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Morning Headlines 11/15/18

November 14, 2018 Headlines Comments Off on Morning Headlines 11/15/18

Mount Sinai Technology Spinout RenalytixAI Completes Initial Public Offering, Raising $29 Million to Combat Kidney Disease

RenalytixAI raises $29 million in an IPO that will be used to fund the launch of AI-enabled applications for the early detection of kidney disease and transplant management.

Dartmouth-Hitchcock Health teams with Philips on Tele-ICU program

Dartmouth-Hitchcock Health (NH) will use technology from Philips to develop a tele-ICU program, initially focusing on medical, surgical, and neurology ICUs.

Introducing Veradigm™ Providing Next Generation Healthcare Solutions for Today’s Healthcare Challenges

Allscripts rebrands its Payer & Life Sciences Division to Veradigm, offering clinical workflow, research, and analytics software and services to providers, payers, and health IT and life sciences companies.

Comments Off on Morning Headlines 11/15/18

A Machine Learning Primer for Clinicians–Part 5

November 14, 2018 Machine Learning Primer for Clinicians Comments Off on A Machine Learning Primer for Clinicians–Part 5

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.

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Previous articles:

  1. An Introduction to Machine Learning
  2. Supervised Learning
  3. Unsupervised Learning
  4. How to Properly Feed Data to a ML Model

How Does a Machine Actually Learn?

Most ML models will have the following components:

  • Weights – units that contain the model parameters and are modified with each new learning experience. a.k.a train epoch.
  • Metric – a measure (accuracy, mean square error) of the distance between the model prediction and the true value of that epoch.
  • Loss or Cost Function – used to update the weights with each train epoch according to the calculated metric.
  • Optimizer – algorithm overseeing the loss function so the model will find the global minimum in a reasonable time frame, basically preventing the model from wondering all over the loss function hyperspace.

The learning process or model training is done in epochs. With each epoch, the model is exposed to a batch of samples. 

Each epoch has two steps:

  1. Forward propagation of the input. The input features undergo math calculations with all the model weights and the model predicts an output.
  2. Back propagation of the errors. The model prediction is compared to the real output. This metric is used by the loss function and its master – the optimizer algorithm – to update all the weights according to the last epoch performance.

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Consider a model, in this case a neural network (NN) that tries to predict LOS using two features: age and BMI. We have a table with 100 samples / instances / rows and three columns: age, BMI, and LOS.

  • Task: using age and BMI, predict the LOS.
  • Input: age and BMI,
  • Output: LOS.
  • Performance: mean square error (MSE),  the squared difference between predicted and true value of LOS.

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Forward Propagation of the Input

Input is being fed one batch at a time. In our example, let’s assume the batch size is equal to one sample (instance).

In the above case, one instance enters the model at the two left red dots: one for age and one for BMI (I stands for Input). The model weights are initialized as very small, random numbers near zero.

All the input features of one instance interact simultaneously through a complex mathematical transformation with all the model parameters (weights are denoted with H from hidden). These interactions are then summarized as the model LOS prediction at the rightmost green dot – output.

Note the numbers on the diagram above and the color of the lines as weights are being modified according to the last train epoch performance. Blue = positive feedback vs. black = negative feedback.

The predicted value of LOS will be far off initially as the weights have been randomly initialized, but the model improves iteratively as it is exposed to more experiences. The difference between the predicted and true value is calculated as the model metric.

Back Propagation of the Error

The model optimizer updates all the weights simultaneously, according to the last metric and loss function results. The weights are slightly modified with each sample the model sees – the cost function is providing the necessary feedback from the metric that measures the distance between the recent prediction vs. the true LOS value. The optimizer basically searches for the global minimum of the loss function

This process is now repeated with the next instance (sample or batch) and so on. The model learns with each and every experience until it is trained on the whole dataset.

The cost function below shows how the model approaches the minimum with each iteration / epoch.

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From “Coding with Data” by Tamas Szilagyi.

Once the training has ended, the model has a set of weights that have been exposed to 100 samples of age and BMI. These weights have been iteratively modified during the forward propagation of the input and the back propagation of errors. Now, when faced with a new, never before seen instance of age and BMI, the model can predict the LOS based on previous experiences.

Unsupervised Learning

Just because there is no output (labels) in unsupervised learning doesn’t mean the model is not constrained by a loss / cost function. In the clustering algorithm from the article on Unsupervised Learning , for example, its cost function was the distance between each point and its cluster centroid, and the model optimizer tried to minimize this function with each iteration.

Loss / Cost Function vs. Features

We can chart the loss function (Z) vs. the input features: age (X) and BMI (Y) and follow the model as it performs a gradient descent on a nice, convex cost function that has only one (global) minimum:

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Sometimes two features can present a more complex landscape of a loss function, one with many local minima, saddles and the one, much sought after, global minimum:

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From “Intro to optimization in deep learning” – PaperSpace Blog.

Here is a comparison of several ML model optimizers, competing to escape a saddle point on a loss function, in order to get to the optimizers’ nirvana – the global minimum. Some optimizers are using a technique called momentum, which simulates a ball accumulating physical momentum as it goes down hill.  Getting stuck on a saddle in hyperspace is not a good thing for a model / optimizer, as the poor red Stochastic Gradient Descent (SGD) optimizer may be able to tell, if it will ever escape.

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From “Behavior of adaptive learning rate algorithms at a saddle point – NVIDIA blog.

Just to give you an idea of how complex a loss / cost function landscape can be, below is the loss function of VGG-56 – a known image analysis model trained on a set of several million images. This specific model loss function has as X – Y axes the two main principal components of all the features of an image. Z axis is the cost function.

The interesting landscape below is where VGG-56 has to navigate and find the global minimum – not just any minimum, but the lowest of them. Not a trivial task.

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From “Intro to optimization in deep learning” – PaperSpace Blog.

Compressing many dimensions an image usually has, into only two (X-Y) – while minimizing the loss of variance – is usually a job performed by principal component analysis (PCA),  a type of unsupervised ML algorithm. That’s another aspect of ML – models that can help us visualize stuff which was unimaginable only a couple of years ago, such as the 3D map of the cost function of an image analysis algorithm.

Next Article

Artificial Neural Networks Exposed

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Morning Headlines 11/14/18

November 13, 2018 Headlines Comments Off on Morning Headlines 11/14/18

‘We ran out of money’: High-profile startup seeking to connect patients with clinical trials shuts down

Driver, whose technology matches cancer patients with clinical trials, runs out of cash and shuts down just two months after its high-profile launch.

The new Google Health unit is absorbing health business from DeepMind, Alphabet’s AI research group

Alphabet will move its London-based DeepMind healthcare AI subsidiary under the newly formed Google Health, which will be led by former Geisinger CEO David Feinberg.

LeanTaaS Secures $15 Million in Series C Investment to Accelerate Growth of Its Healthcare Operations Platform

Smart scheduling and throughput technology vendor LeanTaaS raises $15 million in a Series C funding round, increasing its total to $39 million.

Comments Off on Morning Headlines 11/14/18

News 11/14/18

November 13, 2018 News 9 Comments

Top News

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Driver, whose technology matches cancer patients with clinical trials, runs out of cash and shuts down just two months after its high-profile launch.

The company had 85 employees and 30 cancer centers participating, but its revenue model was to charge patients $3,000 upfront plus a monthly fee to be matched with studies (lesson learned – never base your revenue projections on what healthcare consumers are willing or able to pay unless your product involves recreational drugs, vanity surgery, or sex).

The company says it will try to help its few paying customers transition smoothly, but cautions that it doesn’t have the money to issue refunds.


Reader Comments

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From Randy: “Re: the $20 million donation to Seattle Children’s from former Microsoft CEO Steve Ballmer. I generally agree with the sentiment about big donations to hospitals instead of public health, but the Ballmer gift is to the Odessa Brown Children’s Clinic, which serves the historically underserved, African-American neighborhood in Seattle. They will use it to locate a second facility near the light rail station so that the families of patients who are displaced by Seattle housing prices can still access the clinic’s services.” I saw that and it’s indeed a good cause, although Seattle Children’s makes enough profit that they should have been able to do the right thing without waiting for Ballmer’s donation. Still, I recognize that hospitals – including whose that have employed me – never seemed to be able to get anything done without borrowing more money (probably because they were always erecting or buying new buildings), so perhaps the donation avoided that.

From BH: “Re: breach. [vendor name omitted] contacted one of our partner hospitals to inform them that an employee of the company had their credentials compromised, and that those compromised credentials may have accessed their servers. Not sure yet what products or product lines were affected, but the company that received this notice is a hospital that uses multiple products. I have not yet seen any public statement about this activity or any breach notifications” Unverified, so I’ve left the company name off for now. Forward the email to me, please. 


HIStalk Announcements and Requests

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Thoughts on the acquisition of Athenahealth by Veritas Capital:

  • We’ve now seen health IT’s own example of the damage that can be wrought by a vulture fund that will do anything to make money by running roughshod over whatever company is unfortunate enough to find itself in its crosshairs.
  • The activist investor and minority shareholder, Elliott Management, is a bone-picker, not a long-term investor (this is the company that bought heavily discounted Argentina sovereign debt, then seized one of its navy ships for non-payment). They will pressure the new Athenahealth to cut costs, sell parts piecemeal, and then run another IPO with a new story. That will likely not resonate with Veritas, which has a more measured approach (and healthcare experience) in increasing value by improving operations and strategy. It will be interesting to see how those two owners co-exist.
  • We’ve also seen yet another downside of going public, where you can’t control who buys your shares or what public demands significant shareholders will make.
  • Perhaps the most ironic pairing since Jimi Hendrix opened concerts for the Monkees is combining Athenahealth with the health IT assets of the former GE Healthcare. Integrating those portfolios with the Cotiviti payments processing and analytics business to create something worth more than the sum of their parts will be challenging, especially in establishing a brand identity (quick – what does Emdeon sell?)
  • Athenahealth Chairman Jeff Immelt obviously brought little to the table in his short tenure as a quick Jonathan Bush replacement, spending his days trying to convince potential buyers and likely engineering the pairing of Athenahealth with the assets of GE Healthcare (after being fired by the wildly underperforming GE and previously overseeing the hot mess that was GE Healthcare IT in his executive tour that also included plastics and appliances).
  • It’s likely that the acquisition marks the end of the nascent Athenahealth inpatient EHR business and thus its hopes to become an enterprise player that can compete with Epic, Cerner, and Meditech.
  • Athenahealth struggled with contracting ambulatory EHR demand and some of its competitors have been acquired for presumably unimpressive sums, highlighting big problems with the ambulatory EHR/PM market in the absence of Meaningful Use stimulus and the strong trend toward health systems acquiring practices and replacing their EHR/PM systems with the hospital standard.
  • GE Healthcare’s 2014 workforce management technology acquisition API Healthcare will see new life as a separate company once again. Veritas Capital acquired the well-regarded business in July 2018.
  • Athenahealth’s claims of being a healthcare disruptor — which earned airplay mostly because of its charismatic and investor-entrancing former CEO Jonathan Bush — weren’t always believable  since the company had a lot of India-based workers pushing paper and was an easily swatted fly of Bush’s favorite target Epic, but whatever innovation the company has accomplished or promised is probably not going to happen under private equity ownership and a CEO with no healthcare experience.
  • Jonathan Bush made Athenahealth more interesting than the company deserved.

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HIMSS19 starts in 90 days, so I threw down a few thoughts.


Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre for information.


Acquisitions, Funding, Business, and Stock

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Smart scheduling and throughput technology vendor LeanTaaS raises $15 million in a Series C funding round, increasing its total to $39 million.

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Several health IT startup CEOs form HealthTech4Medicaid, which will advocate for Medicaid’s use of technology (with special emphasis on the ones its members sell). I’ve heard of only a handful of the 40+ companies whose CEOs are involved.

Business Insider fawns over a former exec of Facebook and Google whose company is working on continuous, wearable imaging devices that it hopes to sell in drugstores in competing with MRIs. It’s an interesting idea with a lot of potential pitfalls along the way (such as the FDA’s approval), but the real problem is that investors, startups, and consumers obsess over new diagnostic tools that can create false positives (requiring clinician time and possibly causing harm as the patient gets roped into the healthcare widget factory). We have many problems with US healthcare, but misdiagnosis and under-diagnosis aren’t anywhere near the biggest ones other than to investors looking to make mint.

The best reporter in the business, CNBC’s Chrissy Farr, reports that Alphabet will move its London-based DeepMind healthcare AI subsidiary under the newly formed Google Health, which will be led by former Geisinger CEO David Feinberg. The Google Health name is apparently being recycled from the company’s failed personal health record, which was rolled out in 2008 and shut down in 2011 when the company finally realized the obvious – nobody (including Google executives, no doubt) will bother entering their information into a PHR.


People

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Veritas Capital-owned Virence Health, soon to be merged with Athenahealth under the latter’s name, hires Karl Salnoske (Laureate International Universities) as SVP of engineering and cloud operations; Sal Mahbouba (Ratava Partners) as SVP of professional services and support; and R.J. Timmons (Tenet Healthcare) as SVP and general counsel.


Announcements and Implementations

A Black Book survey of 3,000 hospital-owned or employed practices finds that 40 percent are budgeting to replace their practice management systems in favor of hospital-integrated systems, with 89 percent of hospital executives saying non-integrated EHR/PM systems impede their ability to participate in alternative payment methods. Hospitals say moving to an integrated PM system increases scheduling satisfaction, increases collections, and reduces time and resources required. Allscripts, GE Healthcare, and Cerner topped the integrated ambulatory systems review, while NextGen, Aprima, and Azalea Health took the bottom spots. The results might seem screwy, but as reader Longtime HIT Marketer reminds us, Black Book is not evaluating products or deep-diving with a handful of handpicked customers, but instead is simply reporting the perception of a statistically valid number of users. As he or she adds, “If Allscripts clients believe their products are integrated, then they are integrated.”

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A Dimensional Insight survey of 85 health IT executives finds that few have high levels of trust regarding the financial, clinical, and operational data their organization makes available via self-service tools. The company recommends keeping subject matter experts involved in collecting, transforming and presenting data; automating complex data manipulation logic; and getting frontline data consumers involved.

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Microsoft announces the open source FHIR Server for Azure. And please, enough with the witless “fire” puns since it’s a convenient but illogical way to sound it out (the accurate way will elicit more gasps than giggles).


Other

Analysis finds that half of the $52 billion in quarterly profits of publicly traded healthcare corporations came from just 10 companies, nine of which sell drugs. Drug companies pocketed nearly two-thirds of the profit on just 23 percent of the revenue. The new tax law that reduced corporate tax rates helped, as AbbVie paid just $14 million (0.5 percent) of its $2.76 billion in profit in taxes, while Pfizer’s tax rate was just 1.6 percent.

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St. Charles Health System (OR) removes patient gender from wristbands at the urging of psychologists who say it causes harm to transgender patients while providing no benefits. Epic reviewed how it stores gender or name to determine how the information is used – to address the patient, to communicate with insurers, or for clinical purposes – although it says only one-third of customers use its expanded gender identity categories. It’s a fine line to walk when such patient characteristics as age, race, ethnicity, weight, religion, and genomic characteristics are required to make good clinical decisions, yet aren’t appropriate to use elsewhere, with the saving grace being that electronic systems can show the information only to those who need it. 

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I get the newsletter of innovation and investment advisor CB Insights, which also produces conferences. CEO Anand Sanwal offers these ideas that are pretty much the opposite of health IT conferences:

  • No sponsors on stage, ever – it’s disrespectful to attendees to have speakers who “do a sales pitch, often dressed up as mediocre thought leadership.”
  • All sessions are moderated by impartial, real journalists.
  • No panel discussions since 99 percent of them are terrible
  • “Thought leaders” ruin events – 47 percent of poll respondents say someone loses all credibility if they refer to themselves as a thought leader.
  • Sanwal says that only four of the 100 conferences at which he has spoken in the past four years were content-first and thus good for business, while the rest had negative value. He has learned that writing content has better ROI since the audience is larger and the shelf life is longer.

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The CB Insights rant led me to create my own poll. Which terms turn you off in a LinkedIn profile, Twitter profile, or speaker bio? (note: the self-flattering choices all came from the LinkedIn profiles of health IT folks whose list of accomplishments and tenure per employer are, to be kind, a bit short). I’m the only LinkedIn profile self-reporting as “blowhard” of the many who repeatedly earn the title. Has ‘health IT’s poet laureate” been claimed?

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Weird News Andy pivots from his entertainingly odd stories to laud the nurses of Adventist Health Feather River Hospital (CA), who hastily evacuated patients as the Camp Fire reached the hospital’s parking lot, then had to make their way back to the hospital when their own escape routes were blocked. The hospital employees set up triage in the fire-surrounded parking lot for locals who were unable to evacuate, then were ordered by firefighters to leave when the hospital roof caught fire, by which time roads were less congested because everybody had already fled for safety. 


Sponsor Updates

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  • FDB employees volunteer at the Midwest Food Bank to support those in need.
  • Bluetree will exhibit at the RCM Leaders Forum November 14-16 in Dallas.
  • Collective Medical integrates its care collaboration network with California’s CURES 2.0 prescription drug monitoring program database.
  • CarePort Health will exhibit at the ACMA Western Pennsylvania event November 17.
  • EClinicalWorks publishers customer success stories from Gastro Health and Big Sur Health Center.
  • Carevive Systems will exhibit at the 2018 Palliative and Supportive Care in Oncology Symposium November 16 in San Diego.
  • Impact Advisors is named to Consulting Magazine’s “Fastest Growing Firms” for the second straight year.
  • Diameter Health will exhibit at the NCQA HL7 Digital Quality Summit November 14-16 in Washington, DC.
  • A Riverside Medical Center (IL) study finds that use of Glytec’s EGlycemic Management System reduced hypoglycemia in critical care patients by 73 percent and was associated with patients transferring out 0.25 days faster.
  • Meditech integrates DrFirst’s MyBenefitCheck prescription pricing solution with its Expanse EHR.
  • Mental and behavioral screening technology vendor AssessURhealth is named Tampa Bay Tech’s “Emerging Technology Company of the Year” for 2018.

Blog Posts


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Contacts

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

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Looking Ahead to HIMSS19

November 13, 2018 News Comments Off on Looking Ahead to HIMSS19

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We’re 90 days out from the start of HIMSS19. Notes:

  • Register by December 3 to obtain the early bird discount ($825 for members, $1,055 for non-members).
  • Book a hotel ASAP if you haven’t already. Rooms are available at several close-in hotels at reasonable rates. Or, do as I always do and rent a house or condo through Airbnb or VRBO and then just take Uber or Lyft to the convention center. Do not reply to the shady non-HIMSS emails offering rooms – they’re a scam since HIMSS controls basically every hotel room you’re likely to want.
  • Note the odd dates – the opening reception is Monday evening (February 11),  the opening keynote is Tuesday morning, and the conference ends after a partial day on Friday (that’s going to be a slow conference day for sure).
  • The exhibit hall will be open Tuesday morning and will close Thursday evening.

The online educational agenda is incomplete, with many sessions containing only a placeholder without presenter names (seems a bit late to still be working on that, but it’s not going to change anyone’s plans either way). All keynote speakers announced so far work in for-profit companies – Atul Gawande, MD (of the ABC consortium that hasn’t named itself yet), Susan DeVore (Premier), and Mick Ebeling (Not Impossible Labs). Many of the educational sessions have vendor presenters, quite different from the HIMSS conferences a few years back where the commercial side of health IT was kept separate from the education sessions.

The theme of the conference is the rather dopey “Champions of Health Unite,” perhaps a stretch given that most of the attendees are vendors or IT-related people whose scope and influence in “health” is tiny (we contribute slightly to the work of providers, whose services in turn contribute about 20 percent of a person’s overall health). HIMSS, as usual, proclaims itself an equal partner as we advance information and technology “to meet our biggest challenges head-on and truly transform health,” which you would think would have been accomplished by now since they claim impending “transformation” every year and the US healthcare system is a bigger mess than it’s ever been.

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What we’ll be doing there:

  • Our tiny 10×10  booth is #4085. The location is OK (especially since we’re not selling anything) and several of our neighbors are HIStalk sponsors, which is often fun. We’re near the restrooms, of course, since that’s always the case except that one year we were nearly co-located with the Thai food kiosk.
  • Many small booths remain available. I wouldn’t wait long to get on board, though, since latecomers aren’t listed in the printed guide. I’m always skeptical about companies that aren’t organized enough to sign up given a full year’s notice, especially if they’re pitching project management services.
  • Exhibiting isn’t cheap. Non-member booth space costs $45 to $47 per square foot plus $725 for a corner. HIMSS provides five exhibitor or client badges for each 100 square feet purchased, which makes it a better deal for us even though we only use a couple of those badges.
  • The 10th and final HIStalkapalooza was in 2017, so there’s no need to email me asking for tickets (I still get those requests regularly). You can watch the video of the 10th and final one at HIMSS17 in Orlando if you’re feeling nostalgic.

The biggest individual booths in square feet are:

  • IBM (15,300, total space 15,810 – that cost them well over $600,000 at the corporate member rate of $39 per square foot plus extra for corners – maybe Watson made the call)
  • Allscripts (10,800, total space 11,100)
  • Epic (9,900, total space 13,500)
  • Cerner (8,400, total space 12,300)
  • GE Healthcare (7,000, total space 7,400 – I’m not sure what they’ll be pitching since they’ve sold off their health IT business)

Exhibitors get priority choice for booth space given their HIMSS Exhibitor Priority Points, earned by spending a lot on HIMSS stuff (including participating in other HIMSS-owned conferences and throwing down major advertising dollars to its HIMSS Media PR factory).

You might want to review these reader-provided tips if you’re a first-time attendee.


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We’re be doing our usual HIStalk stuff at HIMSS19:

  • Having interesting characters and pseudo-celebrities hang out in our little booth. Let us know if you want to participate – my definition of celebrity-hood leans toward the offbeat.
  • Talking up HIStalk sponsors a bit beforehand to let folks know what they’re doing there. We will be too busy after January 1 to get new sponsors on board until after the conference since it’s just 41 days between New Year’s Day and the conference’s start.
  • Giving away stuff in our booth, which ranges from the slightly cool but obviously cheap (when I have to pay for it) or nicer, vendor-supplied swag that is higher quality but potentially less cool.
  • Cruising the exhibit hall to write up what we see — the buzz, giveaways, demos, and booth people behaving badly (see my exhibitor tips to avoid being called out, and for God’s sake don’t dress non-clinicians in scrubs).
  • Covering the 5 percent of vendor announcements (most of them unwisely pushed out Monday amidst the mayhem) that contain something even mildly interesting.
  • Maybe having some kind of DonorsChoose fundraising event if I can figure something out.
  • Posting the HISsies results. Which reminds me that I need to get the voting underway soon given the early conference date.

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Morning Headlines 11/13/18

November 12, 2018 Headlines 3 Comments

Veritas Capital Will Acquire Athenahealth for $5.7 Billion

Veritas Capital and Elliott Management subsidiary Evergreen Coast Capital will acquire Athenahealth for $5.7 billion.

FHIR Server for Azure: An open source project for cloud-based health solutions

Microsoft Healthcare releases an open-source project on GitHub to help developers build FHIR-based services and apps in the cloud.

Manatt Adds Prominent Venture Capitalist and Entrepreneur

Healthcare venture fund expert Lisa Lisa Suennen will join Manatt Phelps & Phillips as head of its digital and technology businesses (including its healthcare consulting arm), and the firm’s venture capital fund.

Rapid Escalation of Practice Acquisitions Drives Hospital Systems to Merge Hosts of Physician Technology Platforms by 2021, Black Book Survey

Forty percent of hospital-based respondents plan to replace acquired physician practice EHR and PM systems, with Allscripts being the most recommended integrated solution.

Curbside Consult with Dr. Jayne 11/12/18

November 12, 2018 Dr. Jayne Comments Off on Curbside Consult with Dr. Jayne 11/12/18

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I was intrigued by the results of Mr. H’s recent poll results regarding reader attendance plans for HIMSS19. Only 28 percent of respondents will be going, although the sample size is pretty small at 216 readers. Most of the people I’ve asked recently about their HIMSS plans are under substantial budget constraints, with some employers limiting even high-level IT staffers to only one conference per year. Those with limits seem to generally choose their EHR vendor’s user group meeting, or otherwise a meeting that is more specific to projects that they’re going to be working on in coming months.

Since HIMSS released the educational sessions schedule this week, I decided to do a bit of a deep dive to see what is on the calendar that might be interesting to potential attendees or might bring value to their efforts to persuade their employer to send them.

The first place I landed was the subset of Views From the Top sessions, where attendees can “be inspired by compelling stories from high-ranking leaders in a variety of industries.” The first session that popped up was one presented by Jason Cheah, who is CEO of the Agency of Integrated Care in Singapore. I do enjoy the international sessions, often there are some progressive approaches to healthcare IT problems, although it can be tricky to find nuggets that can be applied back home since the healthcare delivery systems might be significantly different from what we have to work with in the US. I recently spent some time with some physicians from Canada and learned that although some of the issues are the same, there’s enough of a different spin on payment and prioritization of initiatives that some of the best ideas I heard would be difficult to apply at my own hospital.

Wednesday’s session titled “Transparency in Prescription Drug Costs to Help Patients Save Money” will certainly address a US-centric topic, given that the presenters are CVS Health Chief Medical Officer Troy Brennan, MD and Surescripts Chief Executive Officer Tom Skelton. They’re slated to talk about drug cost and benefit plan information transparency and how to better expose that information to patients, prescribers, and pharmacies. Price shopping is a big deal for the patients I currently serve – many are using sites like GoodRx to help make medications more affordable. It’s still a patchwork of coverage, though, as one of my patients found out when a local Walmart refused to honor the $15 price listed in the app, telling the patient it would be $50. The patient didn’t fill it at our office due to a $40 price tag in the first place, and with the drive and the confusion ended up in a situation where our office was closed so they couldn’t get it from us for less, so they didn’t fill it at all. Not good news for the teenager with bronchitis and asthma who really would have benefitted from access to an inhaler overnight.

Another Views From the Top session is titled “Defeat Nation State Actors Stalking the Health Care Sector” and covers cybersecurity best practices and risk exposure management. It sounds interesting, but likely more suited to the technical side of the house as opposed to the average clinical informaticist.

Next, I went to the section titled Reactions from the Field, which is designed to feature “market suppliers ‘in the field’ working closely with healthcare organizations to address common issues in cybersecurity, innovation, life science / pharma, or artificial intelligence.” It goes on to note that there will be four sessions with three panelists each, but no details are published. I’ll have to check back in a month or two to see what that’s all about. The Industry Solutions Sessions are also not listed in detail yet but are slated to include vendor-sponsored case studies presented in hour-long sessions.

The HIMSS Davies Award Sessions are listed and include a number of bread-and-butter type sessions covering issues we deal with on a regular basis: improvement of quality scores; reducing urinary tract infections due to catheter use; decreasing falls; improving pediatric asthma outcomes; sepsis management through clinical decision support and virtual care; clinical risk systems; and achieving the Triple Aim. Although some of the session descriptions clearly stated which organization was presenting, others used acronyms or abbreviations that left me guessing. There also were no presenter names included.

The Government Sessions header also failed to include a list of actual sessions, although it promises to help attendees “get answers to your pressing questions surrounding the Trump Administration and its impact on health and health information technology.” I assume the usual players will be making an appearance, but again will have to check back.

From there it was on to the General Education sessions, where a brand-new Blockchain Forum has been added. There are three specific sessions listed out for those of you looking to get the most current information on everyone’s favorite buzzword. I found a couple of interesting sessions interspersed among various forums, including one on counterfeit pharmaceuticals in the supply chain and another on data interoperability across non-hospital care venues such as long-term / post-acute care facilities.

There do appear to be a couple of new formats and venues for sessions. The SPARK Session (Session Providing Actionable and Rapid Knowledge) is designed to be 20 minutes of quick insights. Sessions are also being grouped into “content streams” aligned with the Quadruple Aim and allowing attendees to focus on domains of technology, information, organizational efficiency, care, environment, and societal challenges. There will also be a Learning Lounge with on-demand viewing of live-streamed sessions. I hope the room is large and the chairs plentiful because it might become the hip place to be for those with tired feet and aching backs.

From a consultant standpoint, I’m hoping there will be some good sessions in the Federal Health Community Forum, although no sessions were listed yet. I’m helping clients through a number of governmental initiatives including the Comprehensive Primary Care Plus (CPC+) program and of course MIPS, so if there’s any easier ways to navigate or advise, I’m hoping to pick up some tips. As with other areas, the details aren’t quite posted yet.

In the email announcing the session listings, HIMSS promised over 400 sessions and there certainly isn’t anywhere near that number posted yet for our consideration. It just goes to show that I should probably go back to planning my HIMSS session attendance like I have for the last several years – at the last minute on the plane while sipping a cocktail and hoping I packed the right shoes. At least by then HIMSS should have all the sessions listed and maybe some presenters.

What’s your strategy for planning your trip to HIMSS? Are the sessions important, or is it more about the exhibit hall, building new relationships, and catching up with colleagues? Leave a comment or email me.

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Veritas Capital Will Acquire Athenahealth for $5.7 Billion

November 12, 2018 News 5 Comments

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Private equity firms Veritas Capital and Evergreen Coast Capital will acquire Athenahealth in an all-cash deal worth $5.7 billion, the companies announced this morning. The $135 per share sales price represents a 12 percent premium over Friday’s close.

Athenahealth wil be combined with Veritas-owned Virence Health, which sells the former GE Healthcare financial, ambulatory, and workforce management product lines. Veritas acquired that business from GE for $1.05 billion in cash in July 2018.

The combined companies will operate under the Athenahealth brand with headquarters remaining in Watertown, MA. After the transaction is completed, Veritas will restore API Healthcare as a separate workforce management technology company. GE Healthcare acquired API Healthcare in January 2014.

Athenahealth’s CEO will be Virence Chairman and CEO Bob Segert, who was hired by Veritas in September 2018. He has no healthcare experience

Evergreen Cost Capital is the private equity subsidiary of Elliott Management Corporation, the activist investor that targeted Athenahealth and forced the ouster of Athenahealth co-founder and CEO Jonathan Bush in June 2018. Elliott Management offered $160 per share bid for Athenahealth in September 2018 but then backed away, either as a result of due diligence or the realization that Athenahealth turmoil had decreased the price required to buy it. The company says it supports the acquisition and will retain its minority share in it.

Some of Veritas Capital’s previous health IT acquisitions include the healthcare business of Thomson Reuters (now IBM Watson Health’s Truven Health Analytics, $1.25 billion); payments processing technology vendor Cotiviti ($4.9 billion); and analytics vendor Verscend (formerly Verisk Health, $820 million). Verscend and Cotiviti were combined under the Cotiviti name upon completion of Verscend’s acquisition of Cotiviti in August 2018.

ATHN shares rose 10 percent in early trading following the announcement prior to the market’s open. They’re up 5 percent in the previous 12 months vs. the Nasdaq’s 7 percent increase. They peaked in the $145 range in early 2014.

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Morning Headlines 11/12/18

November 11, 2018 Headlines 1 Comment

Veritas Capital, Elliott clinch $5.5 billion acquisition of Athenahealth

Reuters reports that Veritas Capital and Elliott Management will acquire Athenahealth for $135 per share.

Corporate America’s blockchain and bitcoin fever is over

Executives of S&P companies are dropping their references to blockchain in earnings calls, with buzzword-dropping down 80 percent as shareholders stopped believing the hype and share prices stopped increasing.

Hackers stole income, immigration and tax data in Healthcare.gov breach, government confirms

CMS notifies 75,000 Healthcare.gov customers – mostly brokers and agents – that the recent data breach did not expose financial or personal health information. 

Monday Morning Update 11/12/18

November 11, 2018 News Comments Off on Monday Morning Update 11/12/18

Top News

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Athenahealth reports Q3 results that had been pushed back a week: revenue up 9 percent, adjusted EPS $1.08 vs. $0.56, beating earnings expectations but falling short on revenue.

The company also delayed its earnings call one week to Monday afternoon after the market’s close.

The unexplained delay might indicate that an announcement about its acquisition interest will be forthcoming. Veritas Capital and Elliott Management were rumored a couple of weeks ago to be close to finalizing their acquisition of the company.

UPDATE: Reuters reports that Veritas Capital and Elliott Management will announce Monday that they will acquire Athenahealth for $135 per share. ATHN shares closed Friday at $120.35.


Reader Comments

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From Spam in a Can: “Re: news items. Wonder if you have thoughts on seemingly contradictory recent news item? An anonymous couple donates $2.1 million to RIP Medical Debt, which will use the money to pay off $250 million in debts. Second, a family donates $200 million to Harvard Medical School.” I’m just riffing here, but my thoughts:

  • It’s kind of sad that charity RIP Medical Debt is even a thing. It buys discounted portfolios of medical bills that have been characterized as uncollectible, then pays them off for consumers who meet its need-based criteria. By then, I would assume that the debtor has moved on, has had their credit destroyed, or didn’t plan to pay their bill anyway. Whoever is holding the debt will appreciate having it paid, I suppose.
  • Providers won’t see the money since the accounts were already written off and, as with all other healthcare discounting and contracting, the rest of us are covering their shortfall.
  • RIP Medical Debt estimates that Americans owe $1 trillion in medical debt.
  • Each $1 donated to the charity allows $100 in debt to be purchased and forgiven.
  • Harvard Medical School’s $200 million pledge was from Ukraine-born Sir Leonard Blavatnik, the wealthiest man in the UK at $21 billion. HMS will spend his money on research projects and startups that presumably won’t offer anything free to patients.
  • Neither of these news items necessarily benefit patients or help improve our mess of a healthcare non-system that ignores public health, is left to deal (poorly) with health-harming economic disparity, and is controlled by a politically entrenched industrial complex (including all of us reading here) whose cost is eating up close to 20 percent of our gross domestic product.

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From Choosy Mothers: “Re: health IT books. You should write one about HIStalk.” A description of how I fill an empty computer screen each day wouldn’t make a compelling read, but I’ve seen some awful books published since Amazon lowered the bar with self-publishing tools. Some healthcare executives have hired vanity book services, where you pay them to repurpose whatever you have lying around (presentations, blog posts, interviews, etc.) into a “book” that requires nearly zero effort, inspiration, or intent to deliver reader value (and authors can even game Amazon’s system into declaring their crappy book to be a “bestseller.”) The worst thing about the democratization of publishing platforms (blogs, podcasts, social media updates, and even hard-to-fill speaking spots for an excessive number of conferences) is that we’re all being bombarded with lightweight, poorly written, ego-stroking and resume-padding filler that an objective editor would have rejected or at least helped improve. On the bright side, it’s easy to identify who to ignore since they’re laying the evidence right in front of you.


HIStalk Announcements and Requests

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HIMSS19 attendance bookmakers might be interested that nearly twice as many HIMSS18 attendees will skip HIMSS19 than non-attendees of HIMSS18 who will go this time around, which on election night would have stoked lengthy analysis and discussion about whether it’s a wave, to whose benefit, and for what reasons.

New poll to your right or here: Who is most responsible for clinician-unfriendly EHRs? Vote and then click the poll’s comments link to explain your vote or the solution you would recommend.

Sunday, November 11 is Veterans Day (celebrated Monday), set aside to honor all US military veterans. You can attend a parade or celebration; fly the flag; visit or volunteer at a VA hospital; ask your employer to honor veteran co-workers; arrange to anonymously pick up a veteran’s check at a coffee shop or restaurant; or I suppose just pay your taxes to support the VA’s $10 billion Cerner contract that hopefully will benefit veterans. Or you do nothing at all because the country they served allows that, too.

Health IT news is uncharacteristically light as everyone in the industry focuses on honoring veterans (OK, maybe that’s not the reason, but I don’t know why otherwise). It’s not a holiday for most of our industry, so you can at least take a mental vacation for the few minutes of saved reading time.


Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre for information.


Sales

  • Parkview Medical Center (CO) chooses Access for electronic signatures and forms.

Government and Politics

Andy Slavitt’s HAMA Forum article enumerates the Triple Threat to the Triple Aim: (a) health disparities associated with income, location, and race; (b) the “single aim” of revenue that overshadows the more important aims; and (c) the weaponization of healthcare by unresponsive politicians and lobbyists.


Other

Executives of S&P companies are dropping their references to blockchain in earnings calls, analysis finds, with buzzword-dropping down 80 percent as its shareholders stopped believing the hype and share prices stopped increasing accordingly.

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CNBC notes that alumni of the failed wristwatch-powered blood pressure monitor Quanttus, formed by MIT researchers in 2012 and shut down in 2016, have moved on to Verily, Apple, Google, and other big consumer firms, some of which are working on blood pressure projects of their own.


Sponsor Updates

  • PointClickCare names Liaison Technologies its Partner of the Year.
  • Lightbeam Health Solutions will exhibit at the 2018 Institute for Quality Leadership November 13-15 in San Antonio.
  • Loyale Healthcare examines industry consolidation and closures in “How to Survive the Growing Wave.”
  • Waystar and Surescripts will exhibit at the NextGen One Users Meeting November 11-14 in Nashville.
  • Netsmart will exhibit at the VAHCH Annual Conference November 13 in Glen Allen, VA.
  • Nordic, Clinical Computer Systems, developer of the Obix Perinatal Data System, and The SSI Group will exhibit at the HIMSS GC3 event November 14-16 in Mobile, AL.
  • PerfectServe will exhibit at the HealthLeaders CNO Exchange November 12-14 in Charleston, SC.
  • ROI Healthcare Solutions publishes a new e-book, “Embracing HR Innovation.”
  • Philips Wellcentive will exhibit at the AMGA 2018 Institute for Quality Leadership November 13-15 in San Antonio.
  • Wolters Kluwer Health donates Lexicomp app subscriptions to clinicians working aboard Mercy Ship hospitals.
  • ZeOmega will exhibit at the TAHP Managed Care Conference and Trade Show November 12-15 in Houston.

Blog Posts


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Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
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Comments Off on Monday Morning Update 11/12/18

Weekender 11/9/18

November 9, 2018 Weekender 3 Comments

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Weekly News Recap

  • Google hires Geisinger President and CEO David Feinberg, MD, MBA to develop its healthcare strategy across its business units
  • Bedside patient engagement company GetWellNetwork acquires HealthLoop, a Silicon Valley-based developer of automated messaging for follow-up care
  • A study of EHR-related medication events in pediatric hospitals, of which 18 percent appear to have caused harm, finds system usability as the cause 36 percent of the time
  • Premier announces that it will acquire clinical decision support vendor Stanson Health
  • Microsoft tells users of its HealthVault personal health record that it will shut down Direct messaging on December 27, 2018
  • ResMed announces plans to acquire MatrixCare for $750 million
  • Allscripts says in its earnings call that it will launch a formal sales process for its stake in Netsmart
  • Two nationally prominent articles observe how poorly hospital EHRs handle the end of daylight saving time, as information entered between 1:00 and 2:00 a.m. is deleted when the system clock is set back

Best Reader Comments

I feel for providers and their in baskets. I previously worked for a gigantic HMO with a huge amount of virtual care and no support staff and it really was a second job. I am sure it is similar for other community providers. At my current employer, we definitely struggle with Revenge of the Ancillaries (or perhaps just curse of complying with billing). For imaging orders, providers have to enter a coded diagnosis and a separate field for reason for test. It makes me cringe every time I watch them. (Midwest Fan)

No one gives a rip about who was promoted to chief marketing officer or of human resources of a vendor’s firm. (leftcoaster)

[Replying to leftcoaster] As a chief marketing officer who is also a company founder and key member of our executive team determining strategy, providing input for product development, and working with customers during implementation, I politely suggest you broaden your view of what a marketing leader really does. (Not Just Glossy Ads)

Just recently finished applying for life insurance and part of that was an hours-long review of medical history where they wanted every place I’ve had care in the last five years. Had to sign ROIs and personally work with a few providers to get my medical record. Also had to have a few labs done with no existing conditions to call for it. (YoungBuck)

Cleveland Clinic Florida release of records – they do have that option in Epic but choose not to use it at this point. They absolutely should get on board and modernize. No reason not to (other than maybe it’s more profitable doing what they do, which is sad). (FactCheckPlease)

The “dilution” effect on systems is real. A really terrific small system can easily become a meh larger system, which can become a truly hated enterprise system. Chefs will recognize this as the “too many cooks in the kitchen” syndrome. (Brian Too)

Does no one see the issue with having a orthopedic surgeon work as a dictation scribe where the productivity is 30 min visit = 1 hour scribing? Does India have too many doctors and not enough jobs for doctors? I think lot of providers still have the paternalistic view that they know best because they are the smartest and the wisest at all times, and everything in healthcare should be catered to them. That has always resulted in bad outcomes for the patient in the past, and that sort of attitude needs to be checked. (“Ancillary” Person)

Regarding the reported archaic workarounds for daylight saving time. What is truly archaic is that we are still changing our clocks twice a year! I don’t see an easy way to alleviate this problem in the EHR when accurate, timed entries are critical to patient care and also required. (CaveNerd)

Atul’s concerns about the problem list are entirely the fault of using an insurance system that demands specific diagnosis codes before they will pay for procedures. Maybe, if we didn’t have a ridiculous payment system, we wouldn’t have ridiculous software designed to feed a ridiculous payment system. (ItsThePayorsDummy)


Watercooler Talk Tidbits

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Readers funded the DonorsChoose teacher grant request of Ms. K in New York, who asked for a document camera (the one they have is shared by four classrooms) and a speaker to replace their broken one so the class can hear the audio portion of videos. She reports, “These supplies went straight from the box to the front of the classroom. Your support transformed our classroom learning environment to where we are now able to hear sound for videos and have students bring work up to have it projected and seen. This has led to more student-led instruction and reflection on their work. By empowering them to use their own work to model through the concepts, give feedback to one another, and be open to how they can be better has been transformational to our classroom culture. Thank you for your continued support!”

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My mention of hospitals still requiring faxes resonated with a reader who works in a large radiology practice. They have HL7 integration and many options for sending results electronically, but they still send 100,000 pages each day by fax. Most interesting is that clients ask them to fax, on average, THREE copies of the same result, which as he concludes,” Yes, we are their copy machine!” I joked that someone should develop a healthcare-only fax integration engine that can parse information from fixed form locations and convert it to HL7-compatible data and he said that’s already been attempted, but was thwarted by low fax image quality and trying to convert handwritten data. The fact that it was even attempted says a lot.

I looked at the records request page of several hospitals and found these consistencies:

  • The patient is expected to know which of several listed health system departments delivered care to them (hospital, clinic, private practice, imaging, etc.) and to complete a form for each. So much for the benefit of being treated by a health “system.”
  • The request forms are often lengthy (several pages) and confusing because they try to cover all situations, such as patients requesting their own records, authorizing someone else to receive their data, or requests by providers rather than patients.
  • Most hospitals require the completed form to be delivered to the HIM department in person, mailed, or faxed. You will immediately understand the consumer challenge in the majority of hospitals where HIM is buried in the basement of the hospital’s busiest building where parking is hard to find and not free (although commendably, some hospitals offer patient drop-off parking spots or free valet parking). Why can’t hospitals offer a service desk in a less-congested area where all patient requests can be handled? Kudos to those hospitals that provide an email address for submitting the form, which works if patients have a scanner at home (none of the hospitals I checked provide a form that can be completed online).
  • The forms often refer to “PHI” as though patients should understand what that means (even when the form indicates what the letters stand for).
  • Requests for billing records are not covered by requests for medical records and are not mentioned on the HIM page.
  • On the plus side, some hospitals gave specific instructions for downloading information from the patient portal, offered the option to receive information via secure email, listed their prices for providing copies of records, listed the legal rights patients have with regard to their records, and gave estimates of how long it would take to receive records (although that ranged from days to many weeks).

California voters reject a proposition that would have capped dialysis profits, a measure opposed by hospitals, doctors, and the two highly profitable national dialysis companies that spent $111 million to squash it.

NIH seeks a contractor to manufacture “marijuana cigarettes” for THC-related studies, also requiring the small business it chooses to provide a placebo for control groups (“nicotine research cigarettes.”)

The SEC files insider trading charges against the airplane mechanic husband of a UnitedHealth Group HR VP who spied on her to obtain confidential merger information. James Hengen is alleged to have made $63,000 in profits by taking positions in two companies that were later acquired by UHG and also tipped off his brother and some co-workers to load up on shares.

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Someone steals a 10-foot-long inflatable colon used by University of Kansas Cancer Center in its “Get Your Rear in Gear” colorectal cancer public education program. In a happy ending, KC police recovered the stolen colon, moved to action by TV colonoscopy queen Katie Couric, who wittily tweeted, “Does anyone know the scope of the crime?” Hopefully, there’s no obstruction of justice. We need to flush out what happened here and get to the BOTTOM of it.” It was returned intact (no semicolon here) although conspiracy theorists question whether the theft was a PR stunt.


In Case You Missed It


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Morning Headlines 11/9/18

November 8, 2018 Headlines Comments Off on Morning Headlines 11/9/18

Google has hired Geisinger’s David Feinberg to lead its health strategy

Google will hire Geisinger President and CEO David Feinberg, MD, MBA to develop its healthcare strategy across its business units.

GetWellNetwork Acquires HealthLoop

Bedside patient engagement company GetWellNetwork acquires HealthLoop, a Silicon Valley-based developer of automated messaging for follow-up care.

Patel to succeed Johnson in Health IT leadership role

Chief Health Information Officer Neal Patel, MD, MPH will replace Chief Informatics Officer Kevin Johnson, MD, MS as head of health IT efforts at Vanderbilt University Medical Center (TN) as of January 1.

Tabula Rasa HealthCare Acquires Cognify an Integration HealthCare Technology Company

Medication safety technology vendor Tabula Rasa HealthCare acquires Cognify, which offers solutions to support the federal PACE program.

Comments Off on Morning Headlines 11/9/18

News 11/9/18

November 8, 2018 News 1 Comment

Top News

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Google will hire Geisinger President and CEO David Feinberg, MD, MBA to develop its healthcare strategy across its business units that include search, cloud, AI, Nest home automation, and Google Fit wearables. 

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Reader Comments

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From Keeping It Real: “Re: NextGen blog post. I guess you get what you pay for in marketing and social advisors since someone was apparently OK with citing a competitor’s opinion piece.” I’m puzzled by the blog post that is attributed to NextGen Healthcare CMIO Robert Murry, MD since it not only cites a blog post of competitor Nextech, the Nextech post is hardly original (a “free” EHR may involve paid add-ons that make it more expensive than a paid system, it basically says). I’m pretty sure this was ghost-written by a NextGen marketing person since Bob has outstanding education and experience (not to mention his esteemed credential as a member of Dann’s HIStalk Fan Club on LinkedIn) and I doubt he’s looking to Nextech for inspiration. I’ll also say that I get puff pieces every day that are supposedly written by vendor C-level executives that clearly were hacked together by a marketing committee who took a quick, “OK, fine, whatever” response from the alleged author as meaning they did great when they clearly did not. 

From Smallie Biggs: “Re: LinkedIn. Is it creepy when people write their entries in the third person or call themselves ‘Mr.’ or ‘Ms.’ in describing how wonderful they are? Absolutely. Stiffly written LinkedIn profiles make me question whether that person has an ounce of creativity or originality in them, and if they applied to work for me, I would be instantly prejudiced into moving on to someone who seems more human.


HIStalk Announcements and Requests

Listening: a good protest song and video from rapper Kap G (whose music I generally dislike) called “A Day Without a Mexican.” Kap G (real name: George Ramirez) proudly wears his Mexican lineage (literally) despite rather light cred given that he was born and raised in College Park, GA. I’m also really, really liking Spain-based Mägo de Oz (Spanish for “Wizard of Oz” with the mandatory metal umlaut thrown in because they have a sense of humor),  which deftly plays an amalgam of heavy metal, Celtic, and 1980s-style power rock, kind of like Iron Maiden, Asia, and Jethro Tull co-creating a Spanish-language metal opera from “Lords of the Dance.” They’re big in a lot of places that aren’t here.


Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre for information.


Acquisitions, Funding, Business, and Stock

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Bedside patient engagement company GetWellNetwork acquires HealthLoop, a Silicon Valley-based developer of automated messaging for follow-up care. Terms of the deal were not disclosed. HealthLoop, which has raised $22 million since launching in 2009, will work with GetWellNetwork to develop an integrated solution called GetWell Loop in the coming months.

Medication safety technology vendor Tabula Rasa HealthCare acquires Cognify, which offers solutions to support the federal PACE (Program of All-inclusive Care for the Elderly) program.


Sales

  • ClinicalConnect HIE (PA) selects Fusion, Analyze, and Quality apps from Diameter Health to automate and standardize data exchange.
  • Charleston Area Medical Center (WV), Fairview Health Services (MN), and University of Minnesota Physicians select release-of-information services from MRO.
  • Pacific Dental Services, which provides back-office services for dental practices, will implement Epic to allow practices to coordinate with other clinicians.

People

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Michael Johnson (Community Health Systems) joins Medhost as CISO.

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Greenway Health promotes Kimberly O’Loughlin to president.

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Chief Health Information Officer Neal Patel, MD, MPH will replace Chief Informatics Officer Kevin Johnson, MD, MS as head of health IT efforts at Vanderbilt University Medical Center (TN) as of January 1. Johnson will retain his position as chair of Vanderbilt University School of Medicine’s Department of Biomedical Informatics. Both men oversaw the hospital’s two-year Epic implementation and optimization efforts.

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Anne Hunt (Castlight Health) joins healthcare messaging vendor Medici as VP and head of product following its acquisition of DocbookMD.

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PatientKeeper names Barry Gutwillig (Kofax) VP of sales and marketing.

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Jeff Miller (The SSI Group) joins AMA-backed Akiri as COO.

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Jennifer LeMieux (JRMH Consulting) returns to healthcare consulting and hospital management company HealthTechS3 as COO.

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Audacious Inquiry names Keith “Motorcycle Guy” Boone (GE Healthcare) as informatics adept. I had to look that word “adept” up and I like it – it can be used as either an adjective or noun to describe someone who is skilled in a particular area.

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HealthStream promotes Trisha Coady to SVP/GM of clinical solutions.

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Peter Siavelis (StayWell) joins Waystar as SVP of health systems.

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Industry long-timer Brian Graves (Concentra Analytics) joins Hospital IQ as VP.


Announcements and Implementations

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Novant Health (NC) goes live on Glytec’s EGlycemic Management System.

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Cedar County Memorial Hospital (MO) goes live on Meditech Expanse with consulting help from Engage.

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Physicians at Upstate University Hospital (NY) develop a training program using Vocera’s Rounds mobile app to capture data about hospitalist behavior during patient interactions and to provide real-time feedback.

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In Maine, the ACO of Northern Light Health (just renamed from Eastern Maine Healthcare Systems, which was oddly pluralized, and not to be confused with Northern Lights Regional Healthcare Centre in Alberta, Canada) adopts PatientPing’s real-time admit-discharge-transfer notification services. The name change creates an awkward title for the flagship hospital, “Northern Light Eastern Maine Medical Center,” which I’m guessing basically nobody will use in favor of the perfectly serviceable old name of Eastern Maine Medical Center or EMMC.


Government and Politics

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After a pilot study with Kaiser Permanente, the FDA releases the open-source code behind its new MyStudies app. The app was developed to give patients, providers, and developers an easier way to report and collect health data that can then be used to inform the development of drug and medical devices, and patient safety efforts.


Other

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Hawaii Pacific Health VP Melinda Ashton, MD describes the origin and progress of the health system’s “Getting Rid of Stupid Stuff” program, which aims to streamline EHR workflows based on nursing and physician requests. Since launching in October 2017, requests have been submitted and acted on in three main categories – documentation that was never meant to occur, documentation that could be done more effectively, and required documentation that end users didn’t fully understand. Ashton says, “When the campaign was unveiled, it was largely met with surprise and sheepish laughter, then applause. We seem to have struck a nerve. It appears that there is stupid stuff all around us, and although many of the nominations we receive aren’t for big changes, the small wins that come from acknowledging and improving our daily work do matter.”

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Mid Atlantic Permanente Medical Group cardiologist and Epic user Ameya Kulkarni, MD posts a thread of tweets reacting to Atul Gawande’s New Yorker piece on the contempt physicians have for their computers, noting more than once that the EHR is not the biggest contributing factor to physician burnout. “To fight burnout,” he says, “we need to think about how our communication systems increase loneliness and reduce agency. These are the key drivers. … And working on loneliness means 1) creating opportunities for real world interaction with colleagues and patients & 2) Simplifying documentation requirements so notes become communication tools again.”

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A study of the EHR experience of medical students in Australia finds that they have no problems learning it, using it, or understanding its advantages. They also don’t feel that using the EHR detracts from patient interaction or rapport. They do, however, say that the EHR doesn’t help them learn as much as they expected.


Sponsor Updates

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  • HCTec staff volunteer at Hope Lodge, an organization in Nashville helping those undergoing cancer treatments.
  • AdvancedMD employees pack over 900 weekend pantry packs for students in the Granite School District.
  • Agfa Healthcare partners with PACSHealth to implement system-wide radiation dose monitoring at the Veterans Integrated Service Networks 19.
  • Apixio will exhibit at RISE: The 12th Risk Adjustment Forum November 11-13 in Marco Island, FL.
  • Aprima publishes a new guide, “How to Switch EHRs.”
  • Over 50 Florida hospitals now receive data through state-based HIE services, including Audacious Inquiry’s Encounter Notification Service.
  • Bluetree will exhibit at the RCM Leaders Forum November 14-16 in Dallas.
  • CenTrak publishes a new customer testimonial featuring Diane Drefcinski from the University of Wisconsin.
  • ChartLogic publishes a new white paper, “How to Prepare for MIPS in 2019.”
  • CompuGroup Medical will exhibit at the AZ HIMSS Tucson Education Event November 15.
  • CoverMyMeds will exhibit at the ECRM pharmacy technology event November 12-14 in Cape Coral, FL.
  • Diameter Health will exhibit at the NCQA HL7 Digital Quality Summit November 14-15 in Washington, DC.
  • Docent Health is mentioned in a new book on healthcare consumerism, “Choice Matters: How Healthcare Consumers Make Decisions (and Why Clinicians and Managers Should Care).
  • DocuTap will accept submissions for its scholarship program through December 2.
  • Elsevier will integrate the National Comprehensive Cancer Network’s Clinical Practice Guidelines in Oncology with its Via Oncology clinical decision support tool.
  • EClinicalWorks will exhibit at the 2018 NNOHA Annual Conference November 12-13 in New Orleans.
  • EPSi will exhibit at the HFMA Region 9 Conference November 11-13 in New Orleans.
  • FormFast will exhibit at the GC3 Conference November 14-16 in Mobile, AL.
  • Spok notes that it has been ranked #1 by Black Book for secure communications in hospitals.
  • Healthwise and Imprivata will exhibit at NextGen UGM 2018 November 11-14 in Nashville.
  • Imat Solutions will exhibit at the TAHP 2018 Managed Care Conference and Trade Show November 12-14 in Houston.
  • Iatric Systems will exhibit at HCCA Regional November 16 in Nashville.
  • Influence Health congratulates four renowned health system customers for their 2018 MarCom Awards.
  • Black Book Market Research ranks Spok number one in secure communications for hospital systems.
  • Divurgent hires Robert Leahey (Axiom Systems) as principal.
  • Piedmont Healthcare (GA) improves clinical documentation and physician productivity with Nuance’s AI-powered solutions.
  • Meditech releases a new podcast on EHR value and sustainability.

Blog Posts


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Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
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EPtalk by Dr. Jayne 11/8/18

November 8, 2018 Dr. Jayne 1 Comment

There was some chatter in the physician lounge this week about a study published in JAMA Network Open looking at the accuracy of EHR medication lists vs. the substances actually found in patients’ blood. Researchers looked at 1,350 patients and found that while a majority of medications were detected in the blood as listed in the EHR, there were many more medications detected that were not reflected in the EHR. Such incomplete documentation prevents systems from performing drug-allergy and drug-drug checking, placing patients at risk.

As much as some clinicians don’t like it, I prefer when patients bring in all their medications and supplements, even if it takes extra time going through a brown bag, shoebox, or tote. That way we can keep the EHR updated and also physically impound medications that patients shouldn’t be taking, if warranted.

There was also a fair amount of conversation around Tuesday’s elections, and the various positions held by candidates regarding healthcare. Kaiser Health News published a great piece looking at the various terms being thrown around during the election, including single-payer, universal healthcare, and Medicare for all. Gubernatorial candidates in California, Massachusetts, and Florida were pushing for state-run single-payer systems, where others were calling for less specific “universal coverage” or “public option” provisions. Like those mentioned in the article, the physicians around my lunch table didn’t fully understand the different models or what they might mean not only to their practices, but to their families.

There was zero chatter around the announcement by CMS that access to Quality and Resource User Reports and PQRS Feedback Reports will be sunset at the end of December. Since 2016 was the last performance period for those programs and 2018 was the final payment adjustment year, there isn’t much of a need for the reports to remain online. Physicians or their authorized representatives can download them until December 31, but it’s unclear how many providers reviewed the data in the first place or whether they tried to use it to drive practice-level improvements. Reports will be available eon the CMS portal for those of you looking for a little bedtime reading.

As I was getting ready to leave, one of my colleagues asked me what I thought of Atul Gawande’s recent New Yorker essay on “Why Doctors Hate Their Computers.” He takes readers through Partners HealthCare’s journey from homegrown EHR to Epic, and all of the physicians around the table were familiar with that 16 hours of training he leads with. (In our case, it was 17, and let me tell you everyone was counting.)

Having run more than a handful of EHR implementation projects, I loved Gawande’s description of his trainer, “younger than any of us, maybe a few years out of college, with an early-Justin Bieber wave cut” whose technique incorporated “the driver’s ed approach: You don’t want to be here; I don’t want to be here; let’s just make the best of it.”

Gawande walks us through his own thoughts about the rise of computers, including the once-coveted Commodore 64, which brings back memories for some of us who have been on the cutting edge. Having been the second person I knew with a modem (the first being the guy from whom my brother bought the used card from), I felt a little bit of his pride and optimism as he readied himself for training. The last three years have quashed that optimism, however, and he has “come to feel that a system that promised to increase my mastery over my work has, instead, increased work’s mastery over me.”

I appreciated his discussion of “the Revenge of the Ancillaries,” where design choices were considered by constituents from various parts of the organization. He makes a point that was telling: “The design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes… Now the staff had a say (and sometimes the doctors didn’t even show.)”

I’ve seen that happen during several build decision projects, and it sounds like there may not have been adequate checks and balances in the governance process. For example, requiring stakeholder signoff in addition to participation in the working groups. Requiring user acceptance testing of critical workflows would also have caught some of the issues he cited, such as hard stops and required fields, prior to the go-live. He also highlights issues with the maintenance of patient problem lists that are exacerbated by governance issues, with duplications and lack of specificity in entries. Cut and paste is also an issue, one that could be addressed by governance and consensus among users about the best way to use the EHR.

Gawande does discuss the phenomenon of governance, noting that, “As a program adapts and serves more people and more functions, it naturally requires tighter regulation. Software systems govern how we interact as groups, and that makes them unavoidably bureaucratic in nature. There will always be those who want to maintain the system and those who want to push the system’s boundaries.”

I’m in agreement, but it’s still a challenge to figure out why organizations don’t spend the time needed up front to define some of these goals. What is the vision for the new system? How does it support the mission? What are the expected outcomes? How do we define success? Instead it’s often a race against a timeline, which may or may not reflect organizational tolerance for a particular speed of change. The best implementation I ever worked on had a motto of “go slow to go fast.” We may have spent more months in the design and build phase than other organizations, but when we went live, we hit the ground running and there were very few changes needed to the system in the first few months.

Mr. H has already commented on the Gawande piece, and one reader shared their thoughts on the physician mentioned who admittedly ignores messages in her inbox and deletes them without reading them. I hope there aren’t any patients reading The New Yorker who might have a concern about their care in her practice, because if she is ever called into court about a missed diagnosis, things aren’t going to end well for her. I can’t imagine publicly admitting that I don’t review results and I doubt that the medical staff administration is going to think too kindly of it.

Reading the piece from the perspective of a clinical informaticist, there’s a lot to unpack, and also a lot of opportunity to potentially improve things for the impacted physicians. I’m not sure what I think about it from a patient perspective or a non-IT perspective, since it oversimplifies and under-explains some of the complexities that have brought us to where we are. That’s what I told my colleague, and I ended with a reminder that the one of the EHR subcommittees still has some openings, so if he wants to be part of the solution, there’s a venue available.

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I don’t frequently call out companies for wacky marketing, but this one is baffling. The subject line of the email advertises a profitability webinar with “cybersecurity strategies you can use,” but the email itself discusses patient experience and how to “cultivate a loyal base.” Oh yeah, and there’s the part where they sent the invitation out less than 24 hours in advance for a webinar that is in the middle of the work day. For mass marketing emails, I’d recommend peer review at a minimum before sending them out. Get it together, folks.

[UPDATE] Greenway Health was quick to read Dr. Jayne’s comment and apologize that their email preview line displayed incorrect wording (the subject line itself was correct). They also note that this was the third in a three-email series, so those who wanted to sign up had ample time well before this email. They also say their surveys and best practices indicate that 2:00 p.m. ET works best for providers.

Do cold emails entice you to join webinars in the middle of the day? How many do you register for that you end up not attending? Leave a comment or email me.

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Email Dr. Jayne.

Morning Headlines 11/8/18

November 7, 2018 Headlines Comments Off on Morning Headlines 11/8/18

Focused on Customer Success, Greenway Health Announces the Appointment of Kimberly O’Loughlin to President

After six months with the company as COO, Greenway Health promotes Kimberly O’Loughlin to president.

FDA launches new digital tool to help capture real world data from patients to help inform regulatory decision-making

The FDA will use data collected directly from patients through its new open-source MyStudies app to inform future drug development and medication and device safety efforts.

Mobile Telehealth Company Medici Acquires DocbookMD

Healthcare messaging and virtual visit company Medici acquires competitor DocbookMD from Scrypts for an undisclosed amount.

Comments Off on Morning Headlines 11/8/18

A Machine Learning Primer for Clinicians–Part 4

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.

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Previous articles:

  1. An Introduction to Machine Learning
  2. Supervised Learning
  3. Unsupervised Learning

How to Properly Feed Data to a ML Model

While in the previous articles I’ve tried to give you an idea about what AI / ML models can do for us, in this article, I’ll sketch what we must do for the machines before asking them to perform magic. Specifically, the data preparation before it can be fed into a ML model. 

For the moment, assume the raw data is arranged in a table with samples as rows and features as columns. These raw features / columns may contain free text; categorical text; discrete data such as ethnicity; integers like heart rate, floating point numbers like 12.58 as well as ICD, DRG, CPT codes; images; voice recordings; videos; waveforms, etc.

What are the dietary restrictions of an artificial intelligence agent? ML models love their diet to consist of only floating point numbers, preferably small values, centered and scaled /normalized around their means +/- their standard deviations.

No Relational Data

If we have a relational database management system (RDBMS),  we must first flatten the one-to-many relationships and summarize them, so one sample or instance fed into the model is truly a good representative summary of that instance. For example, one patient may have many hemoglobin lab results, so we need to decide what to feed the ML model — the minimum Hb, maximum, Hb averaged daily, only abnormal Hb results, number of abnormal results per day? 

No Missing Values

There can be no missing values, as it is similar to swallowing air while eating. 0 and n/a are not considered missing values. Null is definitely a missing value.

The most common methods of imputing missing values are:

  • Numbers – the mean, median, 0, etc.
  • Categorical data – the most frequent value, n/a or 0

No Text

We all know by now that the genetic code is made of raw text with only four letters (A,C,T,G). Before you run to feed your ML model some raw DNA data and ask it questions about the meaning of life, remember that one cannot feed a ML model raw text. Not unless you want to see an AI entity burp and barf.

There are various methods to transform words or characters into numbers. All of them start with a process of tokenization, in which a larger unit of language is broken into smaller tokens. Usually it suffices to break a document into words and stop there:

  • Document into sentences.
  • Sentence into words.
  • Sentence into n-grams, word structures that try to maintain the same semantic meaning (three-word n-grams will assume that chronic atrial fibrillation, atrial chronic fibrillation, fibrillation atrial chronic are all the same concept).
  • Words into characters.

Once the text is tokenized, there are two main approaches of text-to-numbers transformations so text will become more palatable to the ML model: 

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One Hot Encode (right side of the above figure)

Using a dictionary of the 20,000 most commonly used words in the English language, we create a large table with 20,000 columns. Each word becomes a row of 20,000 columns. The word “cat” in the above figure is encoded as: 0,1,0,0,…. 20,000 columns, all 0’s except one column with 1. One Hot Encoder – as only one column gets the 1, all the others get 0.

This a widely used, simple transformation which has several limitations: 

  • The table created will be mostly sparse, as most of the values will be 0 across a row. Sparse tables with high dimensionality (20,000) have their own issues, which may cause a severe indigestion to a ML model, named the Curse of Dimensionality (see below).
  • In addition, one cannot represent the order of the words in a sentence with a One Hot Encoder.
  • In many cases, such as sentiment analysis of a document, it seems the order of the words doesn’t really matter.

Words like “superb,” “perfectly” vs. “awful,” “horrible” pretty much give away the document sentiment, disregarding where exactly in the document they actually appear.

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From “Does sentiment analysis work? A tidy analysis of Yelp reviews” by David Robinson.

On the other hand, one can think about a medical document in which a term is negated, such as “no signs of meningitis.” In a model where the order of the words is not important, one can foresee a problem with the algorithm not truly understanding the meaning of the negation at the beginning of the sentence. 

The semantic relationship between the words mother-father, king-queen, France-Paris, and Starbucks-coffee will be missed by such an encoding process.

Plurals such as child-children will be missed by the One Hot Encoder and will be considered as unrelated terms.

Word Embedding / Vectorization

A different approach is to encode words into multi-dimensional arrays of floating point numbers (tensors) that are either learned on the fly for a specific job or using an existing pre-trained model such as word2vec, which is offered by Google and trained mostly on Google news. 

Basically a ML model will try to figure the best word vectors — as related to a specific context — and then encode the data to tensors (numbers) in many dimensions so another model may use it down the pipeline.

This approach does not use a fixed dictionary with the top 20,000 most-used words in the English language. It will learn the vectors from the specific context of the documents being fed and create its own multi-dimensional tensors “dictionary.” 

An Argentinian start-up generates legal papers without lawyers and suggests a ruling, which in 33 out of 33 cases has been accepted by a human judge.

Word vectorization is context sensitive. A great set of vectorized legal words (like the Argentinian start-up may have used) will fail when presented with medical terms and vice versa.

In the figure above, I’ve used many colors, instead of 0 and 1, in each cell of the word embedding example to give an idea about 256 dimensions and their capability to store information in a much denser format. Please do not try to feed colors directly to a ML model as it may void your warranty.

Consider an example where words are vectors in two dimensions (not 256). Each word is an arrow starting at 0,0 and ending on some X,Y coordinates.

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From Deep Learning Cookbook by Douwe Osinga.

The interesting part about words as vectors is that we can now visualize, in a limited 2D space, how the conceptual distance between the terms man-woman is being translated by the word vectorization algorithm into a physical geometrical distance, which is quite similar to the distance between the terms king-queen. If in only two dimensions the algorithm can generalize from man-woman to king-queen, what can it learn about more complex semantic relationships and hundreds of dimensions?

We can ask such a ML model interesting questions and get answers that are already beyond human level performance:

  • Q: Paris is to France as Berlin is to? A: Germany.
  • Q: Starbucks is to coffee as Apple is to? A: IPhone.
  • Q: What are the capitals of all the European countries? A: UK-London, France-Paris, Romania-Bucharest, etc.
  • Q: What are the three products IBM is most related to? A: DB2, WebSphere Portal, Tamino_XML_Server.

The above are real examples using a a model trained on Google news.

One can train a ML model with relevant vectorized medical text and see if it can answer questions like:

  • Q: Acute pulmonary edema is to CHF as ketoacidosis is to? A: diabetes.
  • Q: What are the three complications a cochlear implant is related to? A: flap necrosis, improper electrode placement, facial nerve problems.
  • Q: Who are the two most experienced surgeons in my home town for a TKR? A: Jekyll, Hyde.

Word vectorization allows other ML models to deal with text (as tensors) — models that do care about the order of the words, algorithms that deal with time sequences, which I will detail in the next articles.

Discrete Categories

Consider a drop-down with the following mutually exclusive drugs:

  1. Viadur
  2. Viagra
  3. Vibramycin
  4. Vicodin

As the above text seems already encoded (Vicodin=4), you may be tempted to eliminate the text and leave the numbers as the encoded values for these drugs. That’s not a good idea. The algorithm will erroneously deduce there is a conceptual similarity between the above drugs just because of their similar range of numbers. After all, two and three are really close from a machine’s perspective, especially if it is a 20,000-drug list. 

The list of drugs being ordered alphabetically by their brand names doesn’t imply there is any conceptual or pharmacological relationship between Viagra and Vibramycin.

Mutually exclusive categories are transformed to numbers with the One Hot Encoder technique detailed above. The result will be a table with the columns: Viadur, Viagra, Vibramycin, Viocodin (similar to the words tokenized above: “the,” “cat,” etc.) Each instance (row) will have one and only one of the above columns encoded with a 1, while all the others will be encoded to 0. In this arrangement, the algorithm is not induced into error and the model will not find conceptual relationships where there are none.

Normalization

When an algorithm is comparing numerical values such as creatinine=3.8, age=1, heparin=5,000, the ML model will give a disproportionate importance and incorrect interpretation to the heparin parameter, just because heparin has a high raw value when compared to all the other numbers. 

One of the most common solutions is to normalize each column:

  • Calculate the mean and standard deviation
  • Replace the raw values with the new normalized ones

When normalized, the algorithm will correctly interpret the creatinine and the age of the patient to be the important, deviant from the average kind of features in this sample, while the heparin will be regarded as normal.

Curse of Dimensionality

If you have a table with 10,000 features (columns),  you may think that’s great as it is feature-rich. But if this table has fewer than 10,000 samples (examples), you should expect ML models that would vehemently refuse to digest your data set or just produce really weird outputs.

This is called the curse of dimensionality. As the number of dimensions increases, the “volume” of the hyperspace created increases much faster, to a point where the data available becomes sparse. That interferes with achieving any statistical significance on any metric and will also prevent a ML model from finding clusters since the data is too sparse.

Preferably the number of samples should be at least three orders of magnitude larger than the number of features. A 10,000-column table had be better garnished by at least 10,000 rows (samples).

Tensors

After all the effort invested in the data preparation above, what kind of tensors can we offer now as food for thought to a machine ?

  • 2D – table: samples, features
  • 3D – time sequences: samples, features, time
  • 4D – images: samples, height, width, RGB (color)
  • 5D – videos: samples, frames, height, width, RGB (color)

Note that samples is the first dimension in all cases.

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Hopefully this article will cause no indigestion to any human or artificial entity.

Next Article

How Does a Machine Actually Learn?

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Morning Headlines 11/7/18

November 6, 2018 Headlines Comments Off on Morning Headlines 11/7/18

Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings

A review of EHR-related pediatric medication events in three hospitals that use Cerner or Epic finds that EHR usability contributed to 36 percent of the reports, while 18 percent appear to have caused patient harm.

Premier Inc. Agrees to Acquire Stanson Health to Integrate Data-Enabled Clinical Decision Support Capabilities within EHRs

Premier will acquire clinical decision support vendor Stanson Health for up to $66.5 million in cash.

Phonak teams up with Microsoft to improve access to hearing care over distance

In what might be the first use of teleaudiology, hearing aid manufacturer Phonak will offer access to hearing care professionals to perform online fitting and tuning via its remote support app.

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