News 1/16/19

Top News

Cerner co-founder Cliff Illig retires from the company’s board “to focus on outside interests.”

You get to do that when you’ve sold dozens of millions of dollars of CERN shares in the past few months and still hold $550 million worth.

I feel like a kid watching Mom and Dad get divorced as companies start losing their colorful founders, making me reevaluate whether I still find them interesting.

Cerner even lost its president, so now it’s exclusively Brent Shafer’s show and I haven’t seen much Neal Patterson-like brilliance or spark from him after a year in his first CEO job.

CERN share price rose a tiny bit Tuesday,  but are down 23 percent in the past year vs. the Nasdaq’s 3 percent loss.

Reader Comments

From Beezer Gutler: “Re: Cleveland Clinic’s Empathy & Innovation Summit. HIMSS is now a ‘partner,’ whatever that means.” I can’t think of many organizations that are less qualified to than HIMSS to provide empathy advice to frontline providers, so I assume that its contribution will be to jam high-paying tech vendors into a program that should be about person-to-person interaction rather than gizmos. The June conference features odd speakers such as bigwigs from Aetna and the AMA (you have to be a pretty awful provider if you have to ask an insurance company how to be empathetic). The conference drew a couple of thousand people last year, although healthcare is notoriously full of people who love to hang around just about any conferences for which patients are indirectly paying via their inflated bills without much hope of ever seeing ROI. It’s fascinating how much money is made by running healthcare conferences – my favorite ironic example is the American Telemedicine Association’s annual conference, which suggests that they believe video is great for practicing medicine but not for watching talking heads.

From Avoiding Buyer’s Remorse: “Re: HIMSS19. What should we expect as first timers in a small booth?” You’ll get some visitors, but most will be just strollers-by looking for giveaways and taking your handouts just to be nice. You’ll feel energized and vital in being part of the “show,” but that high will go away on the plane ride home when you realize that spending the money won’t pan out in sales, and if you were an unknown before, you still are. Shooting your budgetary wad on a HIMSS exhibit as a full-year strategy makes no more sense than binge-eating for three days and assuming you won’t need food for another year. The problem isn’t HIMSS, it’s that exhibitors don’t set reasonable goals and plan well, so I suggest starting with my only partially cynical (which is quite a stretch for me) “Tips for HIMSS Exhibitors.” As holder of an expensive, questionably cost effective three-day lease on a 10×10 space myself, I wouldn’t get my hopes up – we get a lot of visitors just because readers drop by to say hello and that makes it worth it to me, but financially it doesn’t make a lot of sense to be there and you probably won’t get nearly as many folks stopping by.

Webinars

January 17 (Thursday) 1:00 ET. “Panel Discussion: Improving Clinician Satisfaction & Driving Outcomes.” Sponsor: Netsmart. Presenters: Denny Morrison, PhD, chief clinical advisor, Netsmart; Mary Gannon, RN, chief nursing officer, Netsmart; Sharon Boesl, deputy director, Sauk County Human Services; and Allen Pendell, SVP of IS and analytics, Lexington Health Network. This panel discussion will cover the state of clinician satisfaction across post-acute and human services communities, turnover trends, strategies that drive clinical engagement and satisfaction, and the use of technology that supports those strategies. Real-world examples will be provided.

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

Acquisitions, Funding, Business, and Stock

EHR and technology services vendor Parallon Technology Solutions renames itself CereCore.

Walmart leaves CVS’s pharmacy network after failing to reach a price agreement with CVS’s huge Caremark pharmacy benefits management arm.

UnitedHealth Group beats Q4 earnings estimates as its full-year revenue grows to $226 billion and earnings to $17.3 billion. Its Optum services business brought in $8.2 billion in earnings on $101 billion in revenue. It’s good to be a healthcare middleman.

Sales

• California largest non-profit health data network, Manifest MedEx, selects predictive analytics from HBI Solutions.
• Lexington Regional Health Center (NE) chooses Cerner Millennium via CommunityWorks.
• Premier Orthopaedics chooses Allscripts Professional EHR, PM, FollowMyHealth, and Payerpath for its 72-physician practice.

People

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NHS England’s chief digital officer, Juliet Bauer, will leave the organization for a job with NHS-contracted telemedicine vendor Livi.

Announcements and Implementations

CareCloud successfully deploys Medicomp’s Quippe Clinical Documentation throughout its customer base.

DocuTAP launches an urgent care-focused analytics tool called Insight that provides real-time visibility into clinical, operational, and business data.

Northwestern Medical Center (VT) goes live on CommonWell interoperability, embedded in Meditech.

Walgreens signs a deal for its 380,000 employees to use Microsoft technology that includes Office 365, mobility and security tools, and the Azure public cloud. The companies will also work together on R&D for patient engagement and chronic disease management software.

Government and Politics

Sen. Jon Tester (D-MT), ranking member of the Senate’s Committee on Veterans Affairs, expresses his IT concerns to newly confirmed VA CIO James Gfrerer:

• The White House’s proposed VA IT budget contains drastic cuts that don’t reflect new requirements and the VA’s history of “fumbling of IT solutions.”
• The VA needs strong IT leadership since it “cannot continue to operate in a technology environment in which only the largest and latest crisis drives the agenda.”
• While much of the Cerner implementation will be run by the Office of Electronic Health Record Management, the VA must go beyond just maintaining VistA and ensure that infrastructure is ready for the new system.
• The VA must continue to invest resources in projects such as its benefits management system, disability rating system, and financial system.
• Tester warns that CareT, a system being developed for caregiver assistance, may not support the expanded program and might require buying a commercial system, which would be “unacceptable.”
• The Senator asked for a list of the VA’s IT projects, their priorities, and how those priorities were established. 

Other

Baylor St. Luke’s Medical Center fires its president, chief nursing officer, and COO following media reports of patient deaths caused by substandard care.

The National Center for Health Statistics says Americans are even fatter than previously thought, which it discovered after measuring people directly rather than relying on their self-reported numbers in which they often inflate height and under-report weight. As the old saying goes, I’m not fat, I’m just short for my weight.

Those of us who roll our eyes at “influencers” (which is also HIMSS’s new term for “social medial ambassadors who may or not have actual industry influence) will be comforted by the news that they’re being replaced by “avastars,” as companies invest millions to further developer computer-generated, AI-powered synthetic celebrities who not only can generate loyal friends with merchandise-buying potential, but that live forever. Lil Miquela has 1.5 million Instagram followers, of which I would suspect few are significant contributors to society.

Sponsor Updates

• KLAS recognizes Arcadia for its outcomes-producing, analytics-driven insights in its “Value Based Care Managed Services 2018 report.”
• AssessURhealth Co-founder Mallory Taylor will present at the Synapse Summit January 23 in Tampa, FL.
• Bluetree will exhibit at the NJHIMSS 2019 Winter Event January 22 in Monroe Township.
• The Chicago Tribune profiles Burwood Group President Jim Hart.
• CoverMyMeds will exhibit at the ASAP 2019 Annual Conference January 23-25 in Kiawah Island, SC.
• Dimensional Insight publishes a customer spotlight on EvergreenHealth.

Blog Posts

• 2-Factor Authentication: Your security supercharger (AdvancedMD)
• Maybe we shouldn’t believe the hype about hospital mergers and acquisitions (Advisory Board)
• How to Become HIPAA-Compliant: Our 10-Step Guide (Atlantic.Net)
• Promises of Interoperability (Diameter Health)

Contacts

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

Morning Headlines 1/15/19

U.S. Digital Service has an ambitious agenda at the VA

The US Digital Service is building an interface as part of the VA’s EHR Modernization project to help patients easily access their health records during the projected 10-year switch from VistA to Cerner.

NHS England digital chief moves to digital GP company

NHS England’s first Chief Digital Officer, Juliet Bauer, leaves to become an executive at Livi, an NHS contractor for telemedicine services.

Premier Health Signs Definitive Agreement for Acquisition of Cloud Practice Inc., a National Medical Software Application Company

In Canada, primary care-focused health IT company Premier Health acquires EHR and RCM vendor Cloud Practice for $5 million.

Curbside Consult with Dr. Jayne 1/14/19

I’ve always wanted to attend the Consumer Electronics Show, but have never been able to get my January schedule to cooperate. That puts me with the rest of the tech aficionados in perusing various blogs and write-ups to find the best new healthcare-related gadgets.

This year’s CES booked 25 percent more vendors with a health focus, which equated to nearly 15 percent more floor space for health tech offerings. I’ve been poring over reports and write-ups and there were quite a few offerings this year that generated a lot of attention. I thought I’d share some of my favorites:

• Withings showed its Move ECG watch, which is kickily analog but still awaiting FDA clearance. As a physician, I’m not sure of the utility of real-time ECG monitoring for most patients, so it feels more gimmicky than anything else.
• The Y-Brush toothbrush claims to clean your teeth in 10 seconds using precision nylon bristles positioned at an optimal 45-degree angle. The recommended two minutes for brushing isn’t really that long, however, and I’m not sure the mouth guard-looking device is going to get much consumer uptake.
• The Hupnos sleep mask links with an app that listens to your snoring and triggers the mask to vibrate so that the wearer moves to a position that is less likely to result in snoring. The mask can also apply Expiratory Positive Air Pressure (EPAP) to help keep nasal passages open. I’ve been on a couple of flights lately where this device would have been a bonus.
• The Opte Precision Wand from Procter & Gamble’s venture capital division uses blue LED lights to identify dark spots on the skin. Over 100 thermal inkjet nozzles then apply skincare serums, moisturizer, or makeup to even skin tone. They should also consider tattoo covering cosmetics for workers whose employees have restrictive grooming policies, which I’m seeing more and more often in healthcare.
• Verde launched an electricity-generating treadmill that might let me generate enough juice to power the IPad that serves up enough Netflix to keep me sane on any treadmill-delivered workout.
• The Chronolife vest aims to monitor vital signs and use machine learning to predict the possibility of an impending heart attack. It will be marketed to healthcare providers, researchers, and insurance companies. FDA approval is still pending.
• Urgonight is a headset device that links with an app to track electroencephalogram (EEG) patterns to help train people how to generate sleep-enhancing brainwaves. Designers note that it takes three months of regular use to achieve results. It appeared on lists for both the coolest and weirdest devices at CES.
• The Matrix PowerWatch 2 uses solar power and body-generated heat to power its heart rate sensors, GPS, and notifications while linking with both Apple HealthKit and Google Fit . Designers boast that the GPS will last long enough to run a marathon, but it doesn’t specify the pace. I’m betting my marathon time would be substantially longer than its capacity.
• The EyeQue VisionCheck device hooks to a smartphone and provides data needed for vision-correcting eyeglasses. It skips the prescription, and at a price point near $30, it’s cheaper than a co-pay. For those of us who have uneven ears, it’s still worth the extra cost to have a real-life optical practice keep us seeing clearly.
• DFree offers bladder size measurement technology which can help urology patients know when to go. It’s available for purchase at a hefty $500, but can be rented for a $40 monthly trial. DFree is code for “diaper free” and is marketed to help manage incontinence including notifications to both patients and caregivers.
• Kohler’s smart toilet connects with Alexa along with an app-connected, spa-ready bathroom collection.
• ReSound Linx Quattro is a smart hearing aid that uses artificial intelligence to learn the wearer’s preferences and to adjust sound profiles. It also allows music streaming through hearing aids via apps for Android and iPhone. The devices are more than twice the cost of typical hearing aids.
• The Butterfly iQ is a personal ultrasound machine that uses an app to guide the user as he or she obtains images, which can be sent to the user’s healthcare provider. I’m sure physicians will be thrilled about that one.
• Samsung’s Bot Care is a personal health care assistant that can monitor blood pressure and heart rate. Reports beyond that are slim, and the write-ups I saw made it look more like an alpha offering.
• Other robots such as the ElliQ are designed to assist senior citizens while allowing family members to monitor from afar. It integrates a tablet to help seniors navigate social media, video calls, and texting, although it’s got a $1,500 price tag plus a monthly subscription.

Much like HIMSS, CES is full of demos and prototypes and the solutions aren’t always fully vetted or independently tested. It’s buyer beware with various startups and crowd-funding offerings. There were also some unusual products, including a Bluetooth diaper sensor to alert caregivers of recent deposits; a Sony outdoor speaker that includes integrated cup holders; a collapsible vintage cardboard camera; a robotic bread vending machine; a self-cleaning litterbox with text notifications; a bicycling safety vest with airbags; and a robot companion for dogs.

My favorite piece of non-health tech is the GoSun Fusion solar cooker, which can heat an oven to 550 degrees. It sports a Bluetooth thermometer to alert users when their food is done cooking and claims it can convert 80 percent of the sun’s light into heat while keeping the exterior cool. The company is also working on a solar-powered cooler unit, giving camping even more of a high-tech spin.

My thanks to CNET for the best coverage of CES and excellent links and photos. Maybe one of these years the scheduling stars will align and I’ll be able to request a press pass for CES. Las Vegas would be a lot more hospitable than the foot of snow I’m enjoying, so we’ll see what 2020 brings.

What was your favorite piece of news from the Consumer Electronics Show? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 1/14/19

2018 M&A in Review: The Growth of Mega Mergers

The average acquired health system had annual revenue of $409 million in 2018, according to a new Kaufman Hall report on mega-mergers, that also found expansions were prompted more by improving business than patient care.

Offshoring over 1,000 health care jobs? That’s coming soon at Dallas-based Tenet

Tenet Healthcare (TX) tells investors it will look across the enterprise – including its Conifer Health Solutions billing and United Surgical Partners International ambulatory services divisions – to offshore over 1,000 jobs in the next 12 to 18 months.

Man gets 10 years for cyberattack on Boston Children’s Hospital

The US District Court in Boston sentences Martin Gottesfeld to 10 years in federal prison and orders him to pay $443,000 in restitution for his role in the 2014 cyberattack on Boston Children’s Hospital and nearby Wayside Youth and Family Support Network.

Early research on Apple’s Health Records service suggests patients generally like it

UC San Diego Health patients report high levels of satisfaction with using Apple’s Health Record feature to connect to and share their health data with family and friends.

Monday Morning Update 1/14/19

Top News

The average acquired health system had annual revenue of $409 million in 2018, according to a new Kaufman Hall report on health system mega-mergers. Seven billion-plus dollar transactions skewed the average upward. 

Only 20 percent of the sellers were financially distressed, and 75 percent of the buyers were non-profit health systems that are anxious to grow. 

Kaufman Hall lists several reasons that health systems are expanding, all of them involving improving their own business rather than patient care. It notes that the line between for-profit and not-for-profit health systems is blurring, such as HCA’s acquisition of North Carolina-based Mission Health that also involves funding a local non-profit health trust.

The country’s largest health system, HCA, operates 178 hospitals with annual revenue of $43 billion. It is focusing on markets with increasing population and low unemployment.

Kaufman Hall recommends that health systems expand in markets with high growth or strong demographics, seek strong operational or clinical partners, and increase consumer engagement.

Reader Comments

From GuyFromMadna: “Re: Apple. More power to Tim Cook if he can somehow use Apple Watch to solve the crisis of $300 insulin vials or $3,000 out-of-network ED visits. It took me back to Joe Biden’s precision medicine initiative – whatever happened to it?” No technology company or technology itself can solve our mess of a healthcare system and globally underperforming public health. Cook is one of these: (a) naive, which is probable given that companies that have delved much deeper into healthcare than Apple have met their Vietnam after confidently proclaiming themselves disruptors; (b) confusing a narrowly defined view of health that pertains only to a few undiagnosed and often harmless maladies of IPhone-only users; or the most likely answer, (c) desperately trying to feint away from Apple’s rapidly slipping relevance as investors get wary. Claiming that Apple’s best is yet to come and that it involves an industry largely unexplored by Apple is, to me anyway, just silly. Meanwhile, former VP Biden just delivered the keynote address once again at StartUp Health Festival in San Francisco, railing against data silos and most likely thinking about his inevitable presidential run. I haven’t seen any news from his Biden Cancer Initiative, just like I’m still waiting for MD Anderson to justify that “making cancer history” business (no pun intended). At least you know there’s no good treatment for cancer if even rich people are still dying of it.

From AnonymousPlease: “Re: Mid Coast Hospital (ME). Had an extended computer or network outage recently, accordingly to a family member who was told by their lab tech that the computers were down. Sounds like there was an HVAC alarm in the data center that was ignored (reset). By the second time, many servers had overheated.” The hospital’s Twitter account is frozen in mid-2017 and their Facebook doesn’t mention an outage. It seems odd that someone would ignore a data center cooling warning, so I speculate that maybe they shut the alarm off while trying to mobilize an HVAC expert to investigate and then had the temperature get away from them. It would be a tough call to proactively start turning off servers in that situation and they may not have had enough time to activate whatever failover plan they have. Modern servers should be good to at least 110 degrees F, but their individual thermal safeguards can be programmed to take them down at a user-defined temperature. It is, of course, a nightmare trying to recover individual software systems that went down hard even after the server they run on has been brought back online, requiring the enlistment of individual system experts to look at potentially corrupted databases, run disk recovery, free up phantom user sessions, and assess what information was lost.

From Sticky Wicket: “Re: [publication name omitted.] How did they get ‘Bret’ Shafer in rewording another site’s story?” Misspelling Brent Shafer’s name and omitting his Chairman title is sloppy, but I won’t call the writer out since just a year ago she was finishing up college and working as an office assistant. That particular clickbait-heavy news aggregation site seems to hire from a single demographic of freshly-graduated, female journalism majors. It has an audience, so there’s not much else to say.

From Visual Acuity: “Re: National Federal of the Blind lawsuit against Epic. One of our residents is legally blind and can use Cerner using ZoomText, which we installed after trying the Cerner option that allows increasing some (but not all) font sizes. The resident has less flexibility since Zoomtext must be installed on individual machines and not through Citrix. I do think Cerner (and it sounds like Epic as well) could do a better job supporting accessibility even for physicians who aren’t legally blind, but who have reduced visual acuity.” Thanks for the tip on ZoomText. It offers a Windows-only screen magnifier, another version that includes reading screen contents and keypresses, and a super-product that provides those capabilities plus keyboard navigation, customization, and more expressive screen reading. It also sells a large-print keyboard with hotkeys that control its software. I agree that clinicians, especially those over 40 when presbyopia kicks in nearly universally, might find that their fatigue level, eye strain, and headaches from frequent computer use could benefit from a screen magnifier. I should also mention that Windows 10 has a screen magnifier built in – just press the Windows logo key plus the plus sign (or navigate through the Settings/Ease of Access menu options) – but I tried it and it seems laggy, although I haven’t tried ZoomText to compare. It’s hard to envision (no pun intended) how well a screen reader would work, however, so I don’t envy someone trying to navigate an EHR as the computer reads its screen contents aloud.

From Informed Consent: “Re: partnering with IBM. I have experience with a healthcare software vendor that entered a joint project with a large client of IBM. ‘Joint project’ means that IBM took full control with their leverage and contacts even though we were providing the core of the solution for which they had no alternative. IBM insisted on ‘handling the paper,’ which means they beat us down to a sub-share of the client revenue, then took 20 percent off the top of our portion for ‘taking the risk.’ They didn’t allow us to talk to the client (‘we have the relationship’). We got sucked into providing a reasonable quote for the work, then midway through, IBM said the client’s budget had changed and, ‘You need to cut your portion to $X for this deal to work.’ This happened three times in this one deal even though they wouldn’t tell us how much they were billing our customer. We were down to 40 percent of the original quote when the client cancelled. IBM’s motto is, ‘Our clients are our clients, and YOUR clients are our clients.’ Their salespeople kept wanting intros into our client base but wouldn’t provide the same. Our CEO was excited to get a call from the IBM sales team wanting a price call for a client with similar need. I warned that even though it was their lead and their paper, by the end of the call, they will demand that we give them a minimum revenue commitment, for which we will be on the hook for THEIR unvetted client. The CEO scoffed, but sure enough, my prediction came true in our first call.” I considered HAL – err, IBM — somewhat evil even before their current financial desperation and Watson missteps. I admire some of the technology developments, especially their inadvertent creation of the modern PC industry and Microsoft by botching the original IBM PC rollout by snapping together off-the-shelf components (the failed, proprietary MicroChannel architecture came after the horse had long departed from the barn). IBM eventually walked away from the now-commoditized business by selling the PC business to China-based Lenovo, which turned out to be a much better vendor.

HIStalk Announcements and Requests

A convincing 88 percent of poll respondents who self-identify as longstanding HIMSS members say their feelings about the organization are less positive now than five years ago.

Gerald says that at least HIMSS now acknowledges that the annual conference is a “trade show” (or a “boat show,” as Jonathan Bush always said, although at least boat show attendees are spending their own money instead of someone else’s) instead of claiming that its primary purpose is education. He says he hasn’t attended a provider’s educational session there in the past five conferences, which is about the same as my own record.

A reader asked via a poll question what’s wrong with HIMSS. My answer as a longstanding member, off the top of my head:

1. They run their operation like a dues-funded vendor, maximizing revenue at every opportunity.
2. In fact, they really are a vendor, having acquired for-profit companies, conferences, and publications while somehow remaining a non-profit.
3. They wildly overpay their executives compared to similarly-sized, non-profit member organizations (I researched this thoroughly years ago when Steve Lieber first hit the million-dollar annual compensation milestone).
4. They sell access to their provider members to their vendor members in the “ladies drink free” model.
5. Its “vendor points” system rewards the big vendors that are most willing to send HIMSS huge checks, giving those vendors the dominant voice over those that can’t or won’t pay more.
6. Like most other member organizations, they get involved in government programs that have profit potential for their vendor members.
7. They pay lip service at best to patients since there’s no money to be made in supporting better public health, outcomes, or access (much like their provider members, in fairness).
8. Their media operation studiously avoids running anything that looks like real news unless it cheerleads the industry, filling the remaining empty space with inexpertly written filler pitching products and services that are always predicted to improve healthcare but somehow never do.
9. They aggressively demand to be the voice of the industry even though, as in the case of the American Medical Association, many of the people in that industry aren’t members and those who are may not agree with the positions HIMSS takes on behalf of its vendor members and itself.

New poll to your right or here, as suggested by a reader: for provider IT decision-makers: which service do you consult before buying software or services?

Webinars

January 17 (Thursday) 1:00 ET. “Panel Discussion: Improving Clinician Satisfaction & Driving Outcomes.” Sponsor: Netsmart. Presenters: Denny Morrison, PhD, chief clinical advisor, Netsmart; Mary Gannon, RN, chief nursing officer, Netsmart; Sharon Boesl, deputy director, Sauk County Human Services; and Allen Pendell, SVP of IS and analytics, Lexington Health Network. This panel discussion will cover the state of clinician satisfaction across post-acute and human services communities, turnover trends, strategies that drive clinical engagement and satisfaction, and the use of technology that supports those strategies. Real-world examples will be provided.

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

Acquisitions, Funding, Business, and Stock

More JP Morgan Healthcare Conference nonsense: the entire hotel area is so packed that the moneyed minions are meeting in public parks, restrooms, and the furniture department of a nearby Macy’s, with one hotel charging $300 per hour for a table and four chairs with no service. I didn’t really need more depressing examples of what America has turned into, but this one’s at least kind of funny as long as you don’t think about who’s paying.

Sales

• University Hospitals Cleveland Medical Center joins the global health research network of TriNetX.

Other

The conservative-learning National Affairs ponders “The Cost of Hospital Protectionism,” with the obviously brilliant Chris Pope (kudos, seriously – it’s a tough industry to understand and explain) making these points as he looks back on recent hospital industry history:

• The government has done little to reduce healthcare costs other than to shift the responsibility for paying them while protecting hospitals and encouraging them to inflate costs.
• Healthcare insurance is becoming increasingly unaffordable, with premiums tripling since 1999 and entitlements expect to consume 40 percent of the federal budget by 2047.
• Hospital overcapacity encourages hospitals to offer tests and procedures whose per-unit cost is high due to small volumes, often with poorer outcomes.
• The American Hospital Association promoted cost-based Blue Cross insurance during the Great Depression purely to fund the growth of the expenses of its members.
• When Medicare Part A was rolled out in 1965, the instant 75 percent payment increase encouraged hospitals to spend more on buildings, staffing, and technology. Within five years, total hospital spending rose 37 percent even though only 7.5 percent of the population gained insurance.
• Cost-based payment created a “medical arms race” in which hospitals built expensive facilities for expensive procedures, shifting themselves from “institutions of last resort” to all-purpose providers whose costs rose 345 percent in 10 years vs. the Consumer Price Index’s 89 percent rise. As one hospital CEO said, “You could be an idiot and make a fortune on Medicare reimbursement. Any mistake you made got reimbursed.” 
• Hospitals didn’t worry about the introduction of Medicare DRGs in 1983 because those had a 14.5 percent profit margin built in and excluded capital expenditures, physician fees, and post-acute care services, all of which then started to rise.
• Patients with good insurance don’t care about cost because they aren’t paying, choosing instead based on convenience and amenities.
• Commercial insurers have cut into Blue Cross’s dominance by reducing costs, choosing providers based on quality, and introducing managed care that can exclude expensive providers from their network, require prior authorization for expensive procedures, and give doctors financial incentive to reduce the use of unnecessary services. That, along with the rise of ambulatory surgery centers, has slowed the arms race.
• Hospitals use local political influence, community pride, and vast employment to protect their interests and to have favorable legislation enacted that restricts referral of lucrative patients to lower-cost specialty hospitals that often deliver better outcomes.
• HMOs and heavy-handed employer cost-control efforts in the 1990s caused a consumer backlash that was fueled by lobbyists for hospitals and doctors, which triggered states to limit cost control practices.
• Mergers have left 67 percent of hospitals as members of larger systems and often the owners of many more physician practices, but instead of reducing excess capacity, the now-larger health systems are using their clout to increase prices further.

A doctor who received the above “notice” calls out the phony American Board of Cardiovascular Disease, which is hoping that inattentive medical office workers will send a renewal check to the Falls Church, VA edifice in which it conducts its scientific deliberations (photo above – it’s in the UPS Store, not the adjacent UBreak- IFix). It doesn’t even have a website. This would be hilarious if not for Googling, which reveals many cardiologist “diplomates” who actually advertise their fake credential. The Board’s executives apparently live communally in their tiny mailbox along with those of the equally bogus American Academy of Peripheral Vascular Disease, the American Council of Christian Physicians and Surgeons, the American Academy of Surgery, the American Board of Dental Surgery, the American Association of Ethical Physicians, the American Board of Oncology,  National Diabetes Institute, and the American Board of Urogenital Gynecologic Surgery. Being a Diplomate in Internet-Primary Sleuthing in Heath IT myself (no acronym, please), I tracked down the apparent owner of all these organizations – Keith Lasko, MD, DDiv, who had his own medical license yanked by three states in 1990, after which he started all these organizations and several more like them as retribution (or perhaps correctly identifying an underserved market in fake credentials by those entrusted with the public’s health). The reverend-doctor lives on the spectacularly porn-worthy named Vivid Violet Avenue in Las Vegas, although a lawsuit I ran across suggests that his house is being foreclosed upon by “allied infidels” who want to “throw him and his children into the street as unclean dogs,” referring to his “Mosque of the Golden Rule” religious organization, where he has commendably attained the rank of Imram. He also wrote a poorly-received 1980 book titled “The Great Billion-Dollar Medical Swindle.” My conclusion – the “diplomates” are the bad guys here since there’s no way they believe their bogus credentials are real, so their only intention in buying them must be to mislead patients. The Imran is simply meeting the demand.

The Hustle interviews the original voice of Siri, voice-over actress Susan Bennett, paid an hourly rate in the summer of 2005 to read seemingly meaningless sentences such as “Militia Oy Hallucinate Buckram Okra Ooze ”for ScanSoft (later acquired by Nuance). She found out only after hearing Siri for the first time that those meaningless syllables – which she had to read precisely as measured by an audio analyzer strapped to her throat – were then chopped up into fragments that could be reassembled to make new words and sentences. Here’s a health IT connection – some of my favorite interviews are with NVoq CEO and speech recognition pioneer Charles Corfield (April 2014, July 2017), who was an early investor in Nuance acquisition BeVocal, widely rumored to have contributed the basics of mobile device speech recognition that became Siri. He’s always amused when I amateurishly try to pin him down on his Siri contribution, chuckling and intoning in his mellifluous British accent, “I think I shall refer you to Nuance to comment on matters of Siri or otherwise.” Corfield also created the precursor to Adobe FrameMaker, the first desktop publishing program, while working on his astrophysics PhD at Columbia after graduating from Cambridge. He’s one of the most interesting people I’ve ever talked to, a lock for my HISsies vote for “industry figure with whom you’d most  like to have a few beers.” 

Sponsor Updates

• The Nordic team continues its partnership with The River Food Pantry in Madison, WI.
• Lightbeam Health Solutions publishes a new white paper, “Data-Driven Solutions Providers and Payers Need for Value-Based Care Alignment.)
• MDlive publishes a case study featuring Cone Health (NC).
• EClinicalWorks publishes a podcast titled “How Interoperability Fine-tunes a Neurology Network.”
• Netsmart will exhibit at the North Carolina Providers Council Annual Conference January 14 in Greensboro, NC.
• OnPlan Health and Patientco will exhibit at the HFMA Western Region Symposium January 13-16 in Las Vegas.
• Experian Health and Change Healthcare partner to deliver identity management solutions.
• PatientKeeper will exhibit at the HFMA MA-RI Annual Revenue Cycle Conference January 17-18 in Foxborough, MA.
• TheFutureofThings.com includes PatientKeeper in its list of top healthcare apps.
• Huron announces 20 senior-level positions.
• ZeOmega publishes a new case study highlighting how Alliance Behavioral Health is using Jiva to manage care for North Carolinians experiencing mental health challenges, addiction issues, and intellectual disabilities.

Blog Posts

• Evolution of the Data and Data Engineer (Liaison Technologies)
• Call it a Crusade: Why I Started Loyale Healthcare (Loyale Healthcare)
• Why nine hospitals worked together to achieve success for their patients (Meditech)
• How Health Care CFOs Can Survive – And Thrive – In The M&A Boom (Waystar)
• Checklist for a Consumer-Friendly Patient Financial Experience (Patientco)
• Meeting the communication needs of today’s care teams: An interview with CEO Terry Edwards (PerfectServe)
• Clare Medical: Making House Calls Even More Effective with enTouch (PreparedHealth)
• Health IT Predictions for 2019 (Sansoro Health)
• The Next Generation of Care: The Connected Healing Ecosystem (Vocera)
• Pagers’ Popularity: 5 Reasons It’s Still a Top Communication Tool in Healthcare (Spok)
• Why nine hospitals worked together to achieve success for their patients (Meditech)
• Customer innovation: Avera Health. (Voalte)
• 8 Pitfalls for Startup PT Practices (WebPT)
• Three Keys to Get a Venture-Backed Startup Off the Ground (ZappRx)

Contacts

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

Weekender 1/11/19

Weekly News Recap

• Apple CEO Tim Cook tells CNBC that the company’s greatest contribution to mankind will be related to health.
• CMS Administrator Seema Verma says its requirement that hospitals post raw CDM lists will encourage developers to create tools that consumers will find more useful.
• IBM CEO Ginni Rometty says Watson Health is still a viable part of the company’s business and that Watson for Oncology is doing well.
• England’s NHS issues a long-term plan that calls for technology to improve the ability of patients to manage their own health and to give clinicians access to patient records from any location.
• Healthgrades acquires Influence Health.
• Vatica Health acquires CareSync’s care coordination and chronic care management technology following a $1 million bid made last October.
• The Senate confirms James Gfrerer as the VA’s assistant secretary of information and technology, its first permanent CIO in two years.
• SVB Financial Group completes its acquisition of healthcare and life sciences investor Leerink Partners for $280 million in cash.

Best Reader Comments

Maj. Gen. Payne says “I want to give you a transparent review of where we are with MHS GENESIS” and then doesn’t. Unless maybe the author of the article left out parts like “it doesn’t work yet,” or “it failed its only assessment so far” or “it has zero interoperability with community providers.” It’s one thing to not see a train wreck coming, but another to have it wreck at your feet and disavow it. (Vaporware?)

Did everyone forget about the Tata case? I understand Epic (or any other vendor) wanting to protect their intellectual property. (UGM Attendee)

But this [health system selling Epic Community Connect that refuses to participate in an HIE] would not be the vendor. It’s the hospital itself that’s trying to absorb / acquire / whatever the neighboring clinicians. Epic has nothing to do with it other than being the hospital’s EHR. It’d be the same situation if it was Cerner I assume. My guess is the ONC will put out a proposal that tackles something that isn’t actually an issue. (Epic Complainer)

My patience and sympathy for gripes concerning no-shows is sharply limited. OK, yeah, it’s socially poor form and it has economic and medical consequences. Yet when those same providers are asked to explain, justify, or even quantify wait times, they cannot. Or will not. Or we receive a long list of excuses as to why the poor on-time performance of clinicians exists. With no solutions offered, not ever. Can anyone say they have not waited in a reception room, for an appointment that didn’t start on time? Often by an hour or more? (Brian Too)

Coach, is your HIE on any national plug & play network? I believe Carequality’s terms are share one, share all. (Ex-EDI)

The Allscripts 2bprecise product was built on NantHealth’s Geonomics product, which they obtained after investing $200 million into NantHealth, only to lose nearly all of it when that division failed and was the focal point of possible legal issues. Any word on how many sites implement and use this 2bprecise product / service? (Dr. JVan)

The screenshot issue is ironic. As I recall, around 2000, Epic settled (for millions $$) a lawsuit that IDX had filed against them which stated Epic had stolen screenshots and documents from the UW Medical foundation.(HISJunkie)

As for Epic moving into tangent markets for LTC, mental health, etc. it will be very interesting to see how they go about this. Develop or buy? Considering that there are many successful vendors that own these markets, they sure do not have the time to develop, so will they break down and buy? Secondly I think that the sales argument that the organization will want to buy from a single vendor will not carry as much weight as it did selling within the hospital. (HISJunkie)

Epic doesn’t have an IP leg to stand on for the screenshot restriction, but I believe they started putting this into their contracts a while back that the organization wouldn’t allow it from their employees, and it probably hits their “good install” metrics if they do. (DrM)

Watercooler Talk Tidbits

Reader donations funded the DonorsChoose teacher grant request of Ms. B, who asked for 30 sets of headphones for her second grade class. She reports, “When my class received our box of goodies, we opened it together and they were so happy to have new headphones. Our old headphones were taped or broken from the usage due to the prior years of teaching. We also had to borrow from other classrooms in order to have a class set. Through your donation, my students have an opportunity to build their educational skills in all areas of learning. Working during technology time as a whole has enhanced reading comprehension, math, and vocabulary development by providing them comfort as they work in their own personal space. Receiving their personal headsets has opened up a whole new world.”

Facebook employees liken their work environment to a cult, in which they are forced to pretend to love their jobs, keep quiet about the company’s many scandals, and to form fake friendships with co-workers to game the company’s peer review system that encourages employees to submit anonymous, unchallenged feedback to the employee or their manager.

A jury awards $14 million to parents in a lawsuit brought against a hospital and a radiologist in a “wrongful birth” case in which they were not warned that an ultrasound image of their 22-week fetus showed possible abnormalities that might have convinced them to terminate the pregnancy.

Cell phone providers are selling the real-time location data of their customers, creating a gray market for “bounty hunters” who can locate any cell phone to within a few hundred yards. Companies are selling the data that is intended to be used for fraud detection and roadside assistance firms  – in violation of the privacy policies of the cell phone providers — to developers of apps for car salespeople and bail bondsmen.

A urologist removes a patient’s healthy kidney at UMass Memorial Medical Center after pulling up the wrong CT scan by looking up his patient by name alone, which displayed the images of a different patient with the same name who had the same kidney scan performed on the same day. 

The mother of a five-year-old boy whose diabetes is continuously monitored complains that she called Johns Hopkins All Children’s Hospital (FL) to report a high reading, but doctors didn’t call her back for three days. The hospital’s endocrinology department says they will start returning the calls of diabetic patients within 24 hours.

A Qualcomm executive’s keynote at the Consumer Electronics Show is interrupted by his unmuted Alexa device, which demonstrated an uncanny use of AI (during his pitch for using AI in cars) by loudly proclaiming, “No, that’s not true.”

In Case You Missed It

• News 1/11/19
• EPtalk by Dr. Jayne 1/10/19
• Readers Write: Expanding the Horizon of Clinical Surveillance
• Machine Learning Primer for Clinicians–Part 11
• News 1/9/19
• Curbside Consult with Dr. Jayne 1/7/19
• Monday Morning Update 1/7/19

Get Involved

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

Morning Headlines 1/11/19

Change Healthcare Makes Strategic Investment in MDsave

Change Healthcare makes a strategic investment in MDsave, a healthcare price comparison startup that offers consumers discounted services when booked through its website.

PatientPing to Double in Size in 2019

Boston-based PatientPing will hire 100 employees over the next 12 months in an effort to double its staff.

PSI’s Acquisition of QuarterLine Strengthens its Position as a Health IT Leader

Federal health IT vendor Planned Systems International acquires competitor QuarterLine for an unspecified amount.

News 1/11/19

Top News

Apple CEO Tim Cook tells CNBC’s Jim Cramer that the company will soon roll out new healthcare services that have been years in the making. He says those offerings will ultimately revolutionize the way patients manage their health data.

Cook added, “I believe, if you zoom out into the future and you look back, and you ask the question, ‘What was Apple’s greatest contribution to mankind?’ it will be about health.”

Cook’s enthusiasm for healthcare, while not new, comes at a time when the company has seen the health of its own share price suffer as consumers are finally rebelling against the Apple tax of paying premium prices for increasingly commoditized products. Those few days of AAPL’s $1 trillion valuation are receding in the rearview mirror.

Webinars

January 17 (Thursday) 1:00 ET. “Panel Discussion: Improving Clinician Satisfaction & Driving Outcomes.” Sponsor: Netsmart. Presenters: Denny Morrison, PhD, chief clinical advisor, Netsmart; Mary Gannon, RN, chief nursing officer, Netsmart; Sharon Boesl, deputy director, Sauk County Human Services; and Allen Pendell, SVP of IS and analytics, Lexington Health Network. This panel discussion will cover the state of clinician satisfaction across post-acute and human services communities, turnover trends, strategies that drive clinical engagement and satisfaction, and the use of technology that supports those strategies. Real-world examples will be provided.

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

Acquisitions, Funding, Business, and Stock

Change Healthcare makes a strategic investment in MDsave, a healthcare price comparison startup that offers consumers discounted services when booked through its website. The timing seems opportune, given the practically useless price lists hospitals are now federally mandated to post. Perhaps sites like these will give consumers a better, easier-to-understand way to compare costs at different facilities. The Brentwood, TN-based company boasts former senator Bill Frist, MD as a founding investor.

Seattle-based Providence St. Joseph Health’s venture arm announces a second $150 million VC and growth equity fund. Since launching in 2014, it has invested in Collective Medical, Kyruus, Omada Health, Trilliant Health, Xealth, and Wildflower Health.

Northwestern Medicine (IL) requires patients to agree not to pursue class-action lawsuits or jury trials over the mishandling of digital services like Epic’s MyChart. That product was ironically developed by Epic employees who are forced to accept a similar class action waiver, which the US Supreme Court upheld as a valid requirement to prevent employment-related class action lawsuits.

Despite a plethora of recent bad press about IBM Watson’s healthcare capabilities and disingenuous marketing practices, IBM CEO Ginni Rometty says it is still a viable part of the company’s business, and that Watson for Oncology is doing well. The company’s website offers no insight into how many organizations are using Watson for Oncology; its only case study material comes from two hospitals in India.

Boston-based PatientPing will hire 100 employees over the next 12 months in doubling its staff.

Federal health IT vendor Planned Systems International acquires competitor QuarterLine for an unspecified amount.

Sales

• Val Verde Regional Medical Center (TX) will add patient engagement content and software from Allen Technologies to its in-room smart TVs.
• VA hospitals in the Pacific Northwest will implement Carestream’s enterprise imaging technology.

Announcements and Implementations

In Texas, 25-bed Liberty Dayton Regional Medical Center (OH) spends $1 million on transitioning from paper record-keeping to Cerner.

Federal health IT vendor DSS adds newly acquired EDIS software from VeEDIS Clinical Systems to its new Juno EHR.

Stanford Children’s Health (CA) expects to double its telemedicine visits to 2,500 this year. The hospital uses virtual visit technology for clinic-to-clinic, home-to-clinic, and school-to-clinic visits. It introduced a second-opinion service with Stanford physicians last November, though I imagine the $700 presumably out-of-pocket fee might not make it Stanford’s most popular telemedicine service. The hospital is no stranger to high healthcare costs, having taken heat last year for charging a family $23,000 for a single MRI scan.

Solutionreach releases SR Spotlight, a phone-based patient triage system that integrates with practice management software.

Government and Politics

MHS EHR Functional Champion and Air Force Maj. Gen. Lee E. Payne, MD reassures federal health employees that the MHS Genesis project is on track now that the initial testing phases are over, and that the next wave of implementations will benefit from improved training processes. He stressed, however, that end users will have to adjust their workflows to fit the new Cerner-powered system. “If you try to take your existing business processes,” he says, “whether that’s in AHLTA or Essentris, and you try to jam that into the new electronic health record, you will fail.” The DoD rollout, scheduled to be organization-wide by 2024, will continue with wave-one implementations at three clinics in California and one in Idaho.

CMS Administrator Seema Verma reacts to consumer frustration and negative press over the agency’s efforts to make hospital price lists public, noting that, “While the information hospitals are posting now isn’t patient-specific, we still believe it is an important first step & sets the stage for private third parties to develop tools & resources that are more meaningful & actionable.” She added that University of Utah Health, UCHealth (CO), and Mayo Clinic (MN) have gone above and beyond in making their pricing user-friendly and transparent.

Other

Lease requirements force several physicians to keep their practices open at Physicians Regional Medical Center (TN), which began shutting down last November as part of its parent company’s effort to consolidate services in the area. OB/GYN Lowell McCauley, MD is waiting out his six-month notice of termination in a facility that is now “a desolate institution.” His patients have been cancelling their appointments once they reach the parking lot. “It’s not that they’re not comfortable with me and my staff,” he says, “they’re just not comfortable driving in and seeing what looks like a prison.”

University of Washington Medicine researchers seek FDA approval for Second Chance, a phone-based overdose prevention app that will automatically dial 911 if a user’s breathing and movement slows down or stops.

Sponsor Updates

• EPSi will exhibit at the HFMA Western Region Symposium January 13-15 in Las Vegas.
• Loyale Healthcare talks with TransUnion Healthcare Services Principal of Healthcare Strategy Jonathan Wiik about his new book, “Healthcare Revolution: The Patient is the New Payer.”
• HASA leverages Imat Solutions to deliver value to the healthcare community through data.
• The local news highlights the Texas Hospital Association’s efforts to help providers fight the opioid epidemic using Collective Medical technology.
• Cumberland Consulting Group Principal Lori Nobles joins AHIMA’s Commission on Certification for Health Informatics and Information Management.
• Optimum Healthcare IT publishes an infographic titled “5 Phased Approach to an Epic Upgrade.”

Blog Posts

• You Want to Play with FHIR? 5 Tips to Get Started (Healthwise)
• Congratulations to Ed Kopetsky, the 2018 CIO of the Year (Huntzinger Management Group)
• Boost your claims processing solution in 2019 (Hyland)
• CRM for Population Health: Engaging Healthy Consumers (Influence Health)
• Telehealth – Rural Health Center (EClinicalWorks)

Contacts

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

EPtalk by Dr. Jayne 1/10/19

The US Food and Drug Administration has cleared the Embrace smart watch from Empatica for seizure tracking in children as young as six. The watch detects signals associated with generalized tonic-clonic seizures and alerts caregivers. Embrace had been approved for adult use last February, but the extension for children is a big plus for parents. The watch had a 98 percent accuracy rate for detecting seizures during clinical trials.

A Special Communication published in the Journal of the American Medical Association addresses the growth in medical marketing. From 1997 to 2016, medical marketing grew from $17.7 billion to nearly $30 billion, with direct-to-consumer messaging as the most rapidly-growing spending segment. Consumer-facing ads grew from $2.1 billion to $9.6 billion during the period. This includes $6 billion for direct-to-consumer ads for prescription drugs, a total of 4.6 million ads including over 663,000 TV commercials. Since 1997, there has been more than $11 billion in fines for deceptive marketing practices.

I certainly wouldn’t mind going back to the days when we weren’t peppered with ads for erectile dysfunction drugs and treatments for rare cancers while catching the evening news. The piece also addresses non-drug-related medical marketing such as disease awareness campaigns, noting potential harms caused by “medicalizing ordinary experience and expanding disease definitions without evidence of net benefit.”

The American Academy of Family Physicians (AAFP) is responding to the recent CMS proposed rule revising Medicare Advantage regulations. Although AAFP supports the use of telehealth technologies, it disagrees with the CMS plan to allow telehealth providers to count towards a plan’s network adequacy requirement. It proposes that only telehealth providers who also see patients in person should be counted in the payer’s network. AAFP encourages CMS to protect patients from “an encroachment of direct-to-consumer telemedicine not coordinated with the beneficiaries’ usual source of primary care.” AAFP has partnered with telehealth vendor Zipnosis to provide a platform for members who want to deliver their own virtual services.

CMS is at it again, renaming things for no good reason. This time they’ve proudly announced the launch of the “new design for the CMS QMVIG Updates (formerly eHealth) listserv.” I had to dig through the entire email to figure out what QMVIG even stands for – apparently, it’s the Quality Measurement and Value-Based Incentives Group and it is part of the CMS Center for Clinical Standards and Quality. QMVIG is responsible for programs on meaningful measures development, health information technology, and quality compare programs.

The email made a point that “only the name and look of the listserv has changed.” During a government shutdown that is negatively impacting thousands of people, I’d think CMS would have priorities other than rebranding listservs. The January Health IT Advisory Committee meeting has been canceled as part of the shutdown and we won’t be seeing any interoperability rules since that task force was canceled as well.

I had the opportunity to use a different EHR this week and was surprised to see that the Body Mass Index (BMI) calculation was displaying to four decimal points. BMI is calculated based on a patient’s height and weight. Although it’s conceivable that if you measure height to the quarter inch and weight on a digital scale you might get those decimals in the calculation, it’s still distracting to see them since they’re not clinically significant past one decimal point. It’s just one more example of the noise that we see with the EHR. In a paper chart, most of us would have rounded it and called it a day.

The EHR had several other annoying features, including a laboratory results display grid that indicated results were “abnormal” instead of “out of range.” This led to additional discussion with patients as I reviewed their results so that they understood the values weren’t truly “abnormal” or anything to worry about. It also had a single blood pressure field that was free text rather than separate systolic and diastolic fields restricted to appropriate values, leading to staff keying things like 1400/80 and 12090. I’m glad I don’t have to use it on a daily basis.

Being a CMIO isn’t always about the glamorous world of healthcare IT. Sometimes we’re pulled in by other medical leaders to help put data behind a pesky problem. Such was my lot this week when I was asked to gather some data about effectiveness of commercial laundry processes, particularly with our laundry vendor, after our COO read this article about pathogens surviving the wash cycle. After poring through some data, I’m thinking that I might want to investigate a laundry kettle for my own personal use to make sure I’m not tracking anything home on my scrubs.

While researching disinfection protocols, I came across this article discussing the presence of drug-resistant superbug MRSA on ambulance oxygen tanks. Disinfecting the tanks isn’t part of our standard office checklist, but maybe we should add it to the weekly task list.

Speaking of to-do lists, I’m finally starting to get serious about my HIMSS preparations, confirming my actual travel dates and letting my unneeded hotel nights go back into the available pool. I learned my lesson the hard way a few years ago when I waited too long and couldn’t get a booking for my preferred dates and had to leave early. Now, I book a room as soon as the attendee block opens and book it for the entire block, then adjust it in January once I know what my plans are. I have to say I’m a bit envious of exhibitor reps who have their rooms at closer-in hotels booked by corporate meeting planners.

Sadly, I will be attending HIMSS without my trusted Ringly bracelet. I recently got a new phone and couldn’t get the Bluetooth to connect. When I tried to troubleshoot it, I learned that Ringly folded last January after four years in the wearables business. I enjoyed having a functional piece of jewelry that helped me manage my technology without being obnoxious – the color-coded LED blinks and vibration notifications were enough for me. My current Garmin watch can do a lot more than the Ringly, but it lacks the class and elegance. It also lacks the ability to filter notifications like the Ringly did – I could set it to only alert me to texts, emails, and calls from my inner circle rather than letting everything through. Farewell, Ringly as technology, although I’ll still keep you in the bracelet rotation.

What’s your favorite piece of wearable technology? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 1/10/19

Good things are happening’ as DoD continues to roll out MHS GENESIS

MHS EHR Functional Champion and Air Force Maj. Gen. Lee E. Payne, MD reassures federal health employees that the MHS Genesis project is on track, and that the next wave of implementations will benefit from improved training processes.

IBM isn’t retreating from using Watson in health care, CEO Rometty says

Despite a plethora of recent bad press about IBM Watson’s healthcare capabilities, IBM CEO Ginni Rometty says it is still a viable part of the company’s business, and that Watson for Oncology is doing well.

Tim Cook teases new Apple services: Our ‘most important contribution to mankind’ will be in health

Apple CEO Tim Cook reveals the company will soon roll out new healthcare services that have been years in the making, and that will ultimately revolutionize the way patients manage their health data.

DSS Acquires veEDIS Emergency Department Information System Software

Federal health IT vendor DSS adds newly acquired Emergency Department Information System software from VeEDIS Clinical Systems to its new Juno EHR.

Northwestern Medicine MyChart Users: Your Legal Options Just Shrank

Northwestern Medicine (IL) requires patients to agree not to pursue class-action lawsuits or jury trials over the mishandling of digital services like Epic’s MyChart.

Readers Write: Expanding the Horizon of Clinical Surveillance

Expanding the Horizon of Clinical Surveillance
By Janet Dillione

Janet Dillione is CEO of Bernoulli Health of Milford, CT.

Pay-for-performance programs, like the Centers for Medicare & Medicaid Services (CMS) Hospital-Acquired Condition Reduction Program (HACRP), determine provider reimbursement based on a hospital’s ability to meet key patient safety and performance measures. To reap the financial incentives—and avoid the penalties—of HACRP, more hospitals are “investing in clinical surveillance solutions that utilize real-time patient data to reveal deteriorating patient conditions at an early stage,” according to a report released in November by AGC Partners, a multi-vertical research and investment firm.

Continuous surveillance traditionally has been the near-exclusive domain of hospital departments that care for high-acuity patients with the greatest risks for deterioration, such as the ICU. However, the persistence of preventable catastrophic events, such as post-surgical opioid-induced respiratory depression (OIRD) — which accounts for more than half of medication-related deaths in care settings — suggests that the ability to monitor patients continuously and communicate insights to clinical teams in real-time must extend beyond the ICU.

According to a new KLAS report on the subject, “clinical surveillance tools hold the promise of giving caregivers clinically actionable insights that decrease mortality, reduce readmissions, and improve overall patient outcomes, and clinicians expect these alerts to be embedded directly within their workflow.”

However, successfully broadening the utilization of this technology can be complex and disruptive and can bring new uncertainties to the entire organization.

How Scalable is Continuous Surveillance?

For many health systems, continuous surveillance can be broadly used with existing technology infrastructure, especially organizations with critical care units or ICUs. Optimizing that infrastructure’s capabilities and incorporating it into existing clinical workflows is the real heavy lift, but advances in monitoring technology, use of real-time physiological data and smart alarms, and sophisticated analytics and the ability to route that information to remote clinicians show promise for scaling continuous surveillance to a number of patient care departments, including telemetry, maternity, med-surg, and even beyond the walls of the hospital.

Additionally, health systems exploring the viability of continuous surveillance are using their EHRs as a natural starting point. Multivariate, real-time data from medical devices aggregated with retrospective data from EHRs, provides a holistic and complete source of objective information on a patient that can be used for prediction and clinical decision making.

Does It Save Lives—and Costs?

Hospital investments in clinical surveillance and analytics solutions are driven by organizations that are migrating toward value-based care models and are trying to achieve the objectives of value-based care, including improving care quality and outcomes, reducing clinical variation, and reducing healthcare costs.

Similarly, patient safety in the era of value-based care is increasingly defined as preventing adverse events before emergency interventions or costly escalations are required. However, most common monitoring practices are reactive, not proactive –interventions are often applied only after a patient has deteriorated.

A number of hospital-acquired illnesses (HAI) could be prevented by continuous clinical surveillance. Sepsis and respiratory compromise are among the most costly in terms of resources and morbidity and mortality.

• Industry costs. Respiratory failure that requires emergency mechanical ventilation occurs in 44,000 patients per year in the United States. The cost to US hospitals for opioid-induced respiratory depression (OIRD) interventions is estimated at nearly $2 billion per year.
• Hospitalization costs. Respiratory compromise ($22,300), ranks in the top five of 20 conditions that have the highest aggregate costs per stay due to the high frequency of hospitalization.
• Length of stay. Ventilator-associated complications (VAC) can lead to longer stays in the ICU and greater rates of readmission. VAC complications add approximately $40,000 in costs to each case, $1.2 billion in total costs annually.

Will Clinicians Adopt It?

Technology implemented without proper consideration of impacts on workflow and user ability to fulfill their core responsibilities can have deleterious effects on its overall efficacy.

Involving direct-care staff is critical to the success of any new technology. How will this new technology impact how nurses deliver patient care? What adjustments in workflow and practice need to be made, at go-live and beyond? Starting with these questions fosters buy-in from the staff who will be utilizing this equipment. If end users are not involved in the selection, adoption, and implementation of a technology, then the likelihood that they will become owners of that product is significantly lower.

According to a clinical surveillance report released this year by Spyglass Consulting Group, “hospitals recognize the importance of real-time capabilities to enhance patient safety and improve care quality.”

Ultimately, the ability to safely manage patient populations across the enterprise, reduce the cost of care, and align with reimbursement and regulatory incentives are driving and accelerating adoption. Clinical surveillance has arrived in healthcare and the future looks bright.

Machine Learning Primer for Clinicians–Part 11

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

Previous articles:

• An Introduction to Machine Learning
• Supervised Learning
• Unsupervised Learning
• How to Properly Feed Data to a ML Model
• How Does a Machine Actually Learn?
• Artificial Neural Networks Exposed
• Controlling the Machine Learning Process
• Predict Hospital Mortality
• Predict Length of Stay
• Unsupervised Anomaly Detection in Antibiograms

Basics of Computer Vision

The best ML models in computer vision, as measured by various image classification competitions, are the deep-learning, convolutional neural networks. A convolutional NN (convnet) for image analysis usually has an input layer, several hidden layers, and one output layer — like a regular, densely or fully connected NN, we’ve met already in previous articles:

Modified from https://de.wikipedia.org/wiki/Convolutional_Neural_Network

The input layer of a convnet will accept a tensor in the form of:

• Image height
• Image width
• Number of channels: one if grayscale and three if colored (red, green, blue)

What we see as the digit 8 in grayscale, the computer sees as a 28 x 28 x 1 tensor, representing the intensity of the black color (0 to 255) at a specific location of a pixel:

From https://medium.com/@ageitgey/machine-learning-is-fun-part-3-deep-learning-and-convolutional-neural-networks-f40359318721

A color image would have three channels (RGB) and the input tensor would be image height x width x 3.

A convnet has two main parts: one that extracts features from an image and another, usually made of several fully connected NN layers, that classifies the features extracted and predicts an output — the image class. What is different from a regular NN and what makes a convnet so efficient in tasks involving vision perception are the layers responsible for the features extraction:

• Convolutional layers that learn local patterns of increasingly complex shapes
• Subsampling layers that downsize the feature map created by the convolutional layers while maximizing the presence of various features

Convolutional Layer

A convolutional layer moves a filter over an input feature map and summarizes the results in an output feature map:

In the following example, the input feature map is a 5 x 5 x 1 tensor (which initially could have been the original image). The 3 x 3 convolutional filter is moved over the input feature map while creating the output feature map:

Subsampling Max Pool Layer

The input of the Max Pool subsampling layer is the output of the previous convolutional layer. Max pool layer output is a smaller tensor that maximizes the presence of certain learned features:

From https://developers.google.com/machine-learning/practica/image-classification/convolutional-neural-networks

Filters and Feature Maps

Original image:

A simple 2 x 2 filter such as 

[+1,+1]

[-1,-1] 

will detect horizontal lines in an image. The output feature map after applying the filter:

While a similar 2 x 2 filter 

[+1,-1]
[+1,-1] 

will detect vertical lines in the same image, as the following output feature map shows:

The filters of a convnet layer (like the simple filters used above for the horizontal and vertical line detection) are learned by the model during the training process. Here are the filters learned by a convnet first layer:

From https://www.amazon.com/Deep-Learning-Practitioners-Josh-Patterson/dp/1491914254

Local vs. Global Pattern Recognition

The main difference between a fully-connected NN we’ve met previously and a convnet, is that the fully connected NN learns global patterns, while a convnet learns local patterns in an image. This fact translates into the main advantages of a convnet over a regular NN with image analysis problems:

Spatial Hierarchy

The first, deepest convolutional layers detect basic shapes and colors: horizontal, vertical, oblique lines, green spots, etc. The next convolutional layers detect more complex shapes such as curved lines, rectangles, circles, ellipses while the next layers identify the shape, texture and color of ears, eyes, noses, etc. The last layers may learn to identify higher abstract features, such as cat vs. dog facial characteristics – that can help with the final image classification. 

A convnet learns during the training phase the spatial hierarchy of local patterns in an image: 

From https://www.amazon.com/Deep-Learning-Python-Francois-Chollet/dp/1617294438

Translation and Position Invariant

A convnet will identify a circle in the left lower corner of an image, even if during training the model was exposed only to circles appearing in the right upper corner of the images. Object or shape location within an image, zoom, angle, shear, etc. have almost no effect on a convnet capability to extract features from an image. 

In contrast, a fully-connected, dense NN will need to be trained on a sample for each possible object location, position, zoom, angle, etc. as it learns only global patterns from an image. A regular NN will require an extremely large number of (only slightly different) images for training.A convnet is more data efficient than a NN, as it needs a smaller number of samples to learn local patterns and features that in turn have more generalization power. 

The two filters below and their output feature maps — identifying oblique lines in an image. The convnet is invariant to the actual line position within the image. It will identify a local pattern disregarding its global location:

From https://ujjwalkarn.me/2016/08/11/intuitive-explanation-convnets/

Transfer Learning

Training a convnet on millions of labeled images necessitates powerful computers to work in parallel for many days and weeks. That’s usually cost prohibitive for most of us. Instead, one can use a pre-trained computer vision model that is available as open source. Keras (an open source ML framework) offers 10 such image analysis, pre-trained models.  All these models have been trained and tested on standard ImageNet databases. Their top, last layer has the same 1,000 categories: dogs, cats, planes, cars, etc. as this was the standardized challenge for the model.

There are two main methods to perform a transfer learning and use this amazing wealth of image analysis experience accumulated by these pre-trained models:

Feature Extraction

1. Import a pre-trained model such as VGG16 without the top layer. The 1,000 categories of ImageNet standard challenge are most probably not well aligned with your goals.
2. Freeze the imported model so it will not be modified during training.
3. Add on top of the imported model, your own NN — usually a fully-connected, dense NN — that is trainable.

Fine Tuning

1. Import a pre-trained model without the top layer,
2. Freeze the model so it will not be modified during training, except …
3. Unfreeze the last block of layers of the imported model, so this block will be trainable.
4. Add on top of the imported model, your own NN, usually a dense NN.
5. Train the ML model with a slow learning rate. Large modifications to the original pre-trained model weights of its last block will practically destroy their “knowledge.”

Next Article

Identify Melanoma in Images

Morning Headlines 1/9/19

The NHS Long Term Plan

In England, NHS issues a long-term plan that calls for technology to, among other goals, improve patient access and the ability to self-manage health, and give clinicians access to patient records from any location.

Healthgrades Acquires Influence Health

Physician and hospital information publisher Healthgrades acquires Influence Health, which offers web services, listings, reputation management, and CRM.

Amazon’s next big thing? Prime, but for healthcare

Analysts predict that Amazon will create Prime for healthcare, which could focus on offering lower drug prices via its acquired PillPack mail order pharmacy, Alexa services, and using its recently announced medical records analytical service to scribe clinical encounters.

AT&T and Rush System for Health Ink Agreement to Use 5G in Hospital Setting

AT&T and Rush University Medical Center (IL) will create the country’s first 5G-enabled hospital and will explore ways that a faster cellular network can improve operations and patient experience.

News 1/9/19

Top News

In England, NHS issues a long-term plan that calls for technology to:

• Improve patient access and the ability to self-manage health
• Give clinicians access to patient records from any location
• Apply best practices using clinical decision support and AI
• Apply population health prediction techniques to assign resources accordingly
• Capture data automatically to reduce administrative burden
• Protect privacy and give patients control over their medical record
• Link clinical, genomic, and other data to improve treatments

Reader Comments

From Jaye P. Morgan Gong Show: “Re: JP Morgan Healthcare Conference. I really like your post about the moneyed investors dodging the homeless on San Francisco’s sidewalks, but let’s remember Jonathan Bush stopping to administer CPR while he was walking down the street. Of course, we know what happened to him.” That unscripted drama from 2016’s conference said a lot about the character of the former Army medic and EMT, who didn’t hesitate to hit the dirt in his expensive suit to perform CPR. He explained at the time, “It was a lot like the healthcare industry: a lot of people were standing around tweeting about it, but no one was trying to do anything about this guy lying in the street. So I was like, turn him the f*** over! It was really dramatic. It was intense. The crowd was rooting for us.” Among the beauty queen sashes I ordered for that year’s HIStalkapalooza was one for JB that said, “I CPR’ed some random guy.” Meanwhile, Elliott Management’s Paul Singer had best hope that JB isn’t the only bystander if he goes to ground.

From Info Blocker: “Re: health system not sharing information with an HIE. That’s not like Epic.” Epic isn’t the problem here, it’s that one of their customers that doesn’t want to share patient information. Suggesting that EHR vendors are the bad guys distracts from reality. You only need to find one user of any EHR system that is sharing data by any means (HIE, Carequality, CommonWell, API, internal app, etc.) to disprove the idea that it’s not possible for that system to share information. The only way the vendor is the villain is if they charge unreasonable fees to make it happen. 

From See Me, Feel Me: “Re: National Federation of the Blind. Is suing Epic for discrimination, saying that Epic’s failure to support screen readers prevents blind people from working in Massachusetts hospitals.” That’s actually old news from July of last year. The organization does of lot of suing for inaccessible websites, self checkouts that don’t work well for the blind, universities that don’t make every function and benefit accessible, and hospitals that don’t offer all materials in Braille or electronic form. Section 508 of the Rehabilitation Act of 1973 requires the federal government to make its own technologies usable by the disabled, but I don’t think the requirement extends further and I’ve only heard of it in the context of public web pages. I can’t imagine that Cerner – the federal government’s most expensive IT system in history – is natively accessible, so if it supports use by the blind, it’s probably through a third-party screen reader. Good intentions aside, I don’t know how someone who is blind could navigate information-packed displays that require clicking, choosing drop-downs, and displaying dynamic patient information. The lawsuit notes that Epic’s patient-facing applications have been made accessible and concludes that “Epic thinks that blind people are only fit to be patients, not healthcare workers.” I’m not sure the sarcastic tone and claims of discrimination will win friends and influence people.

HIStalk Announcements and Requests

We’re putting together our HIMSS19 guide that features HIStalk sponsors, so if your company is exhibiting or attending, contact Lorre to get our information collection form about your booth, giveaways, or activities. You’re probably spending a fortune to be there, so you might as well get some free exposure. She also convinced me to offer some sweeteners to cash-strapped startups who sign up as new sponsors, especially those who realize that their exhibit hall time leaves them out of the spotlight for the 362 days of the year afterward.

HIMSS will have some holes in its agenda if the federal government shutdown continues for 33 more days, which I assume would leave some attendees and presenters unable to attend.

Ellkay sent some fun stuff my way (via Lorre) for the holidays – a beautifully packaged sampler box of their honey (from their rooftop bee hives) and a really cool drawing of their Christmas party guests with a find-the-object game included. I’m generally indifferent to unimaginative corporate giveaways, but Ellkay does it perfectly in not only providing something novel and useful, but that also expresses who they are.

Webinars

January 17 (Thursday) 1:00 ET. “Panel Discussion: Improving Clinician Satisfaction & Driving Outcomes.” Sponsor: Netsmart. Presenters: Denny Morrison, PhD, chief clinical advisor, Netsmart; Mary Gannon, RN, chief nursing officer, Netsmart; Sharon Boesl, deputy director, Sauk County Human Services; and Allen Pendell, SVP of IS and analytics, Lexington Health Network. This panel discussion will cover the state of clinician satisfaction across post-acute and human services communities, turnover trends, strategies that drive clinical engagement and satisfaction, and the use of technology that supports those strategies. Real-world examples will be provided.

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

Acquisitions, Funding, Business, and Stock

Physician and hospital information publisher Healthgrades acquires Influence Health, which offers web services, listings, reputation management, and CRM.

Change Healthcare and Experian Health will combine their healthcare network and identity management capabilities, respectively, to create an identity management solution.

Patient engagement technology vendor Vatica Health acquires the technology of the defunct CareSync, for which it made a $1 million stalking horse bid to the bankruptcy court in October 2018. CareSync, founded in 2011, burned through nearly $50 million in funding before abruptly shutting down in June 2018.

Analysts predict that Amazon will create Prime for healthcare, which could focus on offering lower drug prices via its acquired PillPack mail order pharmacy, Alexa services, using its recently announced medical records analytical service to scribe clinical encounters, and providing services such as telehealth and medical devices.

Patient matching technology vendor Verato raises $10 million in a Series C funding round, increasing its total to $35 million.

Sales

• St. Luke’s University Health Network (PA) signs a three-year Epic managed services agreement with HCTec.
• Boston Medical Center Health System chooses ZeOmega Jiva for advanced care management in its Medicaid ACO. 

People

CHIME names Stanford Children’s Health CIO Ed Kopetsky, MS as 2018’s John E. Gall Jr. CIO of the Year.

Isaac “Zak” Kohane, MD, PhD (Harvard Medical School) joins the board of Inovalon.

Announcements and Implementations

Vocera launches a new hands-free, voice-powered Smartbadge that offers a larger color screen, improved audio, a dedicated panic button, and extended battery life.

Another 12 health systems representing 250 hospitals join Civica Rx, which will manufacture its own generic drugs – many of them in IV form — to save money and reduce shortages.

Withings will offer consumers a less-expensive EKG device than the Apple Watch with its $129 Move ECG, which hasn’t yet earned FDA’s marketing clearance. AliveCor’s $99 KardiaMobile came out two years ago as the first and arguably best of the lot.

Omrom launches a $499 blood pressure watch that uses an inflatable cuff built into the band rather than the usual questionably accurate optical sensors. It also announces Complete, which adds EKG capability to the blood pressure monitor.

AT&T and Rush University Medical Center will create the country’s first 5G-enabled hospital and will explore ways that a faster cellular network can improve operations and patient experience. 

California health data network Manifest MedEx goes live on NextGate’s EMPI.

Other

Wired magazine notes that China’s healthcare AI efforts, such as imaging analysis, benefit from that country’s less-rigorous privacy regulations that allow vendors to train their systems using millions of readily available patient images. An example is InferVision, which is being tested at Wake Radiology (NC) and Stanford Children’s Hospital.

Vox finds that the ED of taxpayer-funded Zuckerberg San Francisco General Hospital intentionally remains out of network for all private insurers, which the hospital explains is necessary to generate the money it needs to offset charity and Medicaid care. The hospital billed a 24-year-old woman whose broken arm was treated in its ED $24,000 (12 times the Medicare price), of which Blue Cross paid $3,800, leaving her on the hook for over $20,000.

A study published in Health Affairs finds that the 20 top-funded digital health companies have had minimal documented impact on disease burden or cost, with few published studies and an avoidance of measuring outcomes in sicker patients.

A large-scale consumer survey by NRC Health finds that 80 percent would change providers based on convenience alone; long waits and lack of respect are big dissatisfiers; people want to provide feedback quickly after their encounter and preferably by email; and patients don’t care much about provider brand identity and instead focus on their experience with individual clinicians.

Observer polls a panel of experts to name its 20 best “flyover tech” digital health companies that aren’t on either coast:

• Bind (MN) – insurance management for consumers
• Solera Health (AZ) – connecting patients to community organizations and apps
• NightWare (MN) – intervention for PTSD-caused nightmares
• ClearData (TAX) – cloud computing and information security
• Healthe (MN) – eye protection from computer device blue light
• MyMeds (MN) – medication adherence
• Visibly (IL) – online vision testing
• Higi (IL) – health kiosks
• HistoSonics (MI) – non-invasive treatment robotics
• Lumea (UT) – digital pathology
• Springbuk (IN) – actionable health insights
• Sansoro Health (MN) – healthcare data exchange
• LearnToLive (MN) – online mental health treatment
• Smile Direct Club (TN) – teeth straightening aligners
• SteadyMD (MO) – remote primary care that matches the lifestyles of patients and doctors
• Collective Medical (UT) – ED patient data sharing
• Limb Lab (MN) – prosthetics
• Upfront Health (IL) – care journey “next best action”
• AbiliTech Medical (MN) – robotic assistance for those upper-limb with neuromuscular conditions
• Vivify Health (TX) – remote care mobile devices

Tennessee pays contracted doctors a piecework rate for reviewing disability applications, with one of them finishing cases – of which 80 percent were denied — in an average of 12 minutes, allowing him to make $420,000 in the past year and $2.2 million since 2013. At least two of the contracted 50 physicians are felons, while others have had their medical licenses revoked.

In England, experts take a hard-eyed view of sloppily handwritten prescriptions after female patient irritates her eyes with what was supposed to be a soothing ophthalmic lubricant, which the pharmacist mistook as an order for a cream for erectile dysfunction. One might assume that the pharmacist ignored a series of computer warnings for issuing a drug for an inappropriate route of administration and patient sex.

Sponsor Updates

• Divurgent and Gevity will offer their combined healthcare information systems consulting expertise.
• Access and Dimensional Insight will exhibit at the MUSE Executive Institute January 13-15 in Newport Beach, CA.
• AdvancedMD announces the winners of its annual Healthcare Innovator of the Year Awards.
• Tampa Bay Tech awards AssessURHealth with its Emerging Tech Company of the Year award.
• The Best and Brightest names Burwood Group a Wellness Winner.
• The Chartis Group publishes a new report, “Why Your Provider Workforce Plan Isn’t Working.”
• The local news highlights UCSF Medical Center’s use of Collective Medical technology to help “frequent flier” ER patients.
• Divurgent and Gevity announce a strategic business alliance to expand their services across the US and Canada.
• DocuTap announces its 2018 student scholarship essay winners.

Blog Posts

• Are You Ready For Your Next Epic Upgrade? (Optimum Healthcare IT)
• 5 Tips for Adopting Telemedicine into Your Practice (AdvancedMD)
• Bluetree’s take on the new release cycles (Bluetree)
• Hybrid Cloud, not Multi-Cloud, is the Future (Datica)
• 6 Top Cybersecurity Trends to Embrace in 2019 (Burwood Group)

Contacts

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

Morning Headlines 1/8/19

Vatica Health Acquires CareSync’s Technology to Expand Value-Based Care Capabilities

Vatica Health acquires CareSync’s care coordination and chronic care management technology following a $1 million bid made last October.

Stanford Children’s Health CIO Ed Kopetsky Receives Healthcare CIO of the Year Award

CHIME and HIMSS honor Stanford Children’s Health CIO Ed Kopetsky with their CIO of the Year award.

Statement from FDA Commissioner Scott Gottlieb, M.D., on the agency’s new actions under the Pre-Cert Pilot Program to promote a more efficient framework for the review of safe and effective digital health innovations

The FDA releases a regulatory framework, test plan, and working model as part of the next phase of its Pre-Cert program for the review of digital health product applications.

EarlySense Completes $39 Million Financing Round to Accelerate Global Expansion of Contact-Free Sensing and Analytics Solution

Patient monitoring company EarlySense secures $39 million in a financing round led by Hill-Rom and Wells Fargo Strategic Capital.

Curbside Consult with Dr. Jayne 1/7/19

The government shutdown has impacted some electronic media, including the National Zoo’s Giant Panda Cam and the National Park Service website. It hasn’t slowed CMS, which continues to send regular emails about the recent final rule redesigning the Medicare Accountable Care Organization (ACO) program. Referred to as “Pathways to Success,” it is designed to advance five goals: accountability, competition, engagement, integrity, and quality. The program modifies the participation options available to push ACOs toward taking on real financial risk faster than they had been under the previous programs.

I have been under the weather and tried to use my illness-imposed downtime to read my way through various fact sheets and documents around the program, but have had trouble making sense of some of it. The CMS press releases reference different announcements and rules that have been put out, including the Calendar Year 2019 Physician Fee Schedule (aka the November 2018 final rule). According to the release, the Pathways to Success final rule also takes a step back in time, finalizing policies for extreme or uncontrollable circumstances for performance year 2017, which were initially established via an interim final rule in December 2017. I had to read that part of the announcement several times since I’m not exactly sure how that works to modify a program year that ended 370 days ago. I thought maybe it was confusing because I was reading it while I was hopped up on cold medicine, but I eventually decided that it’s just confusing.

In trying to distill the communications, my assessment is this. Medicare has figured out that the majority of ACOs are participating in Track 1 for the maximum time allowable and some of them are generating losses. Track 1 is a one-sided model with sharing of savings without the ACO having to take on risk, therefore Medicare absorbs any losses. The original idea was for organizations to use Track 1 as a way to get their feet wet with shared savings in hopes that they’d quickly move to more risk-bearing agreements. That hasn’t happened, so now the proverbial stick has to come out.

The other existing ACO varieties (Track 2 and Track 2) are two-sided. Eligible ACOs share a larger portion of any savings, but in exchange they’re required to share losses if spending exceeds benchmarks. These programs have been shown to generate savings for Medicare and are improving quality, so Medicare wants to further those types of arrangements.

Medicare has also figured out that so-called low-revenue ACOs (mainly made up of physician practices or rural hospitals) are outperforming high-revenue ACOs, which typically include hospitals. There are challenges for the low-revenue ACOs to move to a more risk-bearing arrangement because those organizations may have less control over how their assigned beneficiaries use services and therefore spend money. Medicare piloted the “Track 1+ ACO Model” during 2018, with the goal of proving that a two-sided model with lower risk would be attractive. Its success influenced the construction of the new redesigned program, according to CMS.

The redesigned program offers two tracks, named BASIC and ENHANCED, which are open for five-year agreement periods starting July 1, 2019. The BASIC track lets ACOs start under a one-sided model and gradually accept higher risks as they move through five levels A, B, C, D, and E. Once they reach the highest level, they’d be recognized as an Advanced Alternative Payment Model (APM) under the Medicare Quality Payment Program. The ENHANCED track is based on the existing Track 3 and allows flexibility for ACOs willing to take on the highest levels of risk. The existing Track 1 and Track 2 programs will be discontinued, as will new application cycles for Track 1+. CMS feels those options would be redundant to the new program.

CMS aims to move BASIC organizations through the alphabetical levels (which they refer to as the “glide path”) by automatically advancing them at the start of a new performance year. Organizations would also be able to jump to a higher level faster if desired. The ultimate goal is to move all ACOs to the ENHANCED track, with high revenue ACOs being required to transition more quickly. There are also stratifications based on whether ACOs are identified as experienced or inexperienced with performance-based risk but to be honest I skimmed over those particulars in my pharmaceutical-induced fog.

The final rule updates the mechanisms for repayment when ACOs have shared losses. Both new tracks may start with lower repayment amounts based on a percentage of Medicare Part A and Part B revenues, with the amounts recalculated annually based on changes in the ACO participant list. Benchmarks will also be recalibrated, incorporating data from ACO experience and regional performance measures. The rule also aims to reduce “opportunities for gaming” by holding terminated ACOs accountable for pro-rated shared losses. ACOs are also able to choose between different beneficiary assignment methodologies and to change their selections for subsequent performance years. Starting in January 2020, eligible ACO providers will be able to receive payment for telehealth services for certain beneficiaries in certain situations. There are also changes to expand the Skilled Nursing Facility (SNF) 3-day rule waiver.

The redesign also allows ACOs under certain two-sided models to operate a beneficiary incentive program, which may allow for incentive payments of up to $20 to assigned beneficiaries who receive certain qualifying primary care services from ACO members. It also clarifies that under existing program regulations, vouchers and gift cards can be provided to beneficiaries assuming they meet other program requirements such as being connected to the beneficiaries’ medical care. There are a few other tidbits in the rule including updates to beneficiary notification requirements. Beneficiaries have to be notified of the opportunity to opt-out of claims data sharing along with how to change their assigned primary clinician. CMS is developing templates for these notices in an effort to reduce the burden to participating practices.

I’m only marginally involved in the ACO realm, so I’m sure those who are deeper in the process might have additional insights. I’ll be looking to read digests and summaries in the coming days until I’m on the mend. Until then, my next reading list involves chicken soup.

Email Dr. Jayne.

Morning Headlines 1/7/19

Senate Confirms James Gfrerer as VA’s Information, Technology Leader

The VA finally has its first permanent CIO in two years after the Senate confirms James Gfrerer as assistant secretary of information and technology.

SVB Financial Group Completes Acquisition of Healthcare Investment Bank Leerink Partners

SVB Financial Group completes its acquisition of healthcare and life sciences investor Leerink Partners for $280 million in cash.

Livongo Names Lee Shapiro Chief Financial Officer

Livongo hires its board member and investor Lee Shapiro as CFO.