that is released and used in production at publicly funded health systems, screenshots, videos, and specific descriptions of functionality / workflow should be shareable with open public (excluding PHI stuff) i.e. greatly limit an EHR vendor’s ability to nix content from web with IP protection claims

* I would allow malpractice carriers to drive the market need for effective electronic clinical documentation through how they price premiums rather than CMS reporting requirements. That should shift the market dynamic away from a great billing product to one built around patient safety.

*Interoperability: generate rich patient records with specific variability and define a set of assertions that are associated with those cases. Send them via CCDA and FHIR and ensure that each EHR can receive, reconcile, and directly incorporate all data into their EHR.

Usability: generate a standard set of the top 10 nursing and physician workflows — give the workflow 100 points. Then for every time the user has to switch contexts from the patient to the computer, deduct seven points. Every time the user has to switch from the keyboard to the mouse, deduct five points. Every keystroke the user has to enter to do a search – deduct one point. Grade it based on standard: 90 percent A, 80 percent B, 70 percent C, 65 percent D.

Error reporting: Put the EHRs under FDA CFR and require they publish all harms with their customer notice to a Federal EHR Adverse Event Reporting System (FEHRAER?). All potential patient safety or safe use issues reported to the same system, but perhaps we would mine those for trends and allow them to remain non-public.

When someone cheats on their MU reporting or MU certification, a change in suit color is in order. Not just fines. but hard time.

* Centrally managed (decentralized storage) common health record structure that all EHR technology vendors and providers of all types are forced to contribute to. This would break up monolithic EHR vendors, stimulate creativity, and allow each provider to select the tools used to contribute to a commonly defined health record. This would solve the interoperability issues and allow the market evolve quickly. Basically we follow the ubiquitous app store approach. We could use a distributed ledger approach to record management.

* We need to focus on the paradigm that exists around our transition from paper-based, trust-based, fee-for-service charting to an electronic health archive and medical billing support infrastructure. There is no direct correlation between the two worlds. And I am not talking about the change felt by payers and providers. We have not changed the patients’ encounter as dramatically as we need to in order to support new world order in healthcare.

Patients are typically scheduled in much the same way as before. The Doctor’s office visit is mostly the same. And what is scary is the huge push and hyper focus for MORE office visits. A vastly different office visit is required. And since everyone is a consumer, we all share the same responsibility to adapt.

One very tangible change would be patients acknowledging that their visit with the physician is being recorded. Recorded sessions will be saved for 24 hours until the medical record has been appropriately updated and accurate labs and meds are ordered and prescribed. This one process change has many downstream benefits to both accuracy and integrity. There are ways to incorporate many levers to assist, however, it starts with changing the patient’s point of view of a doctor’s visit.

* Systems that you can easily dictate into via headset, for example, as you are performing assessments, “breath sounds diminished in left lower lobe, slight wheeze in left upper lobe, strong, loose, productive cough. Resp Rate 14, pulse 84”, etc.
having discussions with patients, “Mr. Gonzales indicates shortness of breath walking up one flight of stairs”. System would be smart enough to catalog information discretely in the right places in the right way to make it interoperable.
Alexa-like recall of important information or tasks “Alexa, please reconcile Mr. Jones medication list and show me any discrepancies” “Alexa, what is Mrs. Smith risk of 30 day readmission and what should we do to mitigate it?” “Alexa, what routine care items / screenings is Ms. D’Meanor due for?”

* At the health system level at a minimum, standardization of content based on evidence should be required. Utilizing 4,000 different order sets, customized care plans with zero evidence, lack of consistent clinical decision support should be disallowed. EHRs only get better when the information available at the point of care is better.

Implement National Patient Identifier, and mandate that it cannot be SSN. Get rid of the old school “funny Money” mentality of charges that all the stakeholders can get an accurate view of value in health care, and not monopoly money gross revenue nonsense that is currently what is floated out there.

* I think we need some UPS-style time and motion studies to understand how to make the EHR more natural and complementary to physician and clinician practice. Some future improvements should be possible based on this understanding, for example:

• Narrowing what is on a screen based on context in the patient encounter
• Narrowing what is on a pick list based on context
• Improving adoption and usability of no-touch UI’s

There is a lot to be learned for the major EHR vendors from the computer gaming industry on having commands and data elements be contextual. I think we need to shatter the “project mentality” in EHR rollouts and just assume optimization never is finished. If any investment deserves the the continuous improvement process, it’s this one.

* Get rid of the need to document every single minutiae. Let the doctors decide and be responsible for what they enter in (if they start making mistakes or not entering important information, it’s on them and their insurance). Have a simpler interface for physicians, and another a complex one for “scribers” (could be the same as what’s currently offered). What’s required for simpler interface should be arrived at by a mix of EHR vendors and physicians (AMA), make this required for certified software. This you could be standardized across the US. If the doctors don’t like it, they can switch to the scribers interface and go nuts but no complaining anymore about the interface. Only the simple interface should be required for the software to be certified.

If the bean counters want something tracked and entered in, let them pay for it in the term of scribes, etc. This will easily track the true cost of of all this data entry which is currently being paid through physician time. Since they love tracking costs, they should love this, right?

Have a tool to download record from patient portal, in an open and readable format. Even better two formats, one human readable, and one machine readable. Make this required and always available if you want to be certified.

Have tool in patient portal and in EHR to submit feedback on the software. A copy goes to the vendor, one to the health system, and a copy goes to regulators, available through FOIA to anyone (once personal details are scrubbed).

Not really something that can be done on EHR side but:

Make health systems pay for failing to share patient’s records (if the above functionality fails). Make this an increasing cost based on delay and also based on the amount of money the health system generates (not profit, as they’re all not-for-profit).

Make the health system generate a single, detailed bill. If the health system is not-for-profit,” it should have both the cost of the material and how much they charge for it in the bill. If the bill goes out past a certain date, the patient doesn’t have to pay it. Let them deal with paying outside the network, etc.

* I worked in financial services technology in 90s and early 00s. If you free the data, innovation will come. We’re in generation 1. There are whole entities just forming that normalize, curate data. Better user centered design will come when SME for particular problems are able to enter at a price point commensurate with value. Add-on and systems next to the EHR will become primary home for tasks for specialized workflows. EHRs that can build and partner for these models will succeed. The ones that stay data locked will be the last system stand alone docs have before getting eaten by local mother ship. That could take decades. Ones that unlock data and become integration partners have a chance at survival.

The larger orgs that command a premium $ in their practice and have a handle on ROI and total cost of practicing will bring support for doctors into exam room. MGH in Boston has been doing this for almost a decade.

There is no perfect technology. Our ability to acknowledge data integration is key is tantamount.

Although politically undesirable, move to a unique patient identifier/set of unique keys per patient would help immensely.

Since early 2013, the Texas Medical Association has recommended to ONC that they should require all EMR data elements to be XML tagged using a single national standard, much like the accounting profession successfully uses XBRL. With a universally-understood tagged data structure, physicians and hospitals would ideally be able to pick up their databases and move them quickly and cheaply between vendors. Vendors then would be forced to compete on their user interface, including usability.

XML is just one approach for tagging. FHIR is analogous to this approach, but it’s not being used in a “pick up your database and change” way, as far as I know.

If, in 2013, the ONC had started us on the XML tag journey (or its equivalent), we would be far, far closer to true interoperability and data sharing.

* Leverage the massive amount of data that has already been collected over the past 10 years. Utilize machine learning to automate the largely repetitive tasks done by clinicians. A run-of-the mill CAP admission already gets the same order set anyway, with the same billing codes. There is no need for things like this to be done manually every single time. Machine learning should be able to take care of 80 percent of the tasks currently done by clinician end users. The other 20 percent are the unique clinical situations where we need clinicians to use their experience and critical thinking skills to solve complex medical problems beyond the capabilities of machine learning.

Mandate interoperability and provide real teeth to enforcing this with real consequences for facilities, systems, and technology that does not share all the data. This includes providing all to the patient. Don’t let perfection stand in the way of progress when it comes to interoperability – start with something and expand on it.

Relegate the EHR to a database and allow for customized solutions as an overlay for specialties and individual workflow.

Stop punishing doctors with data entry and find an alternative to capture of information and allow them to return to the art and joy of medicine.

Require justification form variation from standards of practice established and proven holding clinicians accountable for that variation when they find alternative paths and treatment protocols.

Make the technology a part of medical education and allow those individuals to contribute to rethinking the solutions, workflow, and layout. They are unencumbered by the baggage of paper notes and as digital natives would have new and innovative ideas that we could use. They are also deeply invested in fixing this unholy mess since they are forced to use this archaic solution and are often the data entry clerks of choice as the most junior clinical employee, wasting all their training time on updating the system  — residents spend 70+ percent of their time in their basement room updating the EMR not seeing patients.

My notes would be minimal, perhaps even written primarily by the patient. Diagnoses would be common language and not all the absurd detail ICD-10 brings. Real-time costs would be part of ordering and someone other than me could figure out the charging in the end. Make the screens as simple as an iPad, intuitive so that they just work as expected.

Weekender 3/22/19

Weekly News Recap

• A Reddit “Ask Me Anything” with Providence St. Joseph Health EVP / Chief Digital Officer and venture fund manager Aaron Martin gets ugly with charges of layoffs and a hostile work environment for female employees
• A France-based online medical appointment app vendor’s funding round values it at more than $1 billion
• Fortune’s cover story, “Death By 1,000 Clicks: Where Electronic Health Records Went Wrong,” says EHRs are an “unholy mess” after taxpayers spent $36 billion on their use
• Health Catalyst hires investment bankers to begin its IPO process
• The payment model of England’s NHS, which is based on a medical practice’s location, raises concern as the private company behind the GP at Hand video consultation app draws 40,000 Londoners to its practice
• Change Healthcare files IPO documents
• A survey finds that nurses who work in a positive work environment like their EHRs better and have a higher appreciation for their role in patient care

Best Reader Comments

Having sold EHR software before the government started subsidizing buying as well as after its no surprise the monetary “savings” haven’t been realized. Most physicians under-coded visits prior to using an EHR as they feared failing an audit of required documentation. Using an EHR allows faster accurate coding, which means higher medical costs. When physicians used paper to document care, they usually made very brief notes with the patient in the exam room. Then they spent hours dictating progress or writing progress notes after business hours. This delay often led to missing information in the notes. Many charts were unreadable or missing when needed. The paper records were far from perfect and hid many more medical errors. (Matt)

No one took the time to redesign the healthcare process [before designing EHRs] and develop roles and tasks that automation could efficiently support. A quick read of the Toyota Production System’s approach to adopting new technology shows how backward EHR adoption has been. We do have great examples in health care where automation was handled properly. Voice recognition reduced radiology turn around times to minutes from days. Lab automation and electronic communication linked robotic testing results to the medical record with near instantaneous availability. Bedside MARs measurably improved patient safety. But when it came time to do the big one, we dropped the ball. (Steve O’Neill)

There’s not a Theranos story [with journalism investigating the EHR industry], but there is a story of companies that grew much too quickly, are governed largely by crisis and chaos, have an ethos of “put something out there and fix it later” (or, promise something and create it later), are operated at all levels but the very top mostly by 20-somethings, and have had plenty of lapses of both execution and ethics in the post-HITECH boom. (Fred)

Back in the very first days of the MU program, I sat in a meeting room at a state hospital association conference and heard a CMS regional administrator say, “We won’t pay for that which we can’t measure,” i.e, if you are documenting in a way that makes it difficult or impossible to collect data and compare how you’re doing with other providers, we aren’t going to pay you. Lab results, vital signs, and drug administrations are all relatively easy to collect data for measurement. Medical necessity pass/fail rates are fairly easy. Acceptable Use Criteria will make diagnostic imaging more easily measurable. CPOE made order patterns measurable. Specificity in documentation to get to the most specific diagnosis code possible is measurable. MU was in large part about making as much information as possible measurable. That it took billions of dollars to get an industry notoriously resistant to any oversight in how they function was a feature, not a bug. (MEDITECH Customer)

Physicians are in such limited supply and command such high salaries that the entire clinic or unit orient themselves around having the MD always operate at the “top of their license.” This means that the MD interaction with the patient will consist of 1.) dispensing whatever information only the MD and no one else in the clinic can dispense. 2.) doing the bare minimum to ensure that the patient is billed for number one. Doctors will not get paid >100 dollars an hour to look people in the eye, have a conversation or connection, take a clinical measurement, have an original thought, etc. All of those things can be done by a medical assistant or a nurse or someone cheap. We could assign a scribe to every physician so the wouldn’t ever have to touch an EHR; I think doctors would be marginally happier but not significantly. The reality is that physicians are now employees and no longer run the show. Like the rest of us employees, the only meaningful changes will come from unions or the legislature.(SelfInflictedWound)

I have been in the healthcare industry for years and am guilty of not having a PCP. I had never really thought about the “relationship” aspect of a physician and why it would be beneficial to have someone engaged in my care that has seen me over a period of years rather than a quick trip in when I am not feeling well. Technology continues to change how we interact and socialize with others. It will be interesting to see how the doctor-patient connections morph as technology continues to be more readily available and acceptable in new areas. (Steph M.)

Watercooler Talk Tidbits

Readers funded the DonorsChoose teacher grant request of Ms. T in Texas, who asked for 35 calculators for her elementary school class (I’m not exactly sure what kind of class, but she mentions that all students are girls who have overcome adversity). She reports, “Students today have easy access to a lot of technology, but they are not always taught how to use it correctly. One thing I have noticed in the past is that students struggle to use calculators correctly. This causes a problem as they progress in school and have more access to them and are expected to use them in Algebra. The impact of your gift is that now, students at my school have the ability to be taught how to properly use a calculator before reaching the upper level math classes. Thank you for allowing them this introduction!”

Researchers working with a woman who can detect Parkinson’s disease based on the smell of patients create a diagnostic test as a result, using mass spectrometry to isolate the four compounds that are most responsible. The former nurse can also detect cancer and tuberculosis, which will be the subject of another round of research.

A 59-year-old woman who suffers from early onset dementia is sent from a local hospital to Oregon Health & Science University for urgent heart bypass surgery and valve repair. She then developed a post-op infection that left her hospitalized for a month, after which OHSU billed her for the $227,000 part of her stay that her insurer wouldn’t cover because the hospital is out of its network. Her husband, whose Social Security payments of $1,900 per month make up the family’s entire income, says the hospital never told him about the out-of-network costs or offered a transfer to an in-network hospital. The couple is relieved that OHSU finally agreed to write off the bill under a charity waiver obtained with the help of a non-profit group, but resents getting collection calls for six months.

Bizarre: the Buffalo Wild Wings restaurant chain rolls out a March Madness “Jewel Stool” that is comfortable for men who have just undergone vasectomies, with the idea coming from data pulled from Athenahealth’s netowrk indicating that urologists perform 41 percent more vasectomies on the first Friday of March Madness compared to the typical Friday. Urology practices like the one above are even running March Madness snip specials.

A retired, Harvard-trained cardiologist whose restaurant waitress daughter asked him to cover a busboy shift saves a choking woman just five minutes into the job by performing the Heimlich maneuver.

In Case You Missed It

• News 3/22/19
• EPtalk by Dr. Jayne 3/21/19
• News 3/20/19
• HIStalk Interviews Cedric Truss, DHA, Director Health Informatics Program, Georgia State University
• Curbside Consult with Dr. Jayne 3/18/19
• Monday Morning Update 3/18/19

Get Involved

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

Morning Headlines 3/22/19

BESLER Completes Acquisition of Essential Consulting LLC, a Leader in Hospital Reimbursement Services and Supporting Technology

Hospital RCM company Besler acquires competitor Essential Consulting for an undisclosed amount.

Family’s letter to Providence St. Mary leads to new telemedicine program for critically ill children

A family’s suggestion and donation leads Providence St. Mary (WA) to pilot telemedicine capabilities that enable its providers to consult with neonatologists and pediatric intensivists in Spokane.

750,000 Medtronic defibrillators vulnerable to hacking

Homeland Security alerts consumers to vulnerabilities in 16 types of Medtronic implantable defibrillators that would allow a hacker to access or modify the device’s data, and change device settings.

News 3/22/19

Top News

Providence St. Joseph Health EVP / Chief Digital Officer and venture fund manager Aaron Martin participates in a Reddit AMA (Ask Me Anything) that quickly turns ugly as participants – including claimed former employees of his Digital Innovation Group — press him about layoffs and a reported sexist, bullying, and stressful culture. I’ll paraphrase a few comments, although I’m obviously unable to verify their accuracy:

• Is spending hundreds of millions of dollars on what is essentially a tech start-up consistent with the Sisters of Providence mission?
• Bragging that two-thirds of the leadership team is women doesn’t reflect a culture that favors “young brogrammers.”
• More than 80 employees left last year.
• “People joined DIG because they were inspired by the mission and often took a step back in pay to make a difference. Then, it takes about three weeks at DIG to realize you’ve been tricked. It’s not mission-driven, it’s driven by bullies who care for no one but themselves. I think the leadership team would even turn on each other if needed.”
• Participants questioned whether Martin profits personally from deals on top of his reported $1.6 million in compensation, also claiming that the sale of Circle Women’s Health Platform to Wildflower Health “involved Providence paying Wildflower $4M to take it, kind of like a dowry.”
• A participant said that PSJH’s acquisition of blockchain vendor Lumedic (although not part of Martin’s group) “appears to be the hiring of a group of five executive-level ($$$) friends who used to work together at previous companies with a pointless blockchain vaporware company and no actual intellectual property (patents) or software engineers or working product. Why is PSJH throwing money at scammy, buzzword-slinging suits?”

Reader Comments

From BurbianEHR: “Re: Lahey / Beth Israel post-merger administration layoffs. Starting today.” Unverified, but not surprising.

HIStalk Announcements and Requests

I’ve received some good responses to my “how would you change EHRs” question, although respondents face the same challenges as vendors – you don’t get the pie-in-the-sky satisfaction of submitting a “world peace” type answer because the US health system defines EHR requirements, not vice versa. Your assignment, then, is to describe how you would make EHRs better while still allowing them to function in the unreal realities of our healthcare system.

The Forbes “Death by 1,000 Clicks” article stirred some nostalgia about those heady Meaningful Use days, when EHR vendors turned into shameless used car salespeople in hawking their previously unwanted wares. HIMSS, too – my favorite insanity moment was when HIMSS launched a road show series called “Takin’ HIT To the Streets” (subtitled “The ARRA Era”) in late 2009 as a self-appointed convener of sellers and potential buyers.

My comment from November 2009:

The HIMSS Takin’ HIT to the Streets campaign (gag, even for Doobie Brothers fans) leaps that last boundary of member organization common sense —  they’re paying people to attend the sales presentations of their vendor members. I’ve been watching the remake of the old miniseries “V” and I think maybe vendor visitors have taken over Steve Lieber’s body since the previously furtive and tentative vendor-HIMSS gropefest has advanced to a full-on public consummation.

Webinars

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

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

Acquisitions, Funding, Business, and Stock

Unite Us, whose platform connects providers with community resources to address social determinants of health, raises $35 million in a Series B funding round, increasing its total to $45 million. Two of the three co-founders are military veterans – CEO Dan Brillman served in Iraq and Afghanistan and still flies as an Air Force Reserves major, while Taylor Justice graduated from West Point and spent time as an Army infantry officer. The company was founded in 2013 to connect veterans to resources that could help them adjust to civilian life.

France-based medical appointment app vendor Doctolib raises $171 million in a funding round, valuing the company at more than $1 billion. It recently added video visits and digital prescriptions.

Sales

• LifeBridge Health will implement Artifact Health’s physician query solution to expedite accurate coding of patient records.
• Hospital de la Concepcion (PR) chooses FormFast’s electronic signature system, integrated with Meditech.
• Humana selects Inovalon’s analytics solution.
• First Health of the Carolinas chooses HealthMyne’s imaging decision support for screening and following lung cancer patients.

People

Outgoing CVS Health EVP Meg McCarthy, who has a long background in health IT, is appointed to the board of Marriott International. She served early in her career as a Navy Medical Services Corps lieutenant at Bethesda Naval Hospital and earned an MPH focusing on hospital administration.

Announcements and Implementations

Medhost responds to a whistleblower lawsuit in which two former IT employees of Community Health Systems claim that CHS fraudulently attested for Meaningful Use and that Medhost made false statements to earn Meaningful Use Stage 2 certification for its EHR. Medhost denies the allegations, notes that the federal government has declined to get involved in the lawsuit, and says that its software is successfully used by hundreds of facilities and continues to be chosen by sophisticated clients who have analyzed and compared it extensively.

The American Academy of Family Physicians offers a Primary Care Innovation Fellowship to study EHR usability and support for primary care.

Privacy and Security

A study finds that 79 percent of medication-related Android apps share user data, most commonly their device information, browsing history, and email address. Four apps were found to share medical conditions and six sent the user’s drug list. Recipients include social media companies and two private equity firms. The study notes that HealthEngine, Australia’s most popular medical appointment scheduling app, shares user information with personal injury law firms without providing an opt-out option.

Other

NHS’s new technology group surveys clinicians on what one technology change they would make, with the #1 answer by far being integration of patient records.

A GAO report finds that two-thirds of air ambulance transports, which cost an average of around $40,000, are out-of-network for insured patients. That means they are billed for huge balances even though they didn’t make the decision to call in an aircraft instead of using ground ambulance. Air ambulance providers are prohibiting from balance-billing Medicare and Medicaid patients, but privately insured passengers are fair game.

The Kansas City lakefront estate of former Cerner CEO Neal Patterson is put up for online auction. The 13,000-square-foot house on four acres was built in 1993 by the development company owned by Patterson and Cerner co-founder Cliff Illig, which created the gated Loch Lloyd community in which the house is located. It is appraised at $3.26 million. Patterson died in July 2017.

Several board members of University of Maryland Medical System resign or take leaves of absence following investigative reports indicating that one-third of the board members have business dealings with the health system, one of them being Baltimore Mayor Catherine Pugh, who says she’s a victim of a “witch hunt” in failing to disclose her deal. She sold the health system $500,000 worth of her self-published children’s books, of which not a single copy has ever been bought by anyone else.

I missed this earlier: Rochester Institute of Technology researchers begin commercialization of a cardiovascular monitoring system embedded in a toilet seat, which they expect to sell (via their Heart Health Intelligence startup) to hospitals hoping to reduce readmissions of congestive heart failure patients. I assume it works better for women.

Sponsor Updates

• EClinicalWorks will exhibit at Endo Expo 2019 March 23-25 in New Orleans.
• Hayes Management Consulting will host a networking event at the 2019 HCCA Compliance Institute April 8 in Boston.
• Imprivata will exhibit at Texas HIMSS March 25-26 in Austin.
• InterSystems will exhibit at the AMIA Informatics Summit March 25-28 in San Francisco.

Blog Posts

• What’s New in MIPS 2019 (PMD)
• How to level up for a role in Data & Analytics (Nordic)
• 2019 Health Care Industry Reports Reveal How Technology Adoption Impacts Medication Access (CoverMyMeds)
• Embrace the Evolution of Budgeting and Revolutionize Your Hospital’s Workflow (EPSi)
• Preventing Provider Burnout (Formativ Health)
• 4 Questions with Dennis Delisle, President & CEO, Methodist Hospital Foundation (Optimum Healthcare IT)
• The Rule of 40 in HIT: Should your Company Prioritize Profitability or Growth? (HGP)
• Safety Review: Fluoroquinolone (Healthfinch)
• Three Impacts of a Third-Party Security Breach (Iatric Systems)
• 2019 Update on Radiation Exposure (Impact Advisors)
• Essential Metrics for Improving Access Center Experience: Delighting Patients as Healthcare Consumers (Kyruus)

Contacts

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

EPtalk by Dr. Jayne 3/21/19

Several people texted or emailed links to the recent Fortune /Kaiser Health News investigative article on electronic health records. I enjoyed the video sound bites at the beginning, where various members of the US government were extolling the benefits of electronic records. The piece hooks the reader by opening with a story that details a patient’s death from a brain aneurysm, with the lack of diagnosis being influenced by failure of the head scan order to be transmitted by her physician’s EClinicalWorks EHR.

The article goes on to detail a stunning array of patient safety issues and medical errors tied to EHR use, noting the gag clauses that vendors use to keep their clients quiet. eCW isn’t the only vendor called out in the article – Epic, NextGen Healthcare, Allscripts, and Greenway Health were noted as having been the target of lawsuits and complaints.

It’s a long article, but worth the read. It reminded me of some of the industry’s antics during the push for EHR adoption that I had forgotten: the availability of eClinicalWorks systems at Walmart’s Sam’s Club and various vendors holding nationwide “stimulus tours” and “cash for clunkers” roadshow dinners that offered physicians an opportunity to switch to a new EHR.

Although there wasn’t anything truly shocking in the article, I wonder what non-industry people would think about its content and how the events unfolding in the EHR industry parallel (or don’t parallel) what might be going on in other industries. I’d be interested to hear what any non-health IT folks who read the piece think about our little slice of the economy.

The National Resident Matching Program, a.k.a. “The Match,” was held last week. This year’s process was the largest on record, with 44,600 applicants vying for more than 35,000 residency training positions. Not surprisingly, newly-minted physicians voted with their feet and their pocketbooks. Competitive specialties that filled all available positions included interventional radiology, otolaryngology, plastic surgery, and thoracic surgery. Many of those filled more than 90 percent of their slots with graduating US allopathic (MD) seniors.

Despite the fact that primary care physicians are supposedly in demand, specialties that filled fewer than 45 percent of their slots with US MD seniors included family medicine, internal medicine, and pediatrics. The remaining primary care slots are being filled by osteopathic (DO) seniors and international medical graduates. Until things change dramatically, we’re going to continue to see medical students shy away from the parts of the workforce where they’re needed the most.

I ran across an interesting piece on how working long hours and weekends might affect men and women differently. The underlying study looked at workers in the United Kingdom and found that women are more negatively impacted by long hours. Working on the weekend impacts both subgroups, but in different ways. Women working long hours were more apt to show depressive symptoms than those who worked fewer full-time hours or part-time. Men working long hours didn’t show a significant rise in depressive symptoms.

My family lives in an “opt in” state for data sharing on the state’s health information exchange. Fortunately, the big players in their town all participate. When my uncle was recently hospitalized at Big Health System, my dad was excited to find a pamphlet on the value of opting-in to HIE sharing while going through the admissions documents. Since he understands the value of having multiple clinicians be able to share data, he went to the nursing station to obtain the appropriate forms to opt his brother in. The person he talked to seemed surprised to learn about the pamphlet and didn’t have any idea what forms were needed. He was redirected to the medical records department deep in the bowels of the hospital, and they didn’t have any idea either. He was forced to call the number on the pamphlet to try to get information, which wasn’t terribly fruitful. Documentation 1, Patient 0.

Walmart is taking advantage of domestic medical tourism by sending patients across state lines for consultations and second opinions. The company’s Centers of Excellence Program matches patients with a short list of hospitals, including Mayo Clinic and Geisinger Medical Center, for certain surgeries and treatments. While it was optional for the first six years it was in existence, participation has been required since 2018. Geisinger plans to expand similar programs to other companies besides Walmart. This approach is quite a change from what many of my patients experience, where they can’t find specialists who even accept their insurance.

Maybe your mom was right: going out and getting some fresh air can be a game-changer. A study recently published in the International Journal of Environmental Health Research shows that spending 20 minutes in a park can improve wellbeing. Participants visited urban parks in Birmingham, Alabama during the summer and fall. From experience, being outside in the summer in Alabama can be a challenging mélange of heat and humidity, so I’m glad they included another season. Subjects weren’t told what to do in the park or how long to be there, but were monitored with fitness trackers and questionnaires. Wellbeing scores rose in park attendees.

Washington DC-area pediatrician Robert Zarr has been a fan of sending patients outdoors for a long time, founding ParkRxAmerica to help providers “prescribe Nature” as a way to decrease their patients’ burden of chronic disease and increase health and happiness. Zarr believes that writing the prescription in the EHR just like a medication makes it more specific and motivates patients to actually follow the instructions. This has also been done by National Health Service GPs with good outcomes. The US National Park Service has a Health Parks Healthy People program to advance the idea that “all parks – urban and wildland are cornerstones of people’s mental, physical, and spiritual health, and social well-being and sustainability of the planet.” People who know me know I’m a huge fan of the US National Park Service, and after paying my recent tax bill, I’ve decided to visualize 100 percent of my federal taxes going to support it. I made it to Redwood National Park last summer and would be happy to write a script for anyone who’s interested.

What’s your favorite National Park? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 3/21/19

CMS Awards IMPAQ Contract to Support Patient Safety Measure Development and Maintenance

Impaq International signs a five-year, multimillion dollar contract with CMS for the development, implementation, and maintenance of patient safety measures used in the the Hospital Inpatient Quality Reporting program, Hospital-Acquired Condition Reduction program, and the Promoting Interoperability program.

ZOLL Reports Recent Data Security Incident

Critical care device and software company Zoll notifies customers and patients of a data breach that occurred when a third-party vendor left emails exposed during a server migration late last year.

SA Health upgrades to latest version of Allscripts EMR

SA Health in Australia upgrades its Allscripts Sunrise software after a report found numerous problems with the health system’s EHR and patient administration project.

Morning Headlines 3/20/19

Primus Capital Provides Growth Investment in Harmony Healthcare IT

Health data archiving company Harmony Healthcare IT secures an unspecified amount of funding from Primus Capital.

Unite Us Raises $35 Million to Bridge the Gap Between Health and Social Care

Healthcare and social services coordination software vendor Unite Us raises $35 million in a Series B funding round.

Teladoc Health to Expand Global Reach with Acquisition of MédecinDirect

Teladoc acquires French telemedicine company MédecinDirect.

News 3/20/19

Top News

A Kaiser Health News – Fortune article titled “Death By 1,000 Clicks: Where Electronic Health Records Went Wrong” says the federal government’s Meaningful Use program cost $36 billion, yet 10 years later, the system is an “unholy mess.” It makes these points:

• Malpractice and whistleblower lawsuits have exposed an underreported number of cases in which patients were potentially harmed by EHR problems.
• EHRs remain a “sprawling, disconnected patchwork” of systems that now-unhappy users bought quickly to collect incentive payments.
• Doctors aren’t allowed to publicly talk about observed safety issues because of “gag clause” requirements of either their employer or their EHR vendor.
• A survey found that 20 percent of consumers found mistakes in their EHR records, most often involving medical history.
• User customization makes it hard to compare safety records across health systems and sometimes the site’s own configuration creates the problem.
• Experts note that while the EHR solved several problems, it created a big one lacking visual cues to assure clinicians that they are working in the intended patient’s record.
• A MedStar usability study found that an ED doctor ordering Tylenol is faced with a drop-down that lists 86 options, many of them inappropriate for a given patient.
• The article includes a brilliant comment from WellSpan SVP/CIO Hal Baker, MD: “Physicians have to cognitively switch between focusing on the record and focusing on the patient … I have yet to see the CEO who, while running a board meeting, takes minutes, and certainly I’ve never heard of a judge who, during the trial, would also be the court stenographer. But in medicine … we’ve asked the physician to move from writing in pen to [entering a computer] record, and it’s a pretty complicated interface.” 
• The urgency to dump money into the Meaningful Use program in 2009 – it was part of an economic stimulus program that targeted  “shovel-ready” projects – left too little time to consider interoperability or broader improvements an instead rewarded only widespread adoption.
• EHR vendors rushed out aggressive sales tactics to get their place in the EHR Meaningful Use land grab, figuring they could fine-tune implementations afterward, leading to customer complaints and lawsuits over shoddy software and patient harm.
• An unknown number of doctors and hospitals falsely attested to EHR use to earn incentive payments.
• Patients still can’t get copies of their own medical records easily and inexpensively from hospitals.
• Some patients who are suing for malpractice claim that hospital employees changed EHR entries after the incident and refused to turn over audit logs that would prove it.

Thoughts on the “Death By 1,000 Clicks” Article (And Your Chance to Weigh In)

This article was a good rehash of how we went from the first glimmers of Meaningful Use to today’s “unholy mess.” It doesn’t contain much of anything new for industry followers, but it will reach a mass audience as the Fortune cover story.

The Past, Which By The Way, Can’t Be Changed

• Healthcare was slower than most industries to adopt technology.
• Meaningful Use was an ill-conceived, rushed stimulus project that paid EHR-resistant doctors to use (not necessarily buy) EHRs in government-mandated ways with the vague hope that patient care and cost would improve once they were in place.
• The short payment timelines discouraged innovation as providers were forced to buy the same outdated systems they didn’t want before the government offered bribes.
• EHR vendors fought for their share of the resulting taxpayer-funded windfall with aggressive sales tactics and over-the-top marketing that were a lot more sophisticated than the old EHRs that were gathering dust on their shelves.

Provider Greed Made Today’s Undesirable EHR Situation Possible

• Hospitals and practices bought whatever inexpensive, quickly implemented system would get their faces into the government trough as quickly as possible.
• They did the bare minimum required to earn incentives.
• The government used the honor system of unverified attestation to trigger checks, leading some providers to lie.
• In the case of larger practices and most hospitals, they didn’t ask (and didn’t really care) what physician users thought of the systems they considered before buying.
• They customized new EHRs to work like paper charts and their old systems.
• They under-invested in training, physician support, and optimization, opting instead to push the decisions of committees – often with minimal user involvement – to the front lines.
• Freshly armed with the technical means to allow easy sharing of patient data, they have refused to do so.
• They didn’t allow doctors to publicly share EHR-related patient safety information because of malpractice concerns, competitive worries, and the lack of incentive to help someone else’s patients.

The Challenges to Making It Better

• Doctors and hospitals don’t believe in standardizing processes, either within their own organizations or across competing ones. They all believe they have a self-developed secret sauce that is better than everyone else’s. The same patient will receive different care depending on where they go in the absence of “one best way.” You don’t want to be the developer that has to code around that.
• Doctors and other clinicians are the only professionals who are expected to perform their own clerical work and to perform data entry during professional encounters. Hospitals are willing to force their doctors to perform tasks that other professional employers (law firms, accounting practices, and even dental practices and veterinary practices) would find not only insulting, but a waste of highly-paid resources when lower-skilled employees could do the work.
• The executives who require doctors to use computers generally don’t use them themselves.
• Only a tiny part of what is entered into an EHR directly contributes to patient care and the user of that information is often not the person who enters it.
• Doctors don’t like to have bosses or to have their decisions questioned, yet ancillary departments and EHRs catch and prevent their mistakes regularly, creating tension between doctors and almost everyone else, especially when the doctor is not a hospital employee. Everybody thinks they understand patient care – or at least their particular pet aspect of it — better than everyone else.

The Big Question: What Would An EHR Look Like If Clinicians Designed It For Themselves?

We will never know because clinicians don’t drive our healthcare system. It’s mostly overseen by hospital and practice executives, insurers, regulators, and the government. I would also wager that getting consensus would be impossible since nearly every doctor mistakes their opinion for irrefutable fact.

There’s also the question of whether clinicians have enough of a broad view to design software that will be used by thousands of users. EHR design is the de facto consensus of a broad swath of users in the most heavily represented specialties and user configuration options are the safety valve for practice deviations (which is why EHRs are so deeply configurable).

It’s also a pie-in-the-sky fantasy that a clinical system should be as easy to use as Facebook, Amazon, or an IPhone. It’s true that those systems empower their users with smart design, but their functionality is comparatively simple and users are motivated because their purpose is largely recreational.

The Bottom Line

EHR vendors are incented to create the systems that customers will buy. Companies selling well in a contracting EHR market Cerner, Epic, EClinicalWorks, etc. – are delivering what customers want (“customers” not necessarily being synonymous with “users.”) They have no incentive to build products that everybody hates, and given the competitive environment, they would do whatever they can to gain market share.

The underlying business model drives EHR design, and that’s what a lot of clinicians don’t like (and especially their place in it). That resentment gets pushed both down and up.

There’s still an immediate need for not only allowing, but encouraging system users to publicly and anonymously report patient-endangering software bugs. Vendors have not done a good job in pushing these notices out, and even in cases where they do, word doesn’t always filter down from the hospital’s IT department to end users.

Now Comes Your Part

Enough griping about EHRs or leaving laypeople to draw their own conclusions about them. What would you change? Tell me here,  be specific, and assume (as EHR vendors are expected to do) that our screwy US healthcare system is off the table.

Webinars

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

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

Acquisitions, Funding, Business, and Stock

Health Catalyst hires bankers to initiate its IPO.

Announcements and Implementations

Apple quietly rolls out new models of the IPad Air and IPad Mini. The former has a larger display, a processor that’s three times faster, and support for the Apple Pencil, while the latter hasn’t changed much except to add Pencil support (and thus supports high-margin Pencil sales). Apple seems more focused on the impending announcement of its video streaming service and other high-margin, non-commoditized services.

Sopris Health claims that its chat-powered digital assistant app allows clinicians to create a visit note in 45 seconds, or the time required to walk from one exam room to the next. Co-founder and CEO Patrick Leonard previously worked for Aetna’s consumer technology group and was CTO of the symptom-checking app ITriage that Aetna acquired in 2011 along with its developer, Healthagen.  

A new KLAS report on the medical oncology technology needs of community cancer canters finds that Flatiron Health leads the pack, as Cerner, Epic, and McKesson Specialty Health lag in supporting workflows. Cerner and Epic also score poorly in connecting with EHRs of other vendors.

Government and Politics

A whistleblower lawsuit brought by two former IT employees of Community Health Systems accuses the for-profit hospital chain of submitting fraudulent attestations for Meaningful Use, reaping $544 million in incentive payments in 2012-2015. It adds that CHS acquired 60 hospitals of Health Management Associates that attested to Meaningful Use payments even though their Pulse EHR was poorly integrated and require printing paper at multiple stages during a patient’s stay. The lawsuit also claims that Medhost made false statements to get its EHR certified under Meaningful Use Stage 2. The former employees also say that CHS used Medhost partially because of illegal kickbacks in the form of providing free Medhost Financials with the purchase of its clinical applications.

The White House’s US Digital Service says the VA’s newly developed online eligibility tool for veterans who seek private care under 2018’s MISSION Act is so flawed that it should be scrapped. warning that it will be slow, will cause errors, and will require an extra 5-10 minutes for each appointment booked. The report says VA contractor AbleVets isn’t the problem – it’s the VA’s poor oversight and a rush to bring the system live in June without adequate testing or integration with six existing VA systems. VA doctors are already pushing back, with one saying, “These people are out of their minds. We aren’t housekeepers, doorkeepers, or garbage men.” The VA says it needs $5.6 million to finish work on the system, which it says will cost $96 million in this fiscal year. An inefficient approval and scheduling process caused major delays in the VA’s 2014 rollout of a similar program, creating the need for this new project.

Other

Samuel Shem, MD – who in 1978 wrote what might be medicine’s most enduring novel in “The House of God,” which is a lot like MASH except more clinical and more cynical– calls EHRs “the new bullying to all of us in medicine.” He calls EHRs “an epic intrusion and frustration in our doctors’ lives” that require more time than actually delivering care, He also notes that EHRs are billing machines that have not been proven to improve safety or quality of care. I’ve read “House of God” many times and hereby give you some teasers to encourage you to do the same:

• “The delivery of good medical care is to do as much nothing as possible.”
• “It’s an incredible paradox that being a doctor is so degrading and yet is so valued by society.”
• “Gomers (Get Out Of My Emergency Room) are human beings who have lost what goes into being human beings. They want to die, and we will not let them. We’re cruel to the gomers, by saving them, and they’re cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them.”
• “To do nothing for the gomers was to do something, and the more conscientiously I did nothing, the better they got.”
• “It ain’t easy to do nothing, now that society is telling everyone that their body is fundamentally flawed and about to self-destruct. People are afraid they’re on the verge of death all the time.”

For more insightful medical wit, check out retired ED doc and author Rada Jones, MD, who describes herself as, “I speak like a vampire since I lived most of my life in Transylvania” and who just relocated to Thailand with her husband. She offers “47 Tips to Keep You Away From My ER” (which actually contains 49), one of which is, “NEVER EVER stand around minding your own business. It’s the most dangerous thing known to man. 90 percent of my assault victims were doing just that.”

Glen Falls Hospital (NY) reaches a confidential settlement with Cerner over the $38 million of revenue it lost due to billing problems after go-live.

A study finds that implementing EHR-generated severe sepsis alerts didn’t improve treatment performance measures or patient outcomes. Two-thirds of the alerts were true positive, but only eight percent of those doctors used the EHR sepsis order set, with two-thirds saying they would rather enter their own orders and 58 percent expressing skepticism about whether the alert captured a meaningful change in clinical status.

Stat notes that despite the hype associated with Stanford’s widely reported study of the Apple Watch’s ability to detect atrial fibrillation, it’s hard to look at the overall effects since the study was not a randomized controlled trial and instead just observed what users experienced. It did not look at false positives, how many doctor visits resulted, the conclusions from those visits, and whether wearing the Watch can actually improve the health of a large population.

Doctors in England express concern about fast-growing online visit provider Babylon, which NHS has embraced under its GP at Hand program. Local NHS cost have skyrocketed as 40,000 Londoners have joined Babylon’s program, which as a medical group requires people to leave their local practice (which patients often don’t understand), creating economic upheaval under NHS’s per-patient payment model that looks at where the practice – not the patient – is located. Doctors also complain that Babylon attracts the most easily managed patients, sticking them with the more complex ones under the fixed payment. Insiders also raise questions about the company’s AI-powered chatbot, which sometimes delivers flawed results and has not  been peer-reviewed.

At least 48 adult strangers find that they are half-siblings after taking home genetic tests and sharing their results, their newly discovered father being an Indiana fertility doctor who admits that he used his own sperm instead of that of donors in the 1970s and 1980s. Meanwhile, some former writers for “The Onion” launch a home DNA testing parody site called “DNA Friend.”

Sponsor Updates

• AdvancedMD will exhibit at NATCON March 25-27 in Nashville.
• Aprima will exhibit at the AIMSVAR Annual Conference March 21-22 in San Antonio.
• EClinicalWorks publishes a case study of the implementation of ECW’s population health management tools at Adult Medicine of Lake County (FL).
• Avaya announces further integration with Google Cloud Contact Center AI.
• Bernoulli Health becomes an Affiliate member of the Intel IoT Alliance; its Bernoulli One solution has been named an Intel IoT Market Ready Solution.
• Culbert Healthcare Solutions will exhibit at AMGA March 27-30 in National Harbor, MD.
• Divurgent launches a data and analytics approach to address physician burnout.

Blog Posts

• Visit the Access Virtual HIMSS Booths (Access)
• What NOT to do When Working with a VBC RCM Outsource Supplier (AdvancedMD)
• Massachusetts General’s 3-step approach that cut readmission risk for substance use disorders by 25% (Advisory Board)
• We’re expecting! (Agfa Healthcare)
• Cloud & Managed Server Hosting for Healthcare Professionals (Atlantic.Net)
• Care Team(work): 5 Ways Health IT Supports Collaboration (Spok)
• Part II: 10 of the toughest questions to ask before or during a transition to Epic Single Billing Office (Bluetree)
• ECRI report provides a roadmap for improved patient safety (Bernoulli Health)
• Should I Build or Buy Compliance and Integrations in 2019? (Datica)
• 2019 Update on Radiation Exposure (Impact Advisors)
• Increasing EHR Vendor Usability in Three Simple Steps (ChartLogic)
• The Rise of Specialty Medications: Hope for Patients, Hurdle for Health Care (CoverMyMeds)
• 6 Questions from the 2019 Best in KLAS: Software and Services Report You Should Consider (Dimensional Insight)

Contacts

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

Morning Headlines 3/19/19

Malfunctioning billing system leaves scars on Glens Falls Hospital

Glenn Falls Hospital (NY) reaches a confidential settlement with Cerner after a $38 million loss attributed to its faulty billing system.

Beware the hype over the Apple Watch heart app. The device could do more harm than good

STAT points out that the highly-publicized results of an Apple Heart Study on a-fib detection conducted by Stanford University should be taken with a grain of salt, given that it was an observational study without a control group of non-Apple Watch users.

The messy, cautionary tale of how Babylon disrupted the NHS

Babylon’s GP at Hand telemedicine clinic in London offers NHS patients a tech-friendly alternative to traditional clinics, but is placing an unexpectedly burdensome strain on local resources and staff.

$1 billion Sequoia-backed Health Catalyst has picked lead banks for its IPO

Sources report that Health Catalyst has selected Goldman Sachs and JPMorgan to handle its IPO.

VA’s Private Care Program Headed for Tech Trouble, Review Finds

A US Digital Service review finds that private-care eligibility software developed by AbleVets on behalf of the VA should be scrapped due to numerous flaws resulting from a rushed development timeline.

HIStalk Interviews Cedric Truss, DHA, Director Health Informatics Program, Georgia State University

Cedric Truss, DHA, MSHI is director of the health informatics program and clinical assistant professor of Georgia State University of Atlanta, GA.

Tell me about yourself and your program.

I’ve been at Georgia State since August 2017. We offer a bachelor’s of interdisciplinary studies and health informatics. With that program, we partner with the College of Business, so students take courses under the College of Business and within the College of Nursing and Health Professions.

A reader who ran across your students at HIMSS19 said they were engaged, asked great questions, and were enthusiastic. How would you describe their participation? What impressions were they left with?

I’ve gotten a lot of great feedback from some of the students. For some, it was their first time going, Some went last year in Las Vegas. They enjoyed both of the conferences. They said that they were able to connect with some of the companies and to talk with them about some of the things they have been learning in the program.

For instance, we talk about all of the EHR companies throughout the program, so students talked with individuals from Cerner, Epic, Athenahealth, and Allscripts. They were able to get feedback from those who are actually doing the work and to see how it applies to their learning in the program.

How do you cover the theoretical parts of informatics while also exposing students to the real-world aspects that they saw at HIMSS19?

We have a curriculum that’s set around the different areas of what encompasses health informatics. Throughout those different courses, we talk about the theory of why things are the way they are and how to actually make them work in practice.

We have a local Georgia HIMSS chapter and individuals come in to the program and talk to students in the different courses. They explain how what they are learning is applied. This past year we started doing something new. We’re participating in the academic organization affiliate program that HIMSS offers, so we provided all the students with memberships this year. This was the first time that we’ve done this and it is a success, so we will continue doing it.

Were students surprised at the size of the conference and the level of activity around the industry?

Yes, they were, especially for those for whom it was their first time going. I’m glad that it was in Orlando, because it was much closer. They came back and said, OK, now I know what I want to do, or I can pinpoint it. Being able to see this, I can decide what I really want to do and what I want to go into long term.

Yours is a professional program, where students are required to complete pre-requisites and then apply. What kind of applicants do you typically get?

We mainly get students who know they want to do healthcare, but they don’t want to deal with patient care or have hands-on patient care. That’s the majority of the students that we get. We’ve had some that were in the nursing program, and after seeing what they would have to do, they decided, “I don’t want to do this.” They come check out health informatics and fall in love with it.

We’ve also had a couple of students come from the business school. After looking at some of the CIS majors that they offer, they decide this is a better fit for them and the type of career they’re looking to go into.

What careers do they want to pursue?

A lot of students mention project management and analytics, whether it’s data analytics or performance analytics.

Many informatics programs target people who have earned clinical degrees. How does the science aspect of informatics fit with the caregiver side?

You’re not providing direct patient care, but you are providing patient care. You’re making sure systems are working properly so the caregiver or provider can provide you care. If it’s a nurse or a physician at Clinic A but you’re going to Clinic B, that provider can go into the system to see what you have had done, be able to provide the care that you need, and not do something that’s unnecessary, like maybe give you another vaccination that you’ve already gotten or diagnose you with something that you’ve already been diagnosed with.

You’ve worked in different parts of the industry. Is the academic setting different?

[laughs] It is completely different working in academia versus working in the industry. I did enjoy the industry. I loved it. I don’t get to participate as much now in the industry, but I’ve been able to develop new partnerships with those who are in the industry so I can create the pipelines for students to talk with those individuals who are practicing, do internships at these organizations, and even gain employment at these organizations after graduation. It’s been a great fit for me here in academia.

Is there a recognition among your students that Atlanta is such a stronghold of health IT?

There is. We have a lot of health IT companies here in the state of Georgia. Actually, Georgia is considered the health IT capital. A lot of the students are aware of what’s here and the many different opportunities that they can have. We have a lot of health IT startups here as well. That makes the area stand out quite a bit. It gives students an opportunity to say, if I go through this program and I have this idea, I can have my own startup here as well.

How do your students view their future work life differently than the generations that preceded them?

A lot of them are wanting to do different things. Some of them would like to develop their own business. Some of them are interested in traveling and consulting.

I have a master’s in health informatics, so when I went into that program, my idea was that I wanted to be a CIO. But once I got towards the end of that program, I decided that’s not what I wanted to do any more. The opportunities I have had expanded my knowledge and my interest in different areas. The students see what I’ve done and talking with them gives them an outlook that they can do many different things, whether it’s to start their own company, work for other organizations, or travel and be consultants.

Your doctoral dissertation was on hospital ransomware attacks. What are your takeaways from that?

A lot of hospitals were not focusing on security when they were implementing the EHR. I think they figured that they were covered since they had software and a vendor that potentially had them protected from all of that. But I think they need to take steps and have their own policies and procedures in place to prevent that from happening.

How could someone get involved to help your program?

They can go to healthinformatics.gsu.edu. There’s a lot of information on there and it has some contact information as well. Or if they want to reach out to me directly, ctruss@gsu.edu or 404.413.1222. They’re welcome to call me directly and we can discuss options.

Curbside Consult with Dr. Jayne 3/18/19

There was another big story about telemedicine in the news this week, this time about a young man who had to undergo what sounds like a competency evaluation via video prior to signing a “do not resuscitate” document. Regardless of the telemedicine situation, the story is heartbreaking. A young man with testicular cancer is dying. His wife did not have power of attorney, and it sounds like the hospital was concerned about his ability to legally sign the document.

The focus of the story is the telemedicine angle, whether it’s poor connectivity, level of compassion, etc. I haven’t seen a news piece, however, that addresses the other issues that are brought to light by the situation. Namely, how it got to that point in the first place.

This was a patient with a recurrence of testicular cancer, which is a serious situation. Of course, we don’t have all the medical details of the case, but there are some non-medical issues at play here. For an oncology patient with a young family, we should hope that a comprehensive advance care planning session should include not only discussion of end-of-life wishes, but also the need to have the appropriate legal documents in place. These discussions need to happen early in treatment, while the patient can discuss with their family and make good decisions and before events unfold that put decision-making capacity in question.

Seeing the pictures of his young daughter made me wonder if he had a will, and if so, did the attorney involved (if there was one) also advise on advance directives and power of attorney documents? We always think about healthcare organizations supporting patients in these situations, but what about legal organizations? Are there channels for attorneys to volunteer services to families like this to ensure they have the supports they need? Why is it always the physicians and hospitals that bear the brunt of responsibility for failure in these heart-wrenching situations?

I know I’ve covered this topic before, but everyone needs to have these conversations, whether you’re sick or well. We never know what is going to happen, what illness or speeding car might strike us down. However, in the situation where someone potentially has a terminal illness, it should be happening without fail.

I don’t know about the laws in the jurisdiction where this story occurred, whether a psychiatrist specifically was needed for the determination of capacity or whether anyone else in the hospital could have done it. We don’t know if this was the middle of the night or the middle of the day. Perhaps the video consult was offered up as a way to speed things, if it would have taken longer to bring the appropriate clinician into the hospital. There aren’t a lot of facilities that keep psychiatrists in-house at all times, so maybe the choice that was made was the best one at the time even if it didn’t play out as the family expected. Approaching end of life is challenging enough even when all the paperwork is in place and the family is supportive of the patient’s wishes. 

My thoughts go out to everyone involved. I encourage everyone out there, young or old, healthy or not, to have these conversations with your family members and to make sure you have the right paperwork in order to make the best of a terrible situation when the time comes. Eventually, death comes for us all.

Another situation I ran across this week that demonizes technology without addressing other “comorbid conditions” was an interview with Eric Topol. This time, EHRs are the bad guy, but artificial intelligence is going “make healthcare human again,” at least according to his newest book. I don’t know Dr. Topol other than by what I have ready in his books and in various interviews, but I’m awfully tired of people who seem to have all the answers to what are undoubtedly very complex problems.

Topol lists EHRs as “the single worst part of the deteriorating doctor-patient relationship.” Although I agree they’re a factor, I personally think the worst part of the deteriorating relationship is the devaluation of the relationship itself. Because our medical system in the US is so broken, people no longer value the concept of a lifelong primary care physician who is going to know you as a patient and understand what optimal health means for you. We’ve sacrificed it on the altars of cost and convenience because those elements are more important for many of the people in our society. We’ve decided that it’s more important to treat populations (numbers) than people (outliers) and have incented people to behave in a way that supports that. Providing clinical expertise has become transactional and commoditized.

I feel this acutely every day that I see patients, especially on those days when I am part of a story that starts with a seemingly minor medical problem and ends with, “I went to the urgent care and now I have cancer.” I never dreamed that as an urgent care physician I would diagnose the number of life-threatening conditions that I see on a regular basis. It falls to us because people don’t have primary care physicians, they can’t get in to see them, or they can’t afford to get medical care. Once I diagnose people and refer them to the appropriate subspecialists, they’re generally lost to me unless they follow up with a card or a note. However, they don’t leave my mind and their stories haunt me every time I see a patient with a similar presentation.

Fixing EHRs isn’t going to fix the fragmentation in care. First, we have to decide as a society that unfragmented care is important. We have to decide that primary care and public health are important and we have to support those decisions with our pocketbooks.

I have a friend at a large health system that just spent half-billion (with a “b”) dollars on an EHR rip-and-replace. How much was she able to get as a grant for a school-based health clinic to serve children who never see a physician or other clinician? Zero. She had to pull together a coalition of community organizations to fund it despite her non-profit employer sitting on one of the largest cash reserves in the nation.

Topol says EHRs are “uniformly hated” and that’s just not the case. Sure, we dislike clunky interfaces and click-happy screens, but we sure love being able to process a drug recall in 90 seconds and notify 10,000 patients with a dozen clicks. We never loved our paper charts (and some of us hated them), but in reality, how many people “love” the tools they use for their work? Do mechanics love their tools? Do bankers love their tools? Do teachers love smartboards more than they loved chalkboards or whiteboards? Talking about the dynamics of love/hate just raises emotions and makes it harder for us to rationally evaluate what we’re really working with and how we are able to use it well vs. struggle with it.

Topol does at least give a passing mention to the healthcare disparities in the US, noting that increased use of AI and data “could make things much worse if these tools are only provided for affluent people.” We’re already at that point, where people struggle to pay for basic healthcare. If we can’t universally deliver vaccines (proven cost effective) to all people, are we really going to be able to afford gathering and analyzing all their data (not yet proven to be as spectacular as some people think)?

Fixing the EHR might make the day smoother, but it’s not going to fix the major underlying issues in healthcare. It’s not going to fix a hospital system that lowballs physician salaries in the name of value-based care, but turns around and builds a multi-million-dollar imaging center. It’s not going to fix an insurer that will pay $30,000 for a gastric bypass for a teenager after it wouldn’t pay $2,000 for an intensive weight management program that might have prevented or delayed the need for bariatric surgery. It’s not going to fix nursing ratios on patient care floors that are inhumane, not to mention unsafe.

I don’t have all the answers, but I’m pretty good at stirring up a discussion. What do you think is the worst part of the deteriorating patient-physician relationship? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 3/18/19

Change Healthcare on deck for IPO

Change Healthcare, valued at up to $12 billion, files IPO documents for a $100 million IPO.

Signify Health acquires start-up TAV Health in multimillion-dollar deal

Mobile health evaluation company Signify Health acquires TAV Health, which offers a platform to connect community and health partners to address social determinants of health.

Doctors Create an iPad Program to Help NICU Babies Get Home Faster

Doctors at University of Virginia Children’s Hospital develop an IPad-based system that allows NICU babies to go home earlier, replacing a pen-and-paper and call-in system for parents to report their baby’s feedings and weight.

A huge trove of medical records and prescriptions found exposed

EHR vendor Meditab leaves a server unsecured for nearly a year, giving anyone the ability to read the content of medical faxes in real time.

Monday Morning Update 3/18/19

Top News

Change Healthcare files IPO documents for a $100 million IPO. Analysts estimate the company’s value at up to $12 billion.

The company, of which McKesson owns 70 percent with two private equity groups holding the remainder, reports adjusted net income of $281 million on $3.3 billion in revenue in 2018.

Change took on $6.1 billion in debt to create the business last year in merging the former Emdeon with McKesson’s IT business, after which McKesson was paid $1.25 billion and PE firms Blackstone and Hellman & Friedman received $1.75 billion.

Shares will trade on the Nasdaq under the symbol CHNG.

CEO Neil de Crescenzo’s 2018 compensation was $8.3 million; former CFO Al Hamood (now president of ATI Physical Therapy) was paid $13.3 million; EVP Rod O’Reilly earned $5.6 million; former sales EVP Mark Vachon was paid $6.4 million; and EVP/CIO Alex Choy’s compensation was $3 million.

The six non-employee board members were each paid cash and options worth $400,000 to $573,000.

Seventeen of the 19 company directors and executive officers are male.

HIStalk Announcements and Requests

Last week’s poll is a toss-out since responses were evenly spread and few in number, so let’s move on.

New poll to your right or here, for HIMSS19 provider attendees: did you discover an interesting product or service that you will follow up on? Click the poll’s “comments” link if you vote yes to tell us what piqued your interest.

Webinars

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

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

Acquisitions, Funding, Business, and Stock

Mobile health evaluation company Signify Health acquires TAV Health, which offers a platform to connect community and health partners to address social determinants of health. Signify’s CEO is former Athenahealth SVP/Chief Product Officer Kyle Armbrester.

For-profit hospital operator HCA acquires a majority ownership in for-profit Galen College of Nursing, which offers instruction on five campuses and online.

People

Chris Belmont (Intelligent Retinal Imaging Systems) joins The HCI Group as EVP of strategy and operations.

ROI Healthcare Solutions hires Brent Prosser (Infor) as SVP of sales.

Announcements and Implementations

Peterson Regional Medical Center (TX) goes live on Meditech Expanse with patient accounting and supply chain help from CereCore.

Privacy and Security

Singapore’s Health Sciences Authority reports yet another healthcare-related breach in that country after discovering that one of its contractors failed to secure an online database of blood donors containing the information of 800,000 people. The website of the contractor, Secur Solutions Group, has gone offline.

Other

A large RN survey finds that a hospital’s work environment plays a big part in whether nurses are satisfied with the hospital’s EHR and how they perceive its contribution to patient care and safety.

The Canberra, Australia newspaper reviews the 40 patient safety bulletins issued to EHR users in 2018 by the Cerner project team at Queensland Health, many of related to software updates. They include problems with children’s weights, unexpected drug name changes, switching to the wrong record when multiple patient windows are open, and creation of duplicate encounters.

A Virginia woman complains that her dying husband had to endure a low-quality, 35-minute telemedicine encounter with an Inova psychiatrist who needed to evaluate his “do not resuscitate” request. She complained, “I hope there’s a real reflection in the medical community about the ethics of these teledoctors.”

Doctors at University of Virginia Children’s Hospital develop an IPad-based system that allows NICU babies to go home earlier, replacing a pen-and-paper and call-in system for parents to report their baby’s feedings and weight. The system sends data immediately to Epic. It was developed by Charlottesville-based Locus Health and its use has been expanded to 15 children’s hospitals. The designers are a pediatric cardiologist and his NICU pediatrician wife.

Ontario, Canada scraps a $500,000 public health vaccination reporting system and goes back to paper forms after finding problems caused by incompatibilities with physician EHRs, one of which was that the vaccine names don’t match.

The Atlantic covers the “uniquely American phenomenon” of medical debt, as 60 percent of people who file bankruptcy say medical bills played a major part. It says medical debt will probably increase as fewer people buy insurance, deductibles are raised, sales of poor-coverage junk plans increase, and out-of-network bills increase as insurers narrow their networks. The article focuses on how to negotiate a bill with a hospital:

• Ask about financial assistance, including charity care if uninsured
• Ask to be billed at the same rate Medicare pays
• Ask for a payment plan or full payment discount

A study finds that applying deep learning to just a few hundred patient EHR records can accurately predict the outcome of chronic diseases (rheumatoid arthritis in this case). The same model then works fairly well across other hospitals. The authors believe that decision support should involve training models on aggregated patient data from multiple healthcare systems, then extending the model to other providers.

Sponsor Updates

• NextGate and Nordic will exhibit at Texas HIMSS March 25-26 in Austin.
• Clinical Computer Systems, developer of the Obix Perinatal Data System, will exhibit at the AWHONN Virginia Section Conference March 17-18 in Charlottesville.
• Flywire and Experian Health will exhibit at the HFMA Revenue Cycle Conference March 20-22 in Austin.
• Recondo Technology and MedeAnalytics partner to create a single, powerful revenue cycle management platform.
• PatientPing publishes a new case study, “Houston Methodist Coordinated Care Achieves Savings of Over $680,000 Within First Year of PatientPing Partnership.”
• PatientKeeper will exhibit at Hospital Medicine 2019 March 24-27 in National Harbor, MD.
• SymphonyRM releases a new e-book, “Competing in an Amazon World: Four-Step Action Plan for Health Systems.”

Blog Posts

• Healthcare Strategy for Patient Engagement & Patient Payments: If Hospitals Don’t Drive, Regulators Will (Loyale Healthcare)
• How this health system reduced readmission rates to meet CMS requirements (Experian Health)
• Better Patient Financial Care Requires More than Software (Patientco)
• Keep Patients Safe Through Prevention of Physician Burnout (Practice Velocity)
• How to manage bundled payments? Build a better post-acute care network (PreparedHealth)
• What can healthcare learn from Facebook’s new “privacy-focused vision for social networking?” (Redox)
• API 101 – An Introduction to APIs (Sansoro Health)
• 5 Signs You’re Not Ready to Sell Your Practice (WebPT)

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
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