Morning Headlines 12/6/18

Enzyme Health Adds $1.7M for Clinician Telemedicine Job Marketplace

Austin, TX-based Enzyme Health raises $1.7 million in a seed funding round led by Silverton Partners.

Teladoc Health Refutes SIRF Report Claims

Teladoc refutes claims of inappropriate relations and insider trading made in an article from the Southern Investigative Reporting Foundation.

Researchers find way to catch medical errors as they happen

Pascal Metrics develops software that uses machine learning and EHR data to detect and alert providers to medical errors in real time.

Readers Write: What’s Good for the Dentist is Good for the Medical Doctor as Well

What’s Good for the Dentist is Good for the Medical Doctor as Well
By Robert Patrick

Robert Patrick is president of dental at Vyne of Dunwoody, GA.

Medical professionals might be tired of the endless requirements of mailing x-rays or other documentation to the insurance company every time they file a claim. Some of them might simply want the ability to add their supporting documentation to claims electronically for easier adjudication.

While medical professionals continue to wait for developments and guidance related to the use of electronic attachment solutions and technologies, their dental colleague counterparts have no such obstacles. Even though there’s no formalized standardization from an organization like the Center for Medicare and Medicaid Services (CMS) for dental, there is a range of solutions that have permeated the sector and enjoy robust use by many thousands of dental practices. Why the disparity?

The simplest reason is that the solutions are readily available in the dental sector, Their use has been embraced despite there being little formal regulation or guidance related to submitting electronic attachments. For example, as long as the solutions are compliant with HIPAA, their use is fair game. Per recent reporting, some on the medical side of healthcare are waiting for a push toward standardization in the way electronic attachments are sent before moving forward with similar solutions.

According to reporting by MedPage Today, Robert Tennant, director of health information technology policy at the Medical Group Management Association — a trade group that represents medical practices — said that HIPAA includes a directive for the federal government to develop standards for electronic attachments. But the HIPAA provision still is not seeing traction or light of day. Even when the Affordable Care Act (ACA) was passed in 2010, it included a provision requiring the federal government to issue a final rule on standardizing electronic attachments, and a deadline of January 1, 2014, for doing so, but nothing yet.

The delay, Tennant speculates, might relate to how CMS can address “solicited” versus “unsolicited” attachments. Maybe the use of a secure attachment protocol or portal for data submission could eliminate this concern. For example, with dental electronic attachment solutions, providers can simply upload their supporting documentation via HIPAA-compliant software services. The respective payer is then notified that attachments are available for claim processing. No muss, no fuss. 

While there’s no requirement or mandate for dental providers to submit attachments, just like there is not one for medical doctors, dental providers are leading the way having embraced the move to electronic attachments years ago, unlike their medical colleagues. Any care professional can (?) make use of the technology, and there is a market on the medical side of the fence, so why the delay in adoption?

One potential issue is that some believe submitting attachments to be “a fairly complex transaction” for health plans to implement. “Since CMS also controls Medicare and Medicaid, they would be required by law to implement this standard, and maybe there is some pushback in terms of the cost to implement this transaction,” said Tennant in the report.

Is regulation on electronic attachments forthcoming for medical providers? The federal electronic attachment conversation continues and was included in the federal government’s unified agenda — a plan of action issued by the Office of Management and Budget — that might not be considered until later this year.

According to regulatory guidance, the electronic attachments rule must contain data formats to be used for the attachments. In 2016, the National Committee for Vital and Health Statistics, a public group that advises the Health and Human Services (HHS) secretary on health data issues, laid out its recommendations for electronic attachments, including suggested formats, in a letter to then-HHS Secretary Sylvia Burwell:

• For the request for attachments, the group recommended using the ASC X12 format
• For the response with a submission of attachment, the HL7 format is recommended
• For the acknowledgement of the response, the ASC X12 format is recommended

For reference, the Accredited Standards Committee X12 (ASC X12) provides standards that can be used for nearly all facets of business-to-business operations conducted electronically. The committee aims to:

• Develop high-quality e-commerce standards that are responsive to the needs of the standards user
• Collaborate with other existing standards to make the standards developed more interoperable
• Avoid any conflict, confusion, and duplication of effort
• Publish and promote the standards along with their education
• Drive the implementation and adoption of the standards developed by the committee

Health Level 7, or HL7, refers to a set of international standards for transfer of clinical and administrative data between software applications used by various healthcare providers. These standards focus on the application layer, which is “layer 7” in the OSI model.

The group also recommended that HHS define attachments as the “supplemental documentation needed about a patient(s) to support a specific healthcare-related event (such as a claim, prior authorization, referrals, and others) using a standardized format.”

One thought is that with such guidance and with the backing of CMS, there might be a reduced “provider burden.”

What about the payers? Why not a push by payers for standardized operations? Why don’t payers and providers just decide on standards and implement them without any government help? This hasn’t happened because payers argue that it will cost too much money to implement; no one is going to bother if vendors don’t create products for the providers. Some vendors, of course, are not willing to produce a solution for such without payer’s backing.

In medical care, it seems that everybody’s waiting for somebody else, and no one will do it until the government issues the standard. Perhaps these arguments are valid for physicians, but for dentists, this foundation already is laid. Perhaps infrastructure is the real problem for medical providers. Nevertheless, the technological capabilities exist and have for many years.

If electronic attachments were implemented in medical care, the result could be savings for both health plans and providers, according to the Council for Affordable Quality Healthcare (CAQH), a non-profit alliance of health plans and other organizations whose goal is to streamline healthcare administration. The 2017 CAQH Index report found that only six percent of medical attachments were submitted electronically that year, but the report also found that providers could it save 51 cents per claim – 30 percent of their current cost — if electronic submission were employed, while health plans could save $1.64 per claim, a 94 percent savings.

CAQH launched a project under its Committee on Operating Rules for Information Exchange (CORE) division — a group of about 130 organizations developing operating rules for healthcare administration — to scan and discover where the healthcare industry stands in relation to electronic attachments, including use of a standard format. The organization is examining the varying types of use cases for documentation and the products available in the marketplace to support an automated approach to move the industry forward.

While the number of electronic attachments exchanged is quite small in volume, at least for medical providers, there is a clear path in place that can be executed with or without the support of an organization like CMS or others, as we have seen on the dental side of the house. While doctors may have been waiting for some guidance since HIPAA’s creation in 1996, dentists have been successfully using electronic attachment solutions since at least 1997, and with great results.

Thus, if more than 60 percent of the dentists in America who need to send supporting documentation to payers to get paid for their service are doing so electronically, why can’t the medical professionals of America do the same? America’s dental payers have agreed to participate in electronic attachments while America’s medical payers seem to be waiting for a mandate.

Machine Learning Primer for Clinicians–Part 7

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?
6. Artificial Neural Networks Exposed

Controlling the Machine Learning Process

We’d like a ML model to learn from past experiences, so post-training, it should be able to generalize when predicting an output based on unseen data. The ML model capacity should not be too small nor too large for the task at hand, as both situations are not helping to achieve the goal of generalization.

Under and Overfitting

In the funny yet accurate description below: 

• Knowledge sits in some form, but a ML model with not enough capacity will fail to see any relationships in the data.
• Experience is the capability to connect the proverbial dots. Once a ML model achieves this level, training should stop. Otherwise,
• Overfitting is when the model tries to impress us with its creativity. The ML model just had too much training and is now overdoing it.

Regression and Classification Examples of Under / Overfitting

We are searching for the sweet spot — a good, robust fit so the model would be able to generalize with unseen data.

The model should have sufficient capacity to be able to learn and improve and yet at the same time, not necessarily become the absolute best AI student on the training set.

Underfitting

Consider the left side of the above figure. The upper diagram displays data which is obviously not linear. Still, the ML model we’ve applied is linearly restricted – the model capacity is limited for the task.

The lower diagram displays a classification task, but the model is restricted to a circle. Its capacity is limited, so it cannot classify the dots better than with a circle separation line

When a ML model is underfitting, it basically doesn’t have enough or the right type of brain power for the task at hand or the model is exposed to a poor choice of features during training. We can help the ML model by:

• Using non-linear, more complex models.
• Increase the number of layers and / or units in a NN.
• Adding more features.
• Engineering more complex features from existing ones (using BMI instead of weight and height).

Underfitting is also called high bias and low variance and is one of the causes for a model to underperform. The model has a high bias towards a linear solution (in the regression example above) and a low variance in terms of limited variability of the features learned

Overfitting

You’ve trained your ML model for some time now and it achieves an amazing performance on the training set. Unfortunately, once in production, the ML model is only slightly better than just random predictions. What happened?

As the right side of the above figure shows, the model has used its large capacity to memorize the whole training set. The ML model became a memory bank for the training samples’ features, similar to a database. This overfitting caused the model to over train, to become “creative,” and also to become the best-ever on the training data. 

However, the overfitted model fails on real-life test data because it has lost the ability to generalize. We need the ML model to learn with each experience to generalize, not to become a memory bank

Overfitting is also called low bias and high variance, as the model has a low bias to any specific solution (linear, polynomial, etc.). The model will consider anything, any function, and it has a huge variance. Both factors contribute to an increased overall model prediction error.

How do we achieve a balance between the above two opposing forces of bias and variance? We need a tool to monitor the learning process — the learning curves — and a method to continuously test our model at each and every epoch, the cross-validation technique.

Training, Validation, and Testing Sets

Once you’ve got the data for a ML project, it is customary to cut a random 20 percent of samples, the test set and put it aside, never to be looked at again until the time of testing. Any transformation you plan on doing (imputing missing values, cleaning, normalizing, etc.) should be done separately on the training and test sets. 

This strict separation will easily prevent the scenario where normalizing over the whole data set and learning the average and standard deviation of the test set in the process may influence the model decision making in a way similar to cheating or letting the model know information about the test set, which the model should not know. The rest of the data after removal of this test set is the original training set.

As the model is going to be exposed to the training data multiple times — with different hyper-parameters (see below), architectures, etc. — if we allow the model to “see” the test data repeatedly, the model will eventually learn the test set as well. We want to prevent the model from memorizing all the data and especially to prevent the model exposure to the test set .

The original training set is used in a cross-validation scheme, so the same training set can be used also for validating each learning epoch. In a fivefold cross-validation scheme, we create each epoch, a 80 percent subset from the original training set and a validation set from the remaining 20 percent. Basically, we create a mini-test set for each learning epoch — a validation set — and we move this validation set within the original train set with each learning epoch (experiment in the figure below):

Learning Curves

With a cross-validation arrangement as detailed above, we can monitor the learning process and identify any pathological behavior on behalf of our student ML model during training.

Underfitting learning curves above show both the training and the validation curves remaining above the acceptable error threshold during the epochs of the learning process. Basically the model does not learn: either not enough model capacity or not good, representative enough features it can generalize upon. We need to either increase model capacity, increase the number or complexity of the features, or both. Adding more training samples will not help.

Overfitting learning curves show that pretty early during the learning process, the model started overfitting, when the two learning curves separate. The training curve continued to improve and reduce the training error, while the validation curve stopped showing improvement and actually started to deteriorate. Decreasing the model capacity, decreasing the number of features, or increasing the number of samples may help.

Perfect fit happens when the validation error is below the acceptable threshold and it starts to plateau and separate from the training curve. At that number of training epochs, we should stop, call an end for the learning session, and give our ML model a short class break.

Learning Rate

A ML model has parameters (weights) and hyper-parameters such as the learning rate.

With a too-low learning rate, the model will take its time to find the global minimum of the cost function (left in the above figure). Too high a learning rate will cause the model will miss the global minimum because it jumps around in too large steps. Modern optimizers can automatically modify their learning rate as they approach the minimum in order not to miss it with a too large jump above it.

Data Augmentation

Usually collecting more samples to feed an overfitting model is a time, money, and resource-consuming activity. Consider an image analysis ML model that identifies between dogs and cats in an image. Until recently, this exercise was used by CAPTCHA to distinguish between humans and malicious bots trying to impersonate humans. Machines recently achieved the same level as humans, so CAPTCHA is not using this challenge any more. Nevertheless, dogs vs. cats became one of the basic, introductory exercises in computer vision / image analysis.

While developing such an image classification model, one usually increases the model capacity gradually until the model starts overfitting. Then its customary to add data augmentation, a technique used only on the training set, in which images are being reformatted randomly around the following image parameters:

• Zoom
• Scale
• Brightness
• Skew
• Mirror around vertical / horizontal axes
• Colors

By exposing the algorithm during training to a more diverse range of images, the ML model will start overfitting at a much later epoch, as the training set is more complex than the validation set. This in turn will allow the model to bring the validation error to an acceptable level.

Data augmentation allows a ML model to realize that a cat looking to the right side is still a cat if it looks to the left side. With data augmentation, the ML model will learn to generalize that a dog is still a dog if it is scaled to 80 percent, flipped horizontally, and skewed by 20 degrees. No animals were harmed during this data augmentation exercise.

Regularizers

Eventually, a big enough model will start overfitting the data, even if the training set has been augmented. Another technique to deal with overfitting is to use a regularizer, a model hyper-parameter. Basically it penalizes the model loss function on any large modifications to the model weights. Keeping the changes to the weights within small limits during each epoch is important, as we don’t want the model to literally “jump to any conclusions.”

Dropout

An interesting, different, and surprisingly very efficient approach to overfitting that can prevent a ML model from learning the whole training set by heart is called dropout. Like data augmentation above, dropout technique is used only on the training set. It takes out randomly up to 50 percent of a NN layer units from one learning epoch, like randomly sending home half of the students for one class. How can this strategy prevent overfitting? 

The analogy with these students being dismissed from that class / epoch caused all the other units (students) in the layer to work harder and learn features they were not supposed to learn otherwise. This in turn zeroed the weights for up to half of the units while forcing other units to modify their weights in a way that is not conducive towards a “memory bank.” Shortly, dropout destroys any nascent memory bank a ML model may try to create during training.

Testing

Once training is completed, hyper-parameters have been optimized, data has been re-engineered, the model has been iteratively corrected, etc. then and only then one brings out the hidden testing set. We test the ML model and its performance on the test set will hopefully be close to its real-life performance.

Next Article

Predict Hospital Mortality

Morning Headlines 12/5/18

Curavi Acquires TripleCare, Prepares to Rapidly Expand Telemedicine Services

UPMC-backed Curavi Health acquires competitor TripleCare, a telemedicine vendor that caters to the post-acute, long-term care market.

MEDITECH UK Announces Acquisition of Centennial and the Formation of Medical Information Technology UK LTD

Meditech acquires its London-based partner Centennial Computer Corporation as part of its creation of Meditech UK.

Interoperability 2018: Real Progress with Patient-Record Sharing via CommonWell and Carequality

A KLAS report finds that most EHR vendors are progressing well toward supporting a national patient record network now that CommonWell is connected to Carequality.

Queensland digital hospitals program facing $250m cost blowout

In Australia, Queensland Health’s hospital EHR project will run $188 million over budget if implemented in the remaining hospitals, with an auditor-general’s report noting that Cerner can name its price for contract extensions knowing that alternative systems haven’t been considered.

News 12/5/18

Top News

A ProPublica report finds that the so-called “Mar-a-Lago gang” of three wealthy supporters of President Trump reviewed the VA’s proposed $10 billion Cerner contract before it was signed even though none of them had healthcare IT or military experience, naming themselves as an “executive committee.”

The physician member of the group, Bruce Moskowitz, also pressed the VA to use his self-developed ED locating app instead of collaborating with Apple. He named his son as the VA’s point person for the proposed project that was eventually abandoned.

The group reportedly got VA Secretary David Shulkin fired for being inadequately deferential to them.

Member Ike Perlmutter (chairman of comic book publisher Marvel Entertainment) has reportedly turned his guns on current VA Secretary Robert Wilkie, angered that Wilkie stopped taking his calls and that he released emails that contained Perlmutter’s name in relation to the VA’s no-bid Cerner contract.

Reader Comments

From Avenel Can’t Save This Trainwreck: “Re: Allscripts. Confirming that at least 250 were laid off, 40 of them from sales. Paragon and HHS support to be offshored. Closing offices and laying employees off is necessary because the company has a debt problem.” Unverified. I didn’t see a WARN notices, so perhaps the company is closing offices and offering transfer opportunities to those displaced, meaning that the resulting intentional attrition isn’t technically considered to be a layoff. With regard to your debt observation, I looked up the debt-to-equity ratio of these publicly traded health IT vendors (lower numbers are better):

• Cerner: 9
• NextGen Healthcare: 12
• Athenahealth: 24
• CPSI: 91
• Allscripts: 116

From Smattering: “Re: consulting. Can all these health IT people really make a living as independent consultants?” It should be obvious from the LinkedIn profiles you sent that “consulting” is a euphemism for “desperately seeking a full-time job.” Offering to consult isn’t the same as actually earning a living as a permanent consultant. I suspect that quite a few formerly high-flying health IT executives have been shocked to find that their consulting services were in low demand once they lost their purchasing influence, especially since it’s obvious that a sudden urge to become a consultant coincided with being unceremoniously shown their employer’s door. Reading LinkedIn profiles can be depressing. 

HIStalk Announcements and Requests

Welcome to new HIStalk Gold Sponsor PatientBond. The Elmhurst, IL-based company’s solutions address consumerism and evolving reimbursement models, amplifying patient engagement initiatives by using consumer psychographics (attitudes, values, lifestyles, and personalities) and digital engagement. Health systems use it for marketing, targeted patient acquisition, reducing no-shows, performing digital follow-up, sending health reminders, performing surveys, closing care gaps, and reducing readmissions. Clients include Partners HealthCare, Shawnee Mission Health, Aurora Health Care, and Trinity Health. The company’s psychographics and digital engagement were paired with the American Heart Association’s care plans to create AHA’s Health Motivation Platform to drive patient behavior change. You can determine your own patient segment by taking the company’s 12-question survey. Thanks to PatientBond for supporting HIStalk.

Webinars

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

Medical device manufacturer ResMed continues its recent string of health IT acquisitions by announcing plans to buy inhaler use monitoring technology vendor Propeller Health for $225 million. Madison-based Propeller Health has raised $70 million.  

Medication safety technology vendor Tabula Rasa HealthCare will acquire Australia-based parenteral medication dosing calculation vendor DoseMe.

Meditech acquires its London-based partner Centennial Computer Corporation as part of its creation of Meditech UK.

I was barely interested in McKesson even before it bailed on health IT, but for those who still care, the company will relocate its global headquarters from San Francisco to Las Colinas, TX. Not shockingly, that’s where the company’s incoming CEO Brian Tyler lives (and where costs are much less). Pretty much every place I’ve ever worked that changed office locations ended up near the CEO’s opulent house since the commute time of that one person outweighs that of hundreds of employees despite HR’s claim that its ZIP code analysis makes that location best for everyone.

Athenahealth files the SEC notice of its shareholder vote on the company’s proposed acquisition by subsidiaries of Veritas Capital and Elliott Management. Interesting points:

• The acquirers will take on several billion dollars of debt to finance the acquisition.
• Termination fees of several hundred million dollars are specified for both sides of the transaction.
• 65 companies expressed interest in acquiring Athenahealth — 32 companies and 33 financial sponsors.
• Athenahealth’s board worried that the company could not meet financial expectations due to declining market opportunities because of low customer switching rates from competing products, a declining win rate, and the need to spend more money on product development to remain competitive.
• Athenahealth’s change-in-control plan for its top executives provides each with a one-year severance; a year’s bonus; 9-12 months of medical and dental coverage depending on title; full vesting of unvested shares; and up to $10,000 in outplacement costs. That provides Golden Parachute Compensation ranging from $800,000 (for the former interim CFO) to $5.5 million (for the CFO).
• Former CEO Jonathan Bush would get $4.8 million under a previously negotiated separation agreement. He also owns 900,000 ATHN shares valued at around $122 million.
• Jeff Immelt, who served as board chair for nine months, leaves with $420,000 and shares worth $1.8 million.

Sales

• Arizona HIE Health Current chooses Diameter Health for data interchange and clinical data quality.

People

Harry Greenspun, MD (Korn Ferry) joins consulting firm Guidehouse as chief medical officer.

Announcements and Implementations

An excellent new KLAS report finds that most EHR vendors are progressing well toward supporting a national patient record network now that CommonWell is connected to Carequality, which the authors call “the connection heard round the US” as users of Cerner and Epic can now exchange information. Another factor is the connection of Meditech to CommonWell and NextGen Healthcare to Carequality. Click the above graphic to see fascinating adoption numbers by vendor. Interesting facts:

• Allscripts and Medhost have not enabled connectivity at all.
• Allscripts says it will connect TouchWorks and Sunrise in 2019, but the company hasn’t committed to enabling Paragon, Professional, or other products.
• Longstanding CommonWell member Medhost has yet to connect anything.
• EClinicalWorks customer connections have tripled since March 2018 and CPSI has done a good job in integrating connectivity.
• Virence Health (the former GE Healthcare IT) and Greenway Health have made little progress.
• Cerner customers face the most significant technical hurdles in connecting, requiring 3-6 months to install Resonance and to perform mapping, making Cerner is the vendor furthest away from plug-and-play interoperability.
• Epic and Athenahealth enable connectivity by default and thus nearly all users of Epic and Athenahealth have connected, which has given them the chance to move on to other pressing projects.
• The CommonWell-Carequality connection has removed the final obstacle to widespread sharing of records as nearly all EHR users can connect quickly and inexpensively.
• The biggest interoperability barrier is that providers don’t really care about sharing data and thus don’t bother to actually share records even though EHR vendors have stepped up to make it possible for them to do so.

Another new KLAS report reviews clinical surveillance technology, finding that despite the claims of several vendors, Epic and Cerner are the only vendors whose surveillance tools have significant usage. It notes that Epic’s surveillance tools are the hardest to set up due to lack of vendor guidance and best practices, but users who have gone live have created the largest variety of use cases. Cerner, Epic, Stanson Health, and Bernoulli users say the alerts improve patient care and reduce readmissions

UCSF will study and manage weight loss in newborns by using SMART on FHIR to integrate Epic with NEWT, a free, web-based, hospital-developed newborn weight loss tracking tool. UCFS’s study is called Healthy Start.

UK-based EMIS Group announces a new cloud-based version of EMIS Web, the UK’s most widely-used clinical system. New features include federated appointments, a voice assistant, video consultations, and analytics.

Government and Politics

A Tennessee nurse practitioner pleads guilty to scamming the military’s Tricare medical insurance out of $65 million via the usual route – conducting telemedicine sessions that resulted in prescriptions for expensive compounded medications that were provided by pharmacy co-conspirators who were also charged.

Privacy and Security

A Florida hospitalist staffing group will pay $500,000 to settle HHS OCR charges that it violated HIPAA in 2011-12 by sharing patient information with someone posing as a billing company employee who then exposed the information to the Internet, all without having a business associate agreement with the billing company or having performed a risk assessment.

Other

In Australia, Queensland Health’s hospital EHR project will run $188 million over budget if implemented in the 12 remaining hospitals, with an auditor-general’s report noting that Cerner can name its price for contract extensions knowing that its customer has not considered alternative systems. The report also concludes that the project can’t continue without further funding and says the system does not provide value for money.

Bill Gates names “Bad Blood” as one of five of this year’s books he recommends. Gates says it is “insane” that Theranos hard-coded demo blood testing machines to display a stuck status bar so they could blame connectivity for the machine’s not working. He says Theranos stumbled because it didn’t have healthcare experts on its board; it sported a Steve Jobs-inspired take-no-prisoners outlook that isn’t appropriate for healthcare; and it allowed Elizabeth Holmes to make her personal legacy the company’s most important goal.

In Canada, the health minister of Newfoundland and Labrador blames Telus Health’s Med Access lab results distribution software for delays in delivering results to several hundred patients in the past year.

Darn, this was almost a clean sweep – an offshore company’s expensive CPOE market report lists six “global top players,” five which are trivia questions having not sold CPOE systems for a long time.

A Wired article says that unlike Amazon and Google, Facebook has no interest in furthering mankind beyond simply growing its own business and assuming that the world will benefit, leaving it with a platform whose chief attributes are tracking and targeting users. A member of Canada’s parliament said in a hearing involving the governments of nine countries – at which Facebook CEO Mark Zuckerberg was a no-show – that “While we were playing on our phones and apps, our democratic institutions seem to have been upended by frat-boy billionaires from California.”

I was thrilled to discover Fakespot, an AI-powered analyzer of reviews on Yelp, Tripadvisor, and Amazon that spots reviews that are likely phony and then recalculates the star rating accordingly. Those sites could do this themselves, of course, but then they wouldn’t have nearly as many reviews to brag about and their advertising revenue might be threatened. Amazon should allow reviews only from people who have actually purchased the item via Amazon, Yelp should ignore reviewers who have posted few reviews or who are posting about businesses all over the world (likely for cash unless they travel extensively), and Tripadvisor really can’t do much about the flood of fake reviews since neither of these methods would work for a global travel site.

In Japan, National Center for Child Health and Development will work with Sony to see if that company’s AI-powered robotic dog Aibo can measurably reduce stress and provide emotional support to children facing long hospital stays. Sony is selling Aibo’s “First Litter Edition” for the US market for $2,900, although there’s a wait list and they won’t ship to Illinois for some reason. Reviews have been OK, although some testers didn’t expect that having a robotic pet that learns that, like a real puppy, you have to train them (although presumably not in the peeing or chewing kind of way).  

Speaking of robots, Weird News Andy volunteers to spearhead an ICD-10 revamp to include the trendy electric scooters that are sending 1,000 people a month to EDs. WNA notes the billing challenge when available codes consider only scooters of the mobility and non-motorized varieties. I swear we’re regressing to children in fawning over scooters, wasting most of our free time playing with toys (of the Internet-enabled variety), and reducing discourse about global events and politics to a spirited game of Rock ‘Em Sock ‘Em Robots.

Sponsor Updates

• Burwood Group helps patients connect with Santa at Advocate Children’s Hospital.
• AdvancedMD publishes a new guide, “In or Out-source Your Value-Based Care Revenue Cycle Management.”
• Aprima announces EHR integration with SE Healthcare’s Physician Empowerment Suite software.
• Bernoulli Health will exhibit at the AARC Congress through December 7 in Las Vegas.
• KLAS recognizes Bernoulli Health in its 2018 clinical surveillance report.
• Clinical Architecture will exhibit at the AHIMA Data Institute December 6-7 in Las Vegas.
• Dimensional Insight will exhibit at the MDM-Forum through December 6 in Denver.
• DocuTap’s Eric McDonald will present at 1 Million Cups in Sioux Falls, SD December 5.
• Meditech adds diabetes management capability to Expanse Ambulatory.
• Access releases EFR Mobile, which supports electronic forms and signatures capability on mobile devices.
• EClinicalWorks publishes a podcast titled “Strengthening Patient Engagement in Illinois.”

Blog Posts

• AI takeaways from RSNA 2018 (Hyland)
• PACS limitations demand a new imaging paradigm (Hyland)
• A New Twist on ‘An Apple a Day’: Reflections from Becker’s Revenue Cycle Conference (Meditech)
• The latest technology in health care (Meditech)
• How a health information search engine can help overcome physician burnout (EClinicalWorks)
• Survey says: Cerner clients share where they are in the paperless journey (Access)
• The faces of Agfa HealthCare at RSNA 2018 (Agfa HealthCare)
• Technology, Workflow and Outcomes: Finding Balance for Nurses (Bernoulli Health)
• AWS re:Invent re:Actions – Controlling risk is important, but confusing (Datica)
• Signature Ready (Culbert Healthcare Solutions)
• Are Poor Patient Relationships Killing Your Hospital’s Bottom Line? (Docent Health)

Contacts

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

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.