Morning Headlines 12/4/18

ResMed to Acquire Propeller Health, a Leader in COPD and Asthma Connected Health Solutions, for $225 Million

Connected health technology vendor ResMed will acquire Madison, WI-based Propeller Health for $225 million.

Tabula Rasa HealthCare to Acquire DoseMe, a Precision Dosing Software Company

Tabula Rasa HealthCare will acquire DoseMe, which will become part of its CareVention HealthCare technology and service division.

VA Shadow Rulers Had Sway Over Contracting and Budgeting

Newly released documents show that President Trump’s Mar-a-Lago Trio reviewed confidential VA documents including the $10 billion Cerner contract, despite having zero military or health IT experience.

Minnesota among states suing over health data hack

Minnesota is among several states suing several Indiana companies, including Medical Informatics Engineering, for a 2015 data breach that exposed the PHI of 4 million patients.

Curbside Consult with Dr. Jayne 12/3/18

My former employers at Big Hospital System recently reached out to me, requesting some assistance with practices they’ve acquired. In the years since I left, they’ve consolidated their empire onto a single EHR platform and have streamlined a number of IT departments including the EHR implementation team that I used to manage. The current implementation team is relatively green, having been hired with job descriptions that only allow them to address the new EHR, and not to think critically about or assist with any other systems. They’re also a relatively small team and their time is spoken for over the next 120 days. Whoever made the decisions to restructure the team this way apparently didn’t talk to the business owners of the employed physician group, which has continued to acquire independent practices at a rapid pace. These practices are then left in limbo because they can’t get a deployment slot on the new EHR for months and months, but they still have to try to run a practice either on their legacy system (if they owned rights to it and can keep it) or possibly even on paper.

The acquired physicians are frustrated and rightfully so. Being added to the main health system EHR platform was part of the decision-making for employment for many of these struggling independent practices, allowing them access to a repository of information about their patients along with professional referrals and communications. Several of them were already frustrated with their existing EHRs, and the idea of having to stay on broken systems for another six months is unacceptable. Unfortunately, they either didn’t understand or overlooked the contractual agreement regarding EHR migration, which clearly gives the health system control of the timeline for retirement of their current systems and movement to the mother ship’s platform.

I was asked to do some contract work with these practices, trying to reduce the frustration factor on their existing EHRs while they wait for migration. The health system also asked me to look at the installations from a support perspective, to determine the best strategy to handle upgrades and issues with the systems in the interim. I asked myself why this wasn’t done during the courtship process, and of course it has to do with money and convenience for the employer. That’s the way many physician contracts are these days, unless the contracting practice reads them with a careful eye and is willing to walk away if they don’t get an acceptable outcome. There’s also the factor of the physician group’s leadership assuming that the health system’s IT team would be willing and available to support the new practices and failure to gain an understanding of existing migration and implementation resources before setting a verbal (and unenforceable) timeline in front of the practices they were wooing.

I was happy to take on the work, not only because it was local and would keep me from having to travel much during the holiday season, but also because I know some of the impacted physicians personally, either on a professional basis or through community organizations. The work has been a flashback to my early days as a medical director for informatics, as I’d go out with recently-implemented physicians and try to optimize their day-to-day workflows. It’s always gratifying when you find quick wins that can impact physicians in a positive way – maybe they’re not using medication favorites or order sets. Those findings are common among small practices that may not have had dedicated EHR super users or that may not have spent the money and time needed for advanced training.

I’ve also had some flashbacks about working with systems that don’t seem to have a lot of clinical oversight. When I saw some of the workflows, they made me wonder whether a physician at the EHR vendor performed user acceptance testing before the content went out the door. One of the more obnoxious “features” I saw was part of a lab interface, where the ordering user has to handle those pesky but necessary “ask at order entry” (AOE) questions. For many tests, there should be a 1:1 relationship between the test code being ordered and the specimen type. For example, if you’re ordering “Stool for Ova and Parasites” the specimen type is “stool” and it should only have to be entered once. In one system I worked with, the ordering user (the provider in this case) had to enter “stool” as the specimen type twice for the same test. Since she was a GI doc and was ordering three different stool panels, she had to enter a specimen type of “stool” no less than seven times, even though each test was prefixed with “stool.”

I thought maybe it was just a configuration issue since there are situations where there still needs to be a more specific specimen type entered even though there is specimen information in the test name. For example, urine cultures – even though “urine” is in the test name, one has to specify whether it’s a clean-catch or catheterized specimen, etc. It was clear that it was a design issue, however, when we got to the blood tests, when the user had to select “venous draw” for all seven tests in the basic metabolic panel. That’s pushing absurdity, and no wonder the providers are frustrated since the BMP characteristically is performed using a single blood tube, not seven different samples.

I also ran into some examples of management absurdity. One practice has been performing weekly backups from their server, which resides in a data closet in the office. I asked them if they ever restore from the backups, and they said no. We talked a little bit about the need to practice downtime procedures and to make sure the backups are working properly. They agreed to do some downtime testing, and we restored the most recent backup to their test environment. I thought it was a bit weird that their test environment was hosted outside the practice but their production server was still in the closet. When we restored the backup, the most recent data entry was from June 2013. This led to some detective work, and after burning through some billable hours I was able to determine that they had been migrated from their self-hosted server to a cloud-based platform in the summer of that year. No one must have understood the significance of the migration, because the practice had been paying a third-party IT resource to perform regular backups of a server that was no longer being written to and had spent tens of thousands of dollars over the last five years for no reason. They were grateful that I figured out that they could stop with the backups, but were fairly aggravated about the whole situation.

I’m glad I can help some local physicians, but I hope they realize this is just the beginning of their relationship with Big Hospital System. The grass may have seemed greener on the corporate side of the fence, but now they’re just a handful of physicians among thousands. Despite what they may have been told during negotiations, they’re going to have to wait their turn for everything including migration to the shiny new EHR. In the meantime, I have a feeling we’re all going to get to know each other rather well as I spend some time on the helping side of the help desk.

How does your health system handle practice acquisitions? Are they live on the communal EHR day one? Leave a comment or email me.

Morning Headlines 12/3/18

U.S. judge raises prospect of not approving CVS-Aetna deal

A federal judge involved with the final legal step in the CVS/Aetna acquisition delays court proceedings, telling lawyers that he is very concerned and that “you all are proceeding on a rubber-stamp approach to this.”

AI health firm Myia raises $6.75m in seed funding

Remote patient monitoring startup Myia raises $6.75 million in a seed funding round led by BootstrapLabs and Zetta Venture Partners.

Improving Electronic Health Record Usability and Safety Requires Transparency

Physicians argue against EHR vendor gag clauses, saying that an inability to share screenshots and other types of visual media prevent end users from sharing and learning from usability issues that may endanger patients.

EMIS Group unveils the future of connected healthcare

Emis Group will shift 40 million patient records from its servers onto AWS as part of a continued  push in the UK for more flexible health data exchange.

Monday Morning Update 12/3/18

Top News

Reuters reports that a federal judge involved with the final legal step in the CVS/Aetna acquisition feels as if he has been just a cog in the wheel of a shady business deal – one that vocal opponents have said will drive up costs and steer patients away from traditional providers. Judge Richard Leon, who ended up pushing final court proceedings to December 3, told DoJ, CVS, and Aetna lawyers that after reviewing the approved motion, “I kind of got this uneasy feeling that I was being kept in the dark, kind of like a mushroom. I’m very concerned, very concerned that you all are proceeding on a rubber-stamp approach to this.”

Reader Comments

From underTheRadar: “Re: Allscripts. Allscripts is having significant layoffs this week. Rumor has it that 250 people in services and development will be let go. Merry Christmas.” Unverified. Comments left at TheLayoff.com from within the last week may provide some context:

• Most US based Paragon Support staff will be terminated on either 12/16/2018 or 2/1/2019. Offshore resources are not impacted and hiring.
• Just got the call, position no longer needed, last day 12/14.
• Was told seven US Allscripts offices closing before January, a consolidation effort. Separate from ongoing space reorgs, such as Alpharetta. Anyone know which offices?

HIStalk Announcements and Requests

A tiny pool of respondents finds more value in HIMSS than RSNA. Steve Gould says of RSNA, “Any show that doesn’t ruin Thanksgiving weekend with family provides more value. It is unconscionable that the dates have not moved to run Tuesday-Friday instead of requiring people to arrive either Friday or Saturday for a Sunday morning start.” John Wayne is a fan of neither: “I think both conferences are a waste of time and money and have become cash cows for the organizers with mediocre content, massive and poorly organized exhibit areas, and inconvenient dates with difficult travel requirements. Can’t the Internet make these obsolete?”

New poll to your right or here: As a consumer, are you worried about Amazon potentially using your medical data to influence your purchasing decisions?

HISsies nominations are still open. Coveted honors like “Industry figure in whose face you’d most like to throw a pie” and “Industry figure with whom you’d most like to have a few beers” will be based on your recommendations. Given that Jonathan Bush didn’t leave Athenahealth until June, I suppose he’s still eligible.

Webinars

December 5 (Wednesday) 1 ET. “Tapping Into the Potential of Natural Language Processing in Healthcare.” Sponsor: Health Catalyst. Presenters: Wendy Chapman, PhD, chair of the department of biomedical informatics, University of Utah School of Medicine; Mike Dow, senior director of product development, Health Catalyst. This webinar will provide an NLP primer, sharing principle-driven stories so you can get going with NLP whether you are just beginning or considering processes, tools, or how to build support with key leadership. Dr. Chapman’s teams have demonstrated phenotyping for precision medicine, quality improvement, and decision support, while Mr. Dow’s group helps organizations realize statistical insight by incorporating text notes along with discrete data analysis. Join us to better understand the potential of NLP through existing applications, the challenges of making NLP a real and scalable solution, and the concrete actions you can take to use NLP for the good of your organization.

December 6 (Thursday) 11 ET. “Make the Most of Azure DevOps in Healthcare.” Sponsor: CitiusTech. Presenter: Harshal Sawant, practice lead for DevOps and mobile, CitiusTech. Enterprise IT teams are moving from large-scale, project-based system implementations to a continuously evolving and collaborative process that includes both development and business teams. This webinar will review healthcare DevOps trends and customer stories, describe key factors in implementing a DevOps practice, describe how to assess Azure DevOps, and lay out the steps needed to create an Azure DevOps execution plan.

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

Acquisitions, Funding, Business, and Stock

Remote patient monitoring startup Myia raises $6.75 million in a seed funding round led by BootstrapLabs and Zetta Venture Partners. The San Francisco-based company has developed software that analyzes data from wearables and sensors to predict relapses in chronically ill patients. Co-founder and CTO Bryan Smith came to the company from PokitDok.

Decisions

• Eastland Memorial Hospital (TX) will switch from Azalea Health to a new EHR vendor. Two companies are under consideration.
• Adams Memorial Hospital (IN) replaced its Evident financial management software with technology from Harris Healthcare.
• Titus Regional Medical Center (TX) switched from Allscripts to Epic’s EHR and revenue cycle management software.

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

Announcements and Implementations

Memorial Hospital (NH) moves from three EHRs to Epic as part of its unification with MaineHealth.

In the UK, NHS vendor Emis Group will shift 40 million patient records from its servers onto AWS as part of a continued national push for more flexible health data exchange and easier set up of digital health services like video consults and chatbot triage.

Beatrice Community Hospital and Health Center (NE) goes live on Epic.

Other

In Finland, researchers determine that Instagram can be an accurate predictor of flu outbreaks after combing through 22,000 posts spanning six years and then comparing them with public health data from the same time period.

USA Today points out that the National Practitioner Data Bank is sorely underused by licensing boards when it comes to keeping up with malpractice payments and disciplinary actions taken against doctors. Nearly half of state medical boards checked the database less than 100 times last year, while 13 boards didn’t check it at all, amounting to 137,000 total searches by the boards. The analysis is part of a year-long investigation into medical licensing system deficiencies that have kept dangerous doctors in practice.

In JAMA, physicians argue against EHR vendor gag clauses, pointing out that an inability to share screenshots, video, and other types of visual media prevent end users from sharing and learning from usability issues that may endanger patients. They advocate for policies that require EHR vendors to:

• Permit the release of information in a timely manner when it informs the usability and safety of the EHR product and enables comparison of specific challenges across products.
• Promote a culture of safety that encourages identification and dissemination of usability and safety issues by EHR vendors and provider organizations.

Sponsor Updates

• TriNetX team members make 300 sandwiches for the Life Science Cares Food for Free program.
• LiveProcess will exhibit at the Oklahoma Hospital Association 2018 Convention & Tradeshow December 5-7 in Oklahoma City.
• LogicStream Health, OmniSys, and Sansoro Health will exhibit at the 2018 ASHP Midyear Clinical Meeting December 2-6 in Anaheim, CA.
• Inc.com features Waystar CEO Matt Hawkins in “31 Tech Predictions for 2019.”
• Netsmart will exhibit at the I2I Center for Integrated Health’s Visionary Voices conference and exhibition December 5-7 in Pinehurst, NC.
• The Visiting Nurse Association Health Group joins PreparedHealth’s EnTouch Network.
• Redox will host a networking event at the IHI National Forum December 7 in Orlando.
• Vocera will exhibit at the Healthcare Patient Experience Transformation Assembly December 3 in Denver.
• The Phoenix Business Journal awards WebPT President Heidi Jannenga with the Ed Denison Business Leader of the Year Award.

Blog Posts

• Tackling Complex Integrations to Enable Business Process Automation (Liaison Technologies)
• Managing Adaptive Change in Healthcare (Loyale Healthcare)
• Is Your Hospital Strategically Interoperable? (NextGate)
• Enhancing Autism Services with Technology (Netsmart)
• How to do more with patient portals (Experian Health)
• Medical Bills & Healthcare Payments: Lessons from a Mobile P2P App (Patientco)
• 5 ways your answering service is hurting your practice (PerfectServe)
• These Good Payroll Practices Will Get You Through Year-end Easier (ROI Healthcare Solutions)
• CMS Price Transparency rule enforced January 1, 2019. Are you ready? (TransUnion)
• 10 years on, Voalte still delivers the ‘wow’ factor. (Voalte)
• Q&A With the 2018 Ascend Practice of the Year Winner (WebPT)

Contacts

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

Weekender 11/30/18

Weekly News Recap

• Amazon will launch a software product for payers that combs through electronic patient records to find incorrect coding or diagnoses in an effort to improve quality and lower cost.
• The GAO will investigate rumored VA meddling by three political supporters of President Trump who said they “were anointed by the President” as private citizens, and whom some contend influenced the no-bid, $10 billion Cerner contract.
• Xealth develops software that enables providers to send patients digital recommendations for over-the-counter healthcare products, apps, and services from within their EHR and patient portal.
• CMS and ONC seek feedback on draft recommendations for reducing regulatory and administrative burdens caused by health IT and EHRs.
• Unsealed court documents reveal that two Iranian hackers were responsible for SamSam ransomware attacks on 200 organizations in the US and Canada, including Allscripts.
• CVS Health wraps up its $70 billion acquisition of Aetna, promising to include digital health tools in its “new innovative healthcare model.”

Best Reader Comments

Simply put, PE involvement is one more sign that US health care is first and foremost driven by the pursuit of money rather than promoting the good of our society. (kevin hepler)

Amazon API to mine EHR…to sell ads to medical products
My main issue as an MD is that this sounds VERY sketchy from my standpoint.
The medical record is NOT a place to mine for diagnoses so medical supply companies can send ads to you to purchase their products. Its a super slippery slope and has MANY HIPAA issues. Makes me want to vomit to think all this data entry I am doing is being bought sold and scammed on the patient by the medical industrial complex. (meltoots)

I definitely see the CIO strategic influence reduced, but I think it is more of a reflection of the IT departments in general. As someone trying to push new innovation in this industry, 90% of the conversations stall when the CIO and IT teams engage. The CIO is no longer seen as a champion of innovation, but a roadblock. CIOs need to rise above the vendor pushed roadmaps, go collaborate with their stakeholders, and be a partner in innovation. IMHO (inNOvation)

Setting aside the insanity of the American healthcare system, does the patient expect to be approved for the list and receive a heart (depriving the next person on the list) only to lose it to non-compliance with her immunosuppressive regimen? Transplant drugs can be expensive. The hospital certainly wants to do the transplant. It’s a well compensated procedure along with the bevy of tests that go with it. Spectrum isn’t being cold-hearted, they simply have an approval process that they are following. (Transplant Guy)

Watercooler Talk Tidbits

Megan Callahan (Change Healthcare) joins Lyft as its first VP of healthcare.

Motherboard profiles Australian software developer Mark Watkins and the open-source software he has developed for sleep apnea sufferers. Dubbed “SleepyHead,” the software gives patients the ability to hack into their CPAP machines to retrieve typically inaccessible data they can then use to tweak settings. The software has made all the difference for some: “None of the doctors could get my AHI down and none of them seemed particularly concerned about it, to be honest,” says Christy Lynn. I can see the numbers every day on SleepyHead and I can tweak my settings. I cannot tell you enough how different my CPAP experience is with this software. It’s the difference between night and day. I’m possibly alive because it exists.”

Slate looks at the ethically dubious trend of medical students moonlighting as Instagram influencers/product peddlers. A snippet: “On Instagram, med students already toe the line by advertising for products like protein supplements, which can be high in added sugar and can strain kidney function. It doesn’t take an extraordinary leap of imagination to envision a med student being paid to promote a product on Instagram like Juul—a potentially useful harm reduction tool for smokers but a dangerous recommendation for doctors to make for most people. And for better or worse, the stakes are pretty high—for patients and their health, but also for doctors and their credibility. Many of these influencers, with access already to audiences as large as 60,000 followers and growing, will go on to become the next faces of American medicine.”

Staff at a South African medical practice are “gobsmacked” when cyclist Shaun Wayne walks in after being attacked while cycling along a popular route in Cape Town. After being transferred to several hospitals, Wayne was stitched up and kept for observation, with no apparent brain damage.

Brian Foley, a Cerner IT specialist, is arrested for uploading child pornography after a five-month investigation that netted 13 additional criminals in New Jersey.

In Case You Missed It

• News 11/30/18
• EPtalk by Dr. Jayne 11/29/18
• News 11/28/18
• Curbside Consult with Dr. Jayne 11/26/18
• A Machine Learning Primer for Clinicians–Part 6
• Monday Morning Update 11/26/18

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 11/30/18

Xealth Launches Innovative Feature Allowing Doctors to Digitally Recommend OTC Products

Xealth announces GA of software that enables providers to send patients digital recommendations for over-the-counter healthcare products, apps, and services from within their EHR and patient portal.

UnitedHealth to roll out individual health record, predicts what it will look like in 10 years

UnitedHealth’s individual health record is being beta tested at three ACOs and will soon be available to all beneficiaries and 1 million providers.

Voluntary code of conduct developed by more than 60 industry stakeholders can help facilitate health data exchange with entities not covered by HIPAA

The CARIN Alliance develops a code of conduct to help developers of third-party apps outside the scope of HIPAA appropriately handle consumer health data.

News 11/30/18

Top News

Unsealed court documents reveal that two Iranian hackers were responsible for SamSam ransomware attacks on 200 organizations earlier this year in the US and Canada, including Allscripts. The victims, which also included hospitals and municipalities, wound up paying over $6 million in ransom and incurring over $30 million in lack-of-access losses. Allscripts hasn’t revealed how much money it handed over to the still-at-large hackers, and could wind up losing more money if a class-action lawsuit filed against it by an orthopedics practice in Florida winds up in court.

Reader Comments

From Client Advocate: “Re: SpinSci. Does Anyone know if SpinSci is still in business? And, which hospitals have deployed their solutions successfully? Looking at their website, the company was started in 2005 but the latest documentation is from 2017. Crunchbase lists them as having 49 employees and $1.7M in revenue; either their staff is predominantly outside the US or, after almost 13 years, they may not have ever really taken off? Can anyone shed some light on this organization?” The oddly worded language throughout their website would suggest they’ve at least offshored their copyrighting talent. They say they’re a Dallas-based company with several global locations, including India and China.

Webinars

December 5 (Wednesday) 1 ET. “Tapping Into the Potential of Natural Language Processing in Healthcare.” Sponsor: Health Catalyst. Presenters: Wendy Chapman, PhD, chair of the department of biomedical informatics, University of Utah School of Medicine; Mike Dow, senior director of product development, Health Catalyst. This webinar will provide an NLP primer, sharing principle-driven stories so you can get going with NLP whether you are just beginning or considering processes, tools, or how to build support with key leadership. Dr. Chapman’s teams have demonstrated phenotyping for precision medicine, quality improvement, and decision support, while Mr. Dow’s group helps organizations realize statistical insight by incorporating text notes along with discrete data analysis. Join us to better understand the potential of NLP through existing applications, the challenges of making NLP a real and scalable solution, and the concrete actions you can take to use NLP for the good of your organization.

December 6 (Thursday) 11 ET. “Make the Most of Azure DevOps in Healthcare.” Sponsor: CitiusTech. Presenter: Harshal Sawant, practice lead for DevOps and mobile, CitiusTech. Enterprise IT teams are moving from large-scale, project-based system implementations to a continuously evolving and collaborative process that includes both development and business teams. This webinar will review healthcare DevOps trends and customer stories, describe key factors in implementing a DevOps practice, describe how to assess Azure DevOps, and lay out the steps needed to create an Azure DevOps execution plan.

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

Acquisitions, Funding, Business, and Stock

CVS Health finalizes its $70 billion acquisition of Aetna, promising to include claims data, analytics, connected devices, digital health apps, and remote patient monitoring in a “new innovative healthcare model” that will focus heavily on preventative care. CVS Health CEO Larry Menlo has also said the company will devote more retail space to medical services as it seeks to become a healthcare destination.

Seattle-based startup Xealth announces GA of software that enables providers to send patients digital recommendations for over-the-counter healthcare products, apps, and services from within their EHR and patient portal. Pennsylvania providers Providence St. Joseph Health and UPMC have gone live with the technology (which seems to be retailer-agnostic despite headlines to the contrary) in several departments. Privacy advocates warn that patients may wind up sharing sensitive PHI with retailers like Amazon, though the company will likely get its hands on that information anyway if its just-announced EHR data-mining capabilities come to fruition.

HGP puts together a list of digital health investors by round size, observing that size-agnostic investors like Khosla Ventures (Color Genomics, Iora Health, Oscar Health, Vicarious Surgical) tend to be more driven by the potential for disruption than incremental change, especially when it comes to patient empowerment technologies. 

In local news coverage of Minnesota-based St. Luke’s $300 million expansion plans, President and CEO John Strange vocalizes the tension many hospital execs must be feeling when it comes to managing consumer expectations in the midst of budgeting for new square footage while attempting to adopt the latest and greatest health IT:

“With the technology changes, you are still going to need certain facilities such as operating rooms and ICUs, but more and more care is moving to outpatient. We’re just trying to make sure we have the right facility for the technology and that is an interesting scenario. The real wild card is Amazon and Google getting into healthcare, and there is rumor they are applying for a manufacturing license,” Strange said. “You could see a physician and have your prescription droned out to you. How does the local pharmacy compete against that? The hospital pharmacy is a significant part of our budget. I tell people our competition here is not Essentia. It is Amazon, Google, and Apple.”

Sales

• Southcoast Health (MA and RI) selects collaborative care and telemedicine technology from Orb Health to help it launch chronic care management services.

People

Former UPMC CMIO Dan Martich, MD joins The Chartis Group as principal of its informatics and consulting practice.

Announcements and Implementations

During its annual investor day, UnitedHealth CEO David Wichmann touts the company’s PHR, calling it an “effective closed loop health information exchange centered on the consumer.” The software, which will be offered to all beneficiaries, is being beta tested by three ACOs, and will soon become available to 1 million providers. Wichmann added that it’s capable of connecting to multiple EHRs (one of those likely being Athenahealth, given the company’s attempts to purchase it). UnitedHealth plans to eventually offer the technology to other payers, though it would seem the PHR market has been losing relevance since Apple came on the scene. 

Government and Politics

Ahead of ONC’s annual meeting, HHS releases 74 pages of weekend reading in the form of proposed recommendations for reducing regulatory and administrative burdens caused by health IT. Comments on the draft strategy are due January 28.

Executive Director John Windom says the VA’s Office of Electronic Health Record Modernization will hire 135 people over the next six months as it ramps up Cerner implementation efforts. Five hundred VA and other EHR end users will attend trainings at Cerner’s campus during that same timeframe in preparation for deployment beginning in 2020.

CMS launches the Procedure Price Lookup tool to help consumers compare prices at outpatient facilities and ambulatory surgery centers.

Privacy and Security

An alliance of healthcare stakeholders develops a code of conduct to help developers of third-party apps outside the scope of HIPAA appropriately handle consumer health data. The code of conduct is part of a three-phase framework that the CARIN (Creating Access to Real-time Information Now) Alliance hopes will ultimately compel developers to certify their apps according to its standards. The alliance was formed by former federal health IT heavyweights David Blumenthal, MD David Brailer, MD Aneesh Chopra, and Mike Leavitt.

Atrium Health (NC) reports that over 2 million patient medical records may have been compromised by hackers who targeted its billing services vendor, AccuDoc Solutions, in September.

Other

Healthcare management experts Lawton Burns and Mark Pauly pen a tongue-in-cheek report on the healthcare industry’s tendency to make, believe, and buy in to “deceptive, misleading, unsubstantiated, and foolish statements.” Touching on everything from the failure of Theranos to the misguided marketing blitz behind IBM Watson to CVS Health’s promise to achieve – finally – the Triple Aim with Aetna’s assets, the authors break down the origins of healthcare’s acute tendency to “say something positive when there is nothing positive to say.”

Cleveland Clinic MD Mikkael Sekeres recounts how health information exchange allowed him to follow a patient’s final days from afar.

New healthcare access research from Kyruus finds that convenience is king when it comes to luring consumers through the four walls of a medical facility. Appointment availability, location, insurance acceptance, and clinical expertise were the deciding factors of those looking for new providers. Over half of the largest age groups in the study said they would switch providers if they didn’t offer online appointment scheduling.

Sponsor Updates

• Hyland Healthcare delivers enterprise-first imaging with new innovations and solution upgrades at RSNA through November 30 in Chicago.
• Constellation will offer Imprivata’s OneSign single sign-on technology to its medical liability insurance customers.
• The local paper interviews LogicStream Health CEO Patrick Yoder.
• Diameter Health receives the Distinguished Paper Award at the AMIA 2018 Annual Symposium for its research paper, “Interoperability Progress and Remaining Data Quality Barriers of Certified Health Information Technologies.”

Blog Posts

• Consumerism of Care: Where to Begin? (Part Two) (The HCI Group)
• Top 10 Best Practices For Choosing a Managed Services Partner (HCTec)
• Technology helps radiologists see more, be more (Hyland)
• Strong Financials: The Key to Your CRM Playbook (Influence Health)
• 5 blogs from home care and hospice thought leaders (Meditech)
• Picking an EHR vendor: Is your vision 20-20? (Leidos Health)
• 5 Ws for a successful health IT contract transition (Nordic)

Contacts

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

EPtalk by Dr. Jayne 11/29/18

Recent data from Case Western Reserve University shows that hospitals meeting EHR Meaningful Use standards had average patient stays that were shorter than their non-MU-compliant counterparts. Digging deeper into the data, they looked at four years of information and found that the length of stay was about four hours shorter. In various industry publications, there are plenty of quotes floating around from hospital administrator types talking about how MU-compliant EHRs improve compliance with treatment pathways and improve communication. As a physician, I’m wondering whether that four-hour length of stay is clinically significant. I’m also questioning the quotes from people talking about it generating “significant savings” for large health systems. To do that analysis, you can’t just look at the length of stay – you’d have to look at all the costs and factors contributing to that length of stay, including the cost of the EHR and the payroll costs associated with all the clicks mandated for Meaningful Use; as well as the costs to purchase, implement, and maintain the EHR at the MU-ready level above and beyond clinically-necessary EHR functionality. Nurses and staff can move faster caring for patients when they’re not performing clinically-irrelevant screenings or documenting unnecessary data.

The study, published in the Journal of Operations Management, only looked at hospitals in California and categorized hospitals three ways – those who had “meaningful assimilation” of EHRs, those with full adoption, and those with partial adoption. Comments from the authors note that “results from this study indicate that meaningful assimilation of technology is likely to help free-up clinicians and other valuable resources – this approach is preferable to making additional investments in facilities or hiring additional employees as more people seek hospital services.” This oversimplifies a complex problem. Speaking from experience, length of stay can also be shortened by having more care coordinators with smaller patient loads and greater ability to orchestrate hospital discharges in an efficient manner, making sure the family, the patient, the hospital, home health, and any receiving facilities are all on the same page. That requires hiring human beings, which cost money.

My last hospital stay was four hours longer than it needed to be because the surgeon’s PA rounded over lunch rather than before office hours, and there had to be a physical exam documented prior to discharge despite the fact that I had met all discharge criteria and practically had a car running in the parking lot trying to get out of there. Still, we had to check the boxes for people to get paid, prolonging the stay. The study also doesn’t show causation, merely correlation. It’s likely that hospitals that are fully compliant with Meaningful Use are also participating in other initiatives such as quality improvement projects, promotion of clinical best practices, etc. on a higher level than other hospitals. In order for the study to truly show causation, the authors would have needed to control for those factors as well.

Atlanta-based Sharecare was named to the Deloitte Technology Fast 500 for the second consecutive year. Sharecare promotes itself as a “digital health company that helps people manage all their health in one place,” including helping them calculate and track their “real age” versus their actual chronological one. These kinds of rankings are based on revenue growth rather than clinical or quality factors, although health plans are engaging with Sharecare so there must be clinical data in there somewhere. I’m skeptical about their involvement with Dr. Oz and also their website lead-ins on taking “the first step to growing younger.” We would be better served as a society if we promoted people getting the best health at any given point in time rather than focusing on being younger, etc. There’s something to be said for growing old with grace and not trying to fight the clock with various surgeries, injections, and products. They have a whole section on their site for advertisers titled “Drive measurable results for brands,” including talk of “precision targeting fueled by the largest database of first-party, self-reported health information” including the ability to drive “awareness, engagement, and proven conversion for brand partners.” That kind of calls into question their other motivations, at least in my book.

On that same note, in the news earlier this week, Mr. H asked about private equity in healthcare – specifically, whether the “slash-and-burn, flip-focused” methods were appropriate in healthcare. The Washington Post story he references looks specifically about PE in a nursing home situation. I’ve not personally experienced that, but I have seen plenty of private practices sell to PE organizations, particularly in dermatology and ophthalmology. Providers in those specialties have remained independent for a long time while their lower-paid primary care counterparts have already given up independence for the security of hospital employment. Still, running a practice is daunting, and with the changes in reimbursement and contracting and managing people it’s enticing to want to sell to someone who promises to take care of all the perceived hassles.

However, nearly everyone I’ve encountered who has sold their practices has very quickly found that it becomes all about profitability. The fact that the PE firms are only going after high-profit practices should have been a tip-off – they’re not snapping up general internal medicine or family medicine practices. Physicians gave up having to make human resources decisions only to find their staffs slashed and longstanding employees laid off. Administrators with MBAs but little healthcare experience are making decisions about patient care including what services to offer and whether providers can see uninsured patients. Not all the decisions are correct about profitability in the healthcare context – a colleague recently was forced to institute a policy where uninsured patients were turned away, because his PE overseer didn’t realize that self-pay patients can be profitable due to low billing costs. The 24 year-old administrator saw “uninsured” and thought “indigent,” causing the loss of some longstanding patients who had always paid their bills at the time of check-out. The physician would love to leave, but a 30-mile non-compete radius has him trapped unless he truly wants to start from scratch.

What are your thoughts about private equity organizations in the healthcare space? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 11/29/18

Atrium Says Hackers Accessed Its Billing Records

Billing services vendor AccuDoc Solutions reveals that a September breach of its database may have impacted over 2 million Atrium Health (NC)  patients. 

HHS Issues Draft Strategy to Reduce Health IT Burden

CMS and ONC seek feedback on draft recommendations for reducing regulatory and administrative burdens caused by health IT and EHRs.

Iranian hackers wanted for hijacking Chicago health data company

Unsealed court documents reveal that two Iranian hackers were responsible for SamSam ransomware attacks on 200 organizations in the US and Canada, including Allscripts.

CVS Health Completes Acquisition of Aetna, Marking the Start of Transforming the Consumer Health Experience

CVS Health wraps up its $70 billion acquisition of Aetna, promising to include digital health tools in its “new innovative healthcare model.”

Morning Headlines 11/28/18

Big Tech Expands Footprint in Health

Amazon will launch a software product for payers that combs through electronic patient records to find incorrect coding or diagnoses in an effort to improve quality and lower cost.

GAO to look into whether Mar-a-Lago trio inappropriately influenced VA

The GAO will investigate rumored VA meddling by three political supporters of President Trump who said they “were anointed by the President” as private citizens, and whom some contend influenced the no-bid, $10 billion Cerner contract.

OVMC, EORH Hope To Have Emergency Rooms Back Online

Systems of two OH and WV hospitals remain down following a ransomware attack Friday, with their EDs remaining on partial diversion.

Vivian Lee quietly left her job as a professor at the University of Utah — after her $1 million salary contract ended and a year of turmoil

Former University of Utah health system CEO Vivian Lee, MD, PhD, MBA joins Verily as president of health platforms.

News 11/28/18

Top News

Amazon will announce this week launch of a software product for insurance companies that mines electronic patient records, including both structured and unstructured data. It will look for incorrect coding or diagnoses to improve quality and lower cost.

Reader Comments

From TaTa Toothy: “Re: Key Dental Group. The practice’s EHR vendor locks it out of its patient database after the practice drops its system.” Key Dental Group (FL) says dental software vendor MOGO is refusing to return its 4,000 patient records following termination of its license. The practice put out a press release titled “HIPAA Security Incident” that warns patients that it has no control over how their data will be protected by the vendor. MOGO’s LinkedIn says the product is “HIPPA-compliant.”

From DiJourno: “Re: fake health IT news. Running all positive stories is a clue.” You can easily recognize advertiser-friendly “news” sites by simply checking their 10 most recent stories to see if they wrote anything negative, especially about an advertiser. I explain when people ask why I’m so cynical that: (a) the frontlines health IT view is a far cry from profit-motivated irrational exuberance supported by vendor-friendly news sites; and (b) fluff written by armchair quarterbacks is in ample supply and thus the obvious need is to inject reality. I grade sites this way: (a) can I immediately use what I just read; (b) did I learn something I wouldn’t have found elsewhere; (c) can I at least paraphrase a given story in casual conversation to sound smart? Otherwise, I have  more entertaining ways to waste my time.

HIStalk Announcements and Requests

The earlier-than-usual start of HIMSS19 means it’s time to open up the HISsies nominations, my version of the political primaries. I’ve unsuccessfully hoped every year since the first HISsies in 2008 to avoid dozens of email exchanges like these:

• (Reader) “I can’t believe the stupid choices for the HISsies voting. It’s the same every year and it should have had X as a choice.”
• (Me) “Readers do the nominating. Nobody nominated X. So you are complaining now that you don’t like the choices even though you couldn’t be bothered to take 10 seconds to nominate X yourself?”
• (Reader) No response.

Welcome to new HIStalk Gold Sponsor NextGate. The Monrovia, CA-based company offers a cloud-based identity management solution (patient matching, duplicate record cleanup, provider attribution, and biometric ID), provider registry, and  relation registry. Customer success stories include Geisinger, Rochester RHIO, and two UK providers. The company works with more than 100 provider organizations. Thanks to NextGate for supporting HIStalk.

Webinars

December 5 (Wednesday) 1 ET. “Tapping Into the Potential of Natural Language Processing in Healthcare.” Sponsor: Health Catalyst. Presenters: Wendy Chapman, PhD, chair of the department of biomedical informatics, University of Utah School of Medicine; Mike Dow, senior director of product development, Health Catalyst. This webinar will provide an NLP primer, sharing principle-driven stories so you can get going with NLP whether you are just beginning or considering processes, tools, or how to build support with key leadership. Dr. Chapman’s teams have demonstrated phenotyping for precision medicine, quality improvement, and decision support, while Mr. Dow’s group helps organizations realize statistical insight by incorporating text notes along with discrete data analysis. Join us to better understand the potential of NLP through existing applications, the challenges of making NLP a real and scalable solution, and the concrete actions you can take to use NLP for the good of your organization.

December 6 (Thursday) 11 ET. “Make the Most of Azure DevOps in Healthcare.” Sponsor: CitiusTech. Presenter: Harshal Sawant, practice lead for DevOps and mobile, CitiusTech. Enterprise IT teams are moving from large-scale, project-based system implementations to a continuously evolving and collaborative process that includes both development and business teams. This webinar will review healthcare DevOps trends and customer stories, describe key factors in implementing a DevOps practice, describe how to assess Azure DevOps, and lay out the steps needed to create an Azure DevOps execution plan.

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

Sales

• Australia’s Queensland Health chooses NextGate’s cloud-based Provider Registry to create a statewide referral service directory.
• Sweden-based Västra Götalandsregionen will implement Cerner Millennium in its 17 hospitals and 200 primary care centers, Cerner’s second regional contract in Sweden.

People

Former University of Utah health system CEO Vivian Lee, MD, PhD, MBA, who resigned after clashing with the university’s cancer hospital leadership, joins Verily as president of health platforms. She will oversee products related to health system improvement and population health. She finished her contract with the university as a radiology professor at a salary of $1 million per year.

Announcements and Implementations

MModal launches Scout Follow-Up, an AI-powered radiology follow-up workflow solution.

HIMSS announces its 2019 “Most Influential Women in Health IT” winners:

• Aashima Gupta (Google)
• Kisha Hortman Hawthorne, PhD, MHA, MBA (Children’s Hospital of Philadelphia)
• Christine A. Hudak, PhD, RN (Kent State University)
• Lygeia Ricciardi, EdM (Carium)
• Heather Sulkers (CAMH)

Government and Politics

The GAO will investigate rumored VA meddling by three political supporters of President Trump who said they “were anointed by the President” as private citizens. The three, including concierge doctor Bruce Moskowitz, say they voluntarily offered their help to the VA but were given no authority over the VA’s decisions. The initial ProPublica investigation found that Moskowitz’s negative experience with Cerner led the group to urge then-VA Secretary David Shulkin to perform more due diligence before giving Cerner a $10 billion, no-bid contract. Former officials say Shulkin was fired because of friction with the group over the Cerner contract.

Privacy and Security

BCBS of North Carolina emails a medical claims report for 158 employees of Wilmington, NC to the wrong city.

Systems of two OH and WV hospitals remain down following a ransomware attack Friday, with their EDs remaining on partial diversion.

Other

A Black Book survey finds that the CIO’s strategic role has diminished as non-IT department leaders are making more purchasing decisions. It questions whether the “chief” part of the CIO title is at risk as only 21 percent of CIOs say they are involved in innovation projects and departmental purchasing decisions, with 29 percent viewing their role as tactical. Nearly all C-suite colleagues view CIOs as technology providers and order-takers who don’t need to be involved in transformation and innovation efforts. The report finds that average CIO tenure is down to 3.2 years.

The Washington Post finds that a private equity firm’s acquisition of a national nursing home chain led to dramatically decreased quality of care as the chain was loaded up with debt; cash was extracted to pay investors and PE firm management fees; buildings were sold and leased back at unreasonable rents to free up cash that the private equity company extracted; and employees were laid off as the nursing homes were unable to pay the new debt and rent costs. A company consultant said the bankers and investment people who run the PE firm “did not know a thing about this business at all.” The PE firm says things were going fine until Medicare reduced payments. The PE firm has sold the chain to a non-profit, but the question remains – are the slash-and-burn, flip-focused private equity methods appropriate in healthcare?

I found this “Black Friday for Healthcare”article by Loyale Healthcare CEO Kevin Fleming both interesting and timely. He says:

• The Black Friday phenomenon involves value + enticement + urgency.
• Disruption is caused by a commitment to a delivering a superior customer experience, not by simply rolling out digital tools (he was quoting an article by former Sutter Health SVP/CIO Jon Manis).
• “Delight disruption” in healthcare must include both clinical and financial positive experiences.
• Medical tourism may represent the first wave of healthcare consumerism.
• Amazon knows us better than we know ourselves via its rich database, allowing it offer easy shopping, comparing, and buying, and healthcare is beginning to amass such data.
• Healthcare’s version of retail growth involves offering rewarding personal experiences; enticing consumers with an attractive, affordable product that drives word-of-mouth exposure; and addressing people who delay or avoid care because they think they can’t afford it.

Employees at Mercy South (MO) were scheduled to protest Tuesday after the hospital required employees to receive a flu shot unless they offer medical or religious reasons.

Former Chicago Bears coach Mike Ditka is released from the hospital after being treated for a mild heart attack. Above is the mental picture I immediately conjured given that it’s Thanksgiving and RSNA.

Sponsor Updates

• Medicomp Systems publishes an e-book titled “Interoperability and the Quest to Solve Healthcare’s Seemingly Unsolvable Problem.”
• Bernoulli Health will exhibit at the American Association for Respiratory Care Congress December 4-7 in Las Vegas.
• CoverMyMeds will exhibit at ASHP Midyear December 3-7 in Anaheim, CA.
• Divurgent publishes a new success story on its Physician Efficiency Program.
• PointClickCare recognizes Liaison Technologies as its Partner of the Year.
• LiveProcess will exhibit at the National Healthcare Coalition Preparedness Conference November 27-29 in New Orleans.
• MDLive provides free online health consultations to California residents impacted by wildfires.
• National Decision Support Co. will exhibit at RSNA November 25-30 in Chicago.
• Wolters Kluwer Health will present at the ASHP Midyear Clinical Meeting December 2-6 in Anaheim, CA.
• The Pharmacy Podcast Network features ZappRx.

Blog Posts

• Opening day at RSNA 2018 in Chicago (Agfa Healthcare)
• Top 10 Considerations for HIPAA Compliant File Storage (Atlantic.Net)
• Cutting Through the Noise – Streamlining Alerts to Help Improve Patient Safety (CoverMyMeds)
• Medical Schools in the Digital Age: The teachingEHR (Dimensional Insight)
• Understanding what matters most to hospice patients (Meditech)
• Interoperability and the Quest to Solve Healthcare’s Seemingly Unsolvable Problem (Medicomp Systems)
• Driving Recovery in the Opioid Crisis – The Technology to Get Us There (Netsmart)
• The IT Service Management Series – Part 1: Knowledge Management – Recognizing your most valuable free asset (CloudWave)
• Simplifying the billing process to alleviate patient financial pain points (Experian Health)
• Recap: PatientPing Hosts Texas Community Summit (PatientPing)
• FAQ: Platforms vs. Point Solutions (Spok)
• Avoid a One-Size-Fits-All Patient UX. Here’s How. (Patientco)
• EHR Optimization: Are We There Yet? (PatientKeeper)
• New Jersey Case Manager Fights “Tooth and Nail” for Patients (PreparedHealth)
• Did EHRs Solve Everything? (Optimum Healthcare IT)
• Communication data at a glance. (Voalte)
• How Medicare Advantage is boosting value-based insurance design (Wellcentive)
• What is Defensible Documentation? (WebPT)

Contacts

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

Morning Headlines 11/27/18

Mental health therapy at Walmart? It’s now a thing

Managed care company Beacon Health Options creates a new business to oversee the launch of mental health clinics in retailers like Walmart, promising virtual access to providers during peak hours.

Black Book Survey of More Than 1,500 Executives Confirms the Changing Role of the Healthcare CIO

The purchasing-decision power of hospital CIOs falls over the last three years from 71 percent to 8 percent, according to a Black Book report.

Patients discharged sooner in hospitals with highest use of electronic health records

A Case Western Reserve University study finds that patients are discharged almost four hours earlier at hospitals that use EHRs at the highest federal standard of implementation.

Curbside Consult with Dr. Jayne 11/26/18

While many people were out doing their Black Friday shopping, I was getting clobbered at urgent care. We saw over 1,000 patients across our locations, which is similar to the patient counts that we see during the height of influenza season.

Many of the patients were coming in for fairly low-acuity problems because their primary care physicians’ offices were closed and they were concerned that their conditions would worsen over the weekend. A portion of the patients had issues that had gotten worse over the holiday, while others had holiday-related injuries.

I saw some Thanksgiving-related injuries, including a patient who was injured by a frozen turkey that fell on her, allowing me to use the ICD codes W61.42 “Struck by turkey” and Y93.G1 “Activity, food preparation and clean up.” Another injured her finger “spiralizing” a sweet potato. I couldn’t find a better code for that other than the usual wound codes, but the turkey incident was a challenge for my scribe.

It’s rough enough seeing that large volume of patients (more than 70 of them were on my schedule) but it was made more difficult by an EHR that behaved erratically. I’m pretty sure my EHR has the world’s most user-unfriendly error codes, such as, “The length argument value must be greater or equal to X” and “Error attempting to push run time parameters onto the stack.” Both of those gems allowed the user to click through without incident and allowed return of normal function, so it’s not clear why we were even seeing them. Although I’ve been in the healthcare IT world for a long time and have come to terms with just clicking through and not getting too worked up, some of my staff members were very frustrated by messages that had no meaning.

Due to increasing co-pays and concerns about crowding at the emergency room, we had multiple patients who ultimately needed transfer to a higher level of care, which can be stressful for the staff. Most of the team I worked with have been in the urgent care space a long time, so they weren’t nervous about handling patients with stroke or chest pain symptoms until emergency medical services arrived to transport them to the hospital.

It’s still challenging, though, especially when your schedule gets backed up while you’re caring for a truly sick patient while other patients are popping out to the clinical station because they feel that they’ve been waiting too long. The consumer-style expectations of our patient population continue to rise, and on a busy day full of lacerations and hospital transfers, it’s definitely harder to meet those expectations. Patients are already frustrated because their primary care physicians’ officers are closed, assuming that they have a primary physician, which many do not.

We also had an uptick in patients who were presenting to us for care after being seen at a retail clinic. They had seen a nurse practitioner only to be told that their condition was outside the scope of practice permitted at the retail clinic and that they would need to be seen by a physician for laboratory work, chest x-rays, etc.

We’re happy to take those referrals, but the patients aren’t thrilled to pay an urgent care co-pay on top of whatever was spent at the retail clinic, not to mention the time involved in leaving one facility and traveling to another. The local retail clinics vary dramatically in how they screen patients for scope of practice. Some seem to do the screening upfront and refer the patient prior to any exam, where others see the patient and then refer. The latter doesn’t make for very happy patients.

One of the more challenging parts of my day was caring for a patient who came in with what appeared to be a viral illness but that turned out to be a life-altering diagnosis. In the urgent care trenches, we’re often accused of practicing defensive medicine or ordering too many tests, but when your CT scan detects a serious cancer that the patient had no idea was present, it’s sobering. I’m sure when Monday rolls around we’ll have to deal with the retroactive authorization for the test, but it will be worth it.

I hate having to tell patients about those discoveries. It would be so much better to have a physician who knows the patient give them the news. Patients are generally glad that they have a diagnosis and a plan to move forward, even if the news is not what they expected. I’ve had several situations like this over the last several weeks and I wish there was a way to follow along with the patient’s care. In our region, though, the big health systems aren’t about to share data with an independent urgent care even though their systems are allegedly interoperable.

Today was a much easier schedule and I had a couple of hours where patients only trickled through the door, so I was able to work on some informatics projects. We’ve been faced with shortages of some of our common medications, so I worked on an analysis of diagnosis patterns and volumes to estimate how long we can stretch our supplies. It’s still baffling that we have shortages of key medications in the US, including antibiotics and especially generics. We’re also low on influenza vaccine, so I worked on a strategy to predict demand and redistribute what we had. Not exactly high-powered informatics or big data analysis, but the run-of-the-mill data needs that are common for practices.

I also spent some time with one of our training scribes to talk about proposed changes to our scribe program since we have had to ramp up quickly to prepare for the opening of several new locations. We don’t want to shortchange any of the training, but want to make it as efficient as possible since scribes are the lifeblood of our high-volume days during flu season.

I had some time to play around with data around influenza and was glad to see that our influenza activity is paralleling the CDCs data at around 2 percent of the visit volume. It’s days like today that I’m glad to have an EHR and can extract data for useful purposes. In the coming weeks I’ll be extracting data for more challenging purposes, including our annual analysis of whether we should continue to opt out of the federal incentive programs. That’s a much bigger project, including analysis of provider workflow, documentation time, and click counts on top of the analysis of payer mix, CPT codes, quality measures, and more. It’s not exactly something I look forward to every year, but it’s rewarding to be able to analyze, interpret, and package the data so that informed decisions can be made.

We also had a tornado warning issued while seeing patients, which put our disaster planning skills to the test. There’s not a lot of patient privacy when you have people huddled in the central core of the office, away from the windows that are present in all the exam rooms. People seemed to take it in stride, though, especially since we’re looking at high winds through the evening and snow into the morning. I may be grumbling during the commute, but at least I’m not in Chicago at RSNA where there is still a blizzard warning in effect. Wherever you may be, I hope your weather allows you to stay safe.

Email Dr. Jayne.

A Machine Learning Primer for Clinicians–Part 6

Alexander Scarlat, MD is a physician and data scientist, board-certified in anesthesiology with a degree in computer sciences. He has a keen interest in machine learning applications in healthcare. He welcomes feedback on this series at drscarlat@gmail.com.

Previous articles:

1. An Introduction to Machine Learning
2. Supervised Learning
3. Unsupervised Learning
4. How to Properly Feed Data to a ML Model
5. How Does a Machine Actually Learn?

Artificial Neural Networks Exposed

Before detailing what is a NN, let’s define what it is not. 

As there is much popular debate around the question whether a NN is mimicking or simulating the human brain, I’ll quote Francois Chollet, one of the luminaries in the AI field. It may help you separate at this early stage between science fiction and real science and forget any myths or preconceptions you may have had about NN:

Nowadays the name neural network exists purely for historical reasons—it’s an extremely misleading name because they’re neither neural nor networks. In particular, neural networks have hardly anything to do with the brain. A more appropriate name would have been layered representations learning or hierarchical representations learning, or maybe even deep differentiable models or chained geometric transforms, to emphasize the fact that continuous geometric space manipulation is at their core. NN are chains of differentiable, parameterized geometric functions, trained with gradient descent.” (From “Deep Learning with Python” by Francois Chollet)

You’ve met already an artificial neural network (NN) in the last article. It predicted the LOS based on age and BMI, using a cost function and trained with gradient descent as part of its optimizer.

ANN Main Components

• A model has many layers: one input layer, one or more hidden layers, and one output layer.
• A layer has many units (aka neurons). Some ML models have hundreds of layers and tens of millions of units.
• Layers are interconnected in a specific architecture (dense, recurrent, convoluted, pooling, etc.)
• The output of one layer is the input of the next layer.
• Each layer has an activation function that applies to all its units (not to be confused with the loss / cost function).
• Different layers may have different activation functions.
• Each unit has its own weight.
• The overall arrangement and values of the model weights comprise the model knowledge.
• Training is done in epochs. Each epoch deals with a batch of samples from input.
• Each epoch has two steps: forward propagation of input and back propagation of errors (see above diagrams).
• A metric is calculated as the difference between the model prediction and the true value if it is a supervised learning ML model.
• An optimizer algorithm will update the weights of the model using the loss / cost function.
• The optimizer helps the model navigate the hyperspace of possibilities while minimizing the loss function and searching for its global minimum.
• After model is trained and it makes a prediction, the model uses the final values of the weights learned.

In the following example, a ML model tries to predict the type of animal in an image as a supervised classification task.

• An input layer on the left side accepts as input the image tensors as many small numbers.
• Only one hidden layer (usually there are many layers). It is fully connected to both the input and the output layers.
• An output layer on the right that predicts an animal from an image. It has the same number of output units as the number of animal types we’d like to predict. The probabilities of all the predicted animals should sum up to one or 100 percent.

From giphy.

What Is the Difference Between a NN and a Non-NN ML Model?

Non NN Models:

• One set of weights for the whole model.
• Model has one function (e.g. linear regression).
• No control over model internal model architecture
• Usually do not have local minima in their loss function
• Limited hyperspace of possibilities and expressivity

NN Models:

• One to usually many layers, each layer with its own units and weights.
• Each layer has a function, not necessarily linear.
• Full control over model architecture.
• May have multiple minima as the loss function is more complex.
• Can represent a more complex hypothesis hyperspace.

Remember the clustering exercise from a previous article?

• Task: given the X and Y coordinate of a dot, predict the dot color.
• Input: X and Y coordinates.
• Output: color of dot.
• Performance: accuracy of prediction.

How would a NN model approach the above supervised learning problem ?

Note that no centroids are defined, nor the number of classes (two in the above case) are given.

The loss function that the model tries to optimize results from the accuracy metric defined: predicted vs. real values (blue or orange). Below there are five units (neurons) in the hidden layer and two units in the output layer (actually one unit to decide if yes / no blue for example, would suffice as the decision is binary, either blue or orange.)

The model is exposed to the input in batches. Each unit makes its own calculation and the result is a probability of blue or orange. After summarizing all the layers, the model predicts a dot color. If wrong, the weights are modified in one direction. If right, in the opposite direction (notice the neurons modifying their weights during training). Eventually, the model learns to predict the dot color by a given pair of X and Y (X1 and X2 in the animation below)

From “My First Weekend of Deep Learning at Floyd Hub.”

Advantages of a NN Over a Non-NN ML Model

• Having activation functions, most of them non-linear, increases the model capability to deal with more complex, non-linear problems.
• Chaining units in a NN is analogous to chaining functions and the result is a definitely more complex, composite model function.
• NN can represent more complex hypothesis hyperspace than non-NN model. NN is more expressive.
• NN offers full control over the architecture: number of layers, number of units in a layer, their activation functions, etc.
• The densely connected model introduced above is only one of the many NN architectures used.
• Deep learning, for example, uses other NN architectures: convoluted, recurrent, pooling, etc. (to be explained later in this series). Model may have a combination of several basic architectures (e.g. dense on top of a convoluted and pooling).
• Transfer learning. A trained NN model can be transferred with all its weights, architecture, etc. and used for other than the original intended purpose of the model.

The last point of transfer learning, which I’ll detail in future articles, is one of the most exciting developments in the field of AI. It allows a model to apply previously learned knowledge and skills (a.k.a. model weights and architecture) with only minor modifications to new situations. A model trained to identify animals, slightly modified, can be used to identify flowers. 

Next Article

Controlling the Machine Learning Process

Morning Headlines 11/26/18

Intelerad Medical Systems Acquires Clario Medical

Intelerad acquires radiologist worklist technology vendor Clario Medical.

Naval Hospital Bremerton’s new medical records system making ‘significant strides’

Fourteen months after going live on MHS Genesis, Naval Hospital Bremerton CMIO Lt. Cmdr. Bryan Wooldrige reports that pharmacy wait times are back to normal, care standards are once again being met, and initial workflow glitches have been ironed out.

Nuance Introduces New PowerScribe One Radiology Reporting Platform Powered by AI and the Cloud

Nuance launches PowerScribe One, a radiology reporting platform that includes AI-powered diagnostic and decision support tools.

Hospitals: Patient information safe in EORH, OVMC computer attack

East Ohio Regional Hospital and Ohio Valley Medical Center go on ED diversion after their systems are attacked by ransomware.

Monday Morning Update 11/26/18

Top News

RSNA 2018 kicks off in Chicago’s McCormick Place, running through Friday.

A big focus of the conference is artificial intelligence and machine learning.

RSNA 2017 drew nearly 53,000 registrants, half of them imaging professionals.

Chicago was under a blizzard warning Sunday evening, with up to 13 inches of snow expected, driven by wind gusts of up to 45 mph. Highs Tuesday and Wednesday will be in the mid-20s.

Reader Comments

From Participle Dangler: “Re: your mention of Papa Roach. Lead singer Jacoby Shaddix remains active in hometown causes and supports NorthBay HealthCare’s hospice program.” The Vacaville, CA-born singer – who turned his life around from substance abuse and depression – also supports causes related to hunger and homelessness, having been raised with both.

HIStalk Announcements and Requests

I tossed out last week’s poll due to obvious technological attempts to stuff the ballot box (nearly nobody believes that Allscripts legitimately earned Black Book’s “best integrated EHR/PM” survey finding). I added CAPTCHA protection this week, although I have little doubt that a script kiddie without much else going on in life can crack that as well.

New poll to your right or here: for those who attend both the HIMSS and RSNA conferences, which provides more value? Vote and click the poll’s “comments” link to explain or to suggest another conference that is better than those two.

Webinars

December 5 (Wednesday) 1 ET. “Tapping Into the Potential of Natural Language Processing in Healthcare.” Sponsor: Health Catalyst. Presenters: Wendy Chapman, PhD, chair of the department of biomedical informatics, University of Utah School of Medicine; Mike Dow, senior director of product development, Health Catalyst. This webinar will provide an NLP primer, sharing principle-driven stories so you can get going with NLP whether you are just beginning or considering processes, tools, or how to build support with key leadership. Dr. Chapman’s teams have demonstrated phenotyping for precision medicine, quality improvement, and decision support, while Mr. Dow’s group helps organizations realize statistical insight by incorporating text notes along with discrete data analysis. Join us to better understand the potential of NLP through existing applications, the challenges of making NLP a real and scalable solution, and the concrete actions you can take to use NLP for the good of your organization.

December 6 (Thursday) 11 ET. “Make the Most of Azure DevOps in Healthcare.” Sponsor: CitiusTech. Presenter: Harshal Sawant, practice lead for DevOps and mobile, CitiusTech. Enterprise IT teams are moving from large-scale, project-based system implementations to a continuously evolving and collaborative process that includes both development and business teams. This webinar will review healthcare DevOps trends and customer stories, describe key factors in implementing a DevOps practice, describe how to assess Azure DevOps, and lay out the steps needed to create an Azure DevOps execution plan.

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

Acquisitions, Funding, Business, and Stock

Intelerad acquires radiologist worklist technology vendor Clario Medical.

Announcements and Implementations

Nuance launch PowerScribe One, a radiology reporting platform that includes AI-powered diagnostic and decision support tools. 

Other

Two Ohio hospitals go on ED diversion after their systems are attacked by ransomware.

An Indiana doctor says his lawsuit against EHR/RCM vendor SSIMED (now Meridian Medical Management) for losing 70 percent of his practice’s claims for more than nine years triggered a 2014 DEA raid of his offices for overprescribing narcotics, as accused by former employees of his practice.

Spectrum Health’s transplant clinic tells a patient that they won’t perform a heart transplant because she can’t afford the post-surgical immunosuppressant drugs, suggesting that she undertake “a fundraising effort of $10,000,” after which a newspaper columnist concludes that it’s not a healthcare system if “you can’t have a heart unless you do GoFundMe for $10K.”

In Australia, a conspiracy theorist with no medical background charges $4,000 to serve as an expert witness for estranged parents who disagree on vaccinating their children. She has threatened to sue the newspaper for reporting about her services, defending her “support for the public’s right to vaccination choice.” The doctor – she earned a PhD in humanities — claims that a secret WHO committee orchestrates pandemic hysteria under the direction of the World Bank.

In England, a woman sues a hospital for not telling her about her father’s Huntington’s disease, saying she would have aborted her child (now eight years old) if she had known that the girl has a 50 percent chance of being afflicted by the neurological disease. The woman’s father – who had killed his wife – refused to give doctors permission to tell his daughter about his condition, fearing that she would abort the baby. The legal precedent could be significant – do doctors and hospitals have the legal duty to perform genetic due diligence and to override privacy requirements in telling those who may be affected by an identified genetic disorder? A genetic ethics expert observes:

How much effort should a clinician make in chasing up relatives? And those relatives might be unhappy to be tracked down and given unwelcome information – for example, that they possess a gene that predisposes them to breast cancer. You cannot take back that information once you have given it.

ProPublica finds that CPAP machines used for sleep apnea often are programmed to report usage data back to the patient’s insurance company, the device’s manufacturer, the medical equipment distributor, and the ordering doctor. Insurers say too many patients who are prescribed the costly machines don’t use them regularly. The article notes that an industry has been created around the potentially serious but often undiagnosed condition, with sleep studies, the CPAP machine, and the required ongoing use of supplies raising the financial concerns of insurers. Medicare requires physicians to document that their patients use CPAP for at least four hours per night in at least 21 of each 30 days, a policy quickly adopted by private insurers, and the manufacturers say their surveillance meets those documentation requirements. 

I saw this commercial watching Thanksgiving parade lip-syncing – UPMC is running $3 million worth of national ads for its living-donor liver donor program as it fights with the dominant local health plan. The KHN article notes that hospitals are trying to lure well-insured patients into their hospitals – and to diminish the impact of insurers trying to control costs despite the health system’s market clout — by creating a national and international brand based on high-priced procedures that few people need. Hospital for Special Surgery and Yale New Haven Hospital are also running national TV ad campaigns that, unlike direct-to-consumer drug company ads, are not regulated by FDA for accuracy. Some Internet wags claim that UPMC’s ad is voiced over by Benedict Cumberbatch of “Sherlock” and it does indeed sound like his highly compensated voice.

Weird News Andy’s turkey day must have caused him to miss this story. A Paris hospital that is recruiting participants for a fecal implant study is overwhelmed with calls, emails, and visits after someone takes a photo of the offer and posts it to social media, claiming that anyone who shows up with a fecal sample will be given $57.

Sponsor Updates

• Healthwise will exhibit at the NextGen Patient Experience November 27-29 in San Diego.
• Imat Solutions will sponsor the SHIEC reception at ONC’s 2018 Annual Meeting November 29 in Washington, DC.
• Influence Health customers UCLA Health, Advocate Health Care, Virginia Mason, and Texas Health Resources win seven EHealthcare Leadership Awards.
• InterSystems will exhibit at RSNA November 25-30 in Chicago.

Blog Posts

• Huntzinger Congratulates the Most Wired Recipients (Huntzinger Management Group)
• PACS limitations demand a new imaging paradigm (Hyland)
• Make Sure Remote Access to Your Network is as Safe as a Deadbolt (Iatric Systems)
• 5 Crafty Ways Your Competitors are Poaching Your Patients (Influence Health)
• Engagement without Commitment: The Healthcare Dilemma (InterSystems)
• Community Health Network’s Multi-Channel Approach to Enhancing Patient Access (Kyruus)

Contacts

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

Morning Headlines 11/21/18

Apple in Talks to Give Veterans Access to Electronic Medical Records

Apple and the VA discuss developing software that would enable veterans to transfer medical records to their iPhones.

Jump Technologies Receives $2M in Follow-on Series B Funding, Bringing Total Round to $5.5M

Hospital supply chain management software vendor Jump Technologies raises $2 million with help from Mount Sinai Ventures.

Office 365, Azure users are locked out after a global multi-factor authentication outage

Microsoft brings its cloud-based, multi-factor authentication services for Office 365 back online after a global outage Monday morning.

How Geisinger Health System Reduced Opioid Prescriptions

Geisinger Health (PA) attributes a 30-percent decline in opioid prescriptions to a multi-pronged approach that includes EHR-based interventions, e-prescribing, and access to the state’s PDMP.