Morning Headlines 1/4/19

Alphabet’s Verily gets $1 billion in funding round led by Silver Lake

Alphabet’s life sciences company Verily —  the former Google Life Sciences — raises $1 billion in a new capital funding round.

Medsphere Acquires HealthLine Solutions, Expands CareVue Platform

Medsphere acquires supply chain vendor HealthLine System a few weeks after raising $32 million.

Best Buy bones up on health care biz

Best Buy promotes Asheesh Saksena to president of its new health division, which will focus on helping seniors age in place.

Medici starts 2019 by buying another Austin health-tech startup

Telemedicine vendor Medici acquires competitor Chiron Health for an undisclosed amount.

News 1/4/19

Top News

Alphabet’s life sciences company Verily —  the former Google Life Sciences — raises $1 billion in a new capital funding round.

CEO Andrew Conrad says that the money will prepare the company to “execute as healthcare continues the shift toward evidence generation and value-based reimbursement models.”

Some of Verily’s projects include smart contact lens, continuous glucose monitors, development of bioelectric medicines, hand tremor reduction software, retinal imaging, surgical robotics, healthcare performance measurement, risk prediction models for chronic disease management, and precision medicine.

Reader Comments

From Dr. Demento: “Re: Annals of Internal Medicine article on machine learning and inequitable treatment. I’m wondering how you’ll respond to these, especially the editorial.” The article says that because machine learning analyzes historic data, it will perpetuate longstanding health disparities that are based on racism and classism, an issue that has arisen in other areas such as trying to predict which citizens are likely to commit crimes. The article provides a healthcare example of using ML to predict patient deterioration, which might underrepresent African American patients who were treated differently, or discharge care planning that might place too much emphasis on patients from high-income ZIP codes since they have more control over discharge conditions such as transportation, home meds, etc. I see the potential problem, but all aspects of life contain certain assumptions and biases and it’s asking a lot of a machine to somehow iron them out even though we ourselves are usually unaware of them. There’s also the issue of whether a machine is being “unfair” when it makes observations that may or may not need to consider social determinants of health instead of simply making a recommendation that works for most people. I’m all for being aware of these issues and fine-tuning the algorithms accordingly, but ML has to reflect an inherently unfair reality (see: Flint’s water crisis). I worry more about it drawing incorrect inferences because, like the humans that oversee it, the technology can’t always distinguish between correlation and causation. The bottom line is that humans should always be managing the machine, second-guessing it, and demanding transparency into how it arrives at its conclusions because we’re the adults in the room. Expecting a machine to be less biased than the human history it learns from is a nice idea and worth keeping in mind, but we’re probably a long way from making that the most important issue in machine learning.

HIStalk Announcements and Requests

HISsies ballots went out via email Thursday morning to readers who subscribe to HIStalk updates and have recently clicked the link to read new posts.

I’ve lamented lately that healthcare providers rarely use electronic signature platforms such as DocuSign to process emailed forms, clinging instead to mailed paper copies and faxes. I received an emailed contract for a family event this week sent via ESign Genie – it’s just $8 per sender per month. It’s probably naive to think that just because providers could improve their own efficiency, delight their customers, and improve their records retention for just $8 per month that they will actually do so, but at least we customers know that if they don’t, they simply don’t care what makes life easier or better for us.

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

Medsphere acquires supply chain vendor HealthLine System a few weeks after raising $32 million that it said would be used for acquisitions.

Epic expands sales to include dentists and life insurance and diagnostics companies as VP of Population Health Alan Hutchison says the company is “moving beyond the walls” as it seeks to create – and dominate – the single repository space for patient health data. Hutchinson adds that the company is also in talks with assisted-living and nursing home facilities.

Apple drags the stock market down after lowering revenue guidance, which the company blames on poor sales in China due to that country’s economic problems and its trade war with the US. Analysts noted that despite Apple’s blaming the Chinese economy alone, the market for expensive phones is falling apart everywhere and consumers are pushing back against the “Apple tax” in which they faithfully line up every year to pay a premium for a commodity product. AAPL shares dropped 10 percent Thursday and the company is now a long way from its recent trillion-dollar valuation, as share price has dropped nearly 40 percent since early October.

Jvion raises a growth equity investment of an unspecified amount, led by JMI Equity. The Atlanta-based company, which last raised $9 million in 2016, seems to have evolved from a coding optimization and analytics vendor to “the market leader in healthcare AI.”

Good news for patients already scrambling to pay for outrageously priced meds: Pending regulatory approval, Bristol-Myers Squibb will acquire Celgene in a $74 billion deal that will combine two of the nation’s biggest pharma companies.

HIMSS forms a media partnership with FindBiometrics, a publisher of biometric ID solution news.

A fascinating ProPublica article looks at the forced “retirement”of older employees, noting that more than half of American workers over age 50 leave jobs because of their employer’s decision, not their own, imperiling their financial planning for retirement. Notes:

• Only 10 percent of those older employees who are pushed out find a job paying the same or more
• Both employers and employees use the term “retirement” to save face
• Companies pitch long-term benefits such as 401Ks and promotions even though they know full well most employees will never benefit from them
• Employers can force older workers out the door by changing their job responsibilities, pay, hours, work locations, or annual review expectations
• Employers use “stealth layoffs” of early retirement and eliminated positions to replace older workers with younger, cheaper employees or to offshore their jobs
• Federal protections have been cut way back as companies – many of them publicly traded and desperately trying to prop up earnings – have made pleas to “remake their workforces”
• Employees who refuse to relocate for job opportunities are often cast aside for more eager co-workers
• IBM is an example of layoffs, forced retirements, and mandatory relocations that push older workers to leave – not just of those who make more money, but to skew the mix younger by ditching older workers
• Companies intentionally skirt age discrimination laws by forcing job applicants to list their education dates (as a proxy for birthdate), hoping to avoid the high insurance premiums and perceived lower productivity of older workers
• The article concludes that older workers need to keep up their learning (especially technology); network instead of wasting time chasing online ads; save money under the assumption that their entire earning career could be limited to the 30 or so years after college and before being forced out of the job market; and to avoid waiting too long to work for themselves instead of for someone else

People

Zac Jiwa (MI7) joins The Karis Group as president/CEO.

Best Buy promotes Asheesh Saksena to president of its new health division, which will focus on technology and services to help seniors age in place. The company acquired senior-focused mobile device and emergency call service company GreatCall last October for $800 million.

NLP software vendor Talix names Bob Hetchler SVP of sales and Eileen Rivera VP of marketing. Both come from Ciox Health.

Announcements and Implementations

Mercy Health Network selects PatientPing’s real-time patient notification service for its ACO members in Iowa.

Health Level Seven International publishes the FHIR Release 4 standard.

KLAS publishes Part 1 of its overview of population health management technology, noting the “good product, good relationship” vendors above and listing the weak partners as Allscripts, Athenahealth, and Philips Wellcentive. HealthEC is the only vendor KLAS calls out as excelling at providing strategic guidance. HealthEC and Health Catalyst finished tops for helping healthcare organizations negotiate value-based reimbursement contracts, while Forward Health Group finished best in ongoing optimization and training. Philips Wellcentive and NextGen Healthcare slipped year over year after acquiring their respective products, while Allscripts and Athenahealth haven’t met customer functionality expectations.

Privacy and Security

HHS publishes cybersecurity guidelines for managing threats and protecting patients, plus technical resources and templates for healthcare organizations of varying sizes.

Other

An NHS provider’s tweet lamenting a string of no-show patients goes viral in England, prompting many to suggest that patients be fined for missing appointments. NHS data show that missed appointments cost the national service $273 million each year and result in over 1 million wasted clinical hours.

Nurses at Intermountain Medical Center in Utah comfort grieving families with printouts of their loved one’s last EKG enclosed in a tube with a note that reads, “May my heart be a gentle reminder of the love I have for you.”

Eric Topol, MD pokes fun at the hype surrounding wearables, a timely observation given the many people who will likely spend the next few weeks addicted to their devices as they struggle to maintain what will soon become short-lived New Year’s resolutions.

This question never seems to go away – is it OK that Epic (reading between the lines here) has a reputation of bringing its legal muscle to bear on anyone who uses a screenshot of its software in an research article, especially if the screen in question was built or customized by a customer? Epic, despite being full of nice people most of the time, is somewhere between rigorous and paranoid in sending the lawyers after anyone (even a customer) who says or writes basically anything about Epic’s contracts, products, project management methods, training materials, or documentation outside of an Epic-controlled environment. If you have experience with this as a provider either way, let’s hear your story.

A couple sues OB/GYN John Boyd Coates, MD after discovering that he, rather than an anonymous sperm donor, is the father of their 41 year-old daughter. The discovery came to light after their daughter received results from a consumer genetics test. Coates delivered the baby girl himself in 1977.

Sponsor Updates

• ROI Healthcare Solutions publishes its 2018 highlights.
• Cerner adds prescription pricing and benefit information from CoverMyMeds to e-prescribing workflows within its EHR.
• Healthcare Growth Partners publishes its December Health IT Insights.
• Nordic posts a podcast titled “Preparing for changes to value-based care reimbursement in 2019.”
• AdvancedMD publishes a case study featuring Surgical Specialists of Jackson (MS).
• Atlantic.Net announces GA of its Windows Server 2019 Datacenter Cloud Serve OS for use in its Public Cloud.
• Datica releases its new book, “Complete Cloud Compliance: How regulated companies de-risk the cloud and kickstart transformation.”

Blog Posts

• Primary care’s next high-return opportunity: Substance use disorder treatment (Advisory Board)
• Happy and Health 2019! (Agfa Healthcare)
• Five Ways You’re Already Using Machine Learning: A Day with AI (Apixio)
• Best Practices for Switching EHRs (Aprima)
• Why Is It Important to Test Backups? (Atlantic.Net)
• Get the most out of your decision support tools (Bluetree)
• ‘Twas the Night Before Clinical Surveillance (Bernoulli Health)
• 6 Top Cybersecurity Trends to Embrace in 2019 (Burwood Group)
• Informed Decisions at the Point-of-Prescribing – A Possible Solution for Medication Adherence (CoverMyMeds)
• Update from the 2nd NCQA Digital Quality Summit (Diameter Health)

Contacts

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

EPtalk by Dr. Jayne 1/3/19

I mentioned being tired from seeing patients the day after Christmas. Now that we’ve done our month-end close, I know why. We broke our own record and saw nearly 1,300 patients that day, 70-something of which were on my schedule. It truly takes a village to be able to care for that many patients and I’m grateful that my practice’s leadership believes in systems-based care and building teams so that they can run like well-oiled machines. The Centers for Disease Control lists nine states as having high flu activity and another 11 with widespread activity, so it might be a long winter.

This article in the Journal of the American Medical Informatics Association caught my eye with its title: “Cranky comments: detecting clinical decision support malfunctions through free-text override reasons.” I’ve done my share of chart reviews where providers have entered interesting comments when faced with an alert, so I was eager to read more. The authors looked at their database to identify those clinical decision support rules that had at least 10 override comments. The comments were classified into three categories based on whether the user felt the rule was “broken,” “not broken, but could be improved,” or “not broken.” They also looked at the comment frequency and a “cranky word list heuristic” to rank the rules based on the override comments.

Parsing the comments uncovered malfunctions in more than a quarter of all the active rules in the system, which was higher than expected. The authors recommend that “even for low-resource organizations, reviewing comments identified by the cranky word list heuristic may be an effective and feasible way of finding broken alerts.”

For those who are curious, representative override comments included items such as “you are stupid,” “stupid EPIC (sic) reminder,” and comments with many exclamation points. Other cranky words include: dumb; idiot; please stop; why; misfire error, epic, and wrong. The authors note that “swear words were originally included but are omitted from this list because they did not yield comments. Other organizations may wish to include them.”

I’ve heard a fair amount of chatter among physicians regarding the new rule that starting this month in which all US hospitals must publish their price lists online in a downloadable format. Nearly everyone I’ve heard from agrees that having the charges isn’t terribly helpful. What one would really need to know is the negotiated rate between the insurer and the hospital. Alternatively, knowing the hospital’s self-pay discount might be helpful.

Hospital lobbying organizations are concerned that patients might forego care if they see prices that are too high, not understanding that most services are discounted. Of course, there’s nothing stopping hospitals from publishing that data, but we’re not likely to see it soon. I poked around on the websites of the local health systems and within their patient portals but haven’t been able to find anything. I’d be interested to hear from readers who may have actually downloaded one.

On the flip side, CMS has put forward a proposal to require pharmaceutical companies to publish Medicare and Medicaid prices for drugs featured in TV ads. Physicians I’ve talked to are supportive of that idea, and many would like to see TV advertising of drugs eliminated completely. I don’t usually watch broadcast TV, but was exposed to it over the holidays at relatives’ houses. There certainly are a lot of drug ads out there and some of them aren’t even clear on what condition the drug is designed to treat or which patient population is being targeted. Print ads aren’t much better, and even some of the ads in physician trade publications are confusing.

At the beginning of every year, I do some general office housekeeping tasks, including updating my filing and accounting systems for the year and making sure all my recurring calendar appointments are in order. As I was paging through the weeks, I realized that HIMSS is just around the corner and I’m feeling like the next month is really going to be a crunch. I have some serious shoe shopping to do before then, along with breaking in any new purchases. My favorite pair of “trade show shoes” met its demise last year and finding just the right kicks to get me through hours and hours of the exhibit hall will be a challenge. Advance registration discounts end January 14, so if you’re planning to go but haven’t registered yet, you can still save a few bucks.

Working in healthcare IT has been a great way to meet people who work non-traditional hours. Some people make their employment choices based on their enjoyment of overnight shifts because it suits their personalities as “night owls.” Telemedicine and teleradiology have opened up additional options, which has led to the need for support personnel covering the physicians who are staffing those shifts.

I spent some time working at an observatory and know that I do well on the night shift, but only when I can completely tweak my schedule to support it long-term. The occasional night shift kills me. The New York Times recently ran a piece about businesses that are encouraging their employees to work at periods of maximal wakefulness as a way to boost productivity and to help avoid safety incidents due to fatigue.

The US Navy recently migrated the traditional 18-hour submarine schedule to a 24-hour one, and other companies are allowing employees to select day or night shifts based on their preferences. Working remotely can help as well. I know I’m more productive when I work in focused blocks of time outside of the office and having even a 20-minute nap in the afternoon makes a huge difference for me. That’s supported by the “window of circadian low,” which forecasts a midafternoon dip in wakefulness for most people, as mentioned in the article.

The piece mentions strategies employed by pharmaceutical manufacturer AbbVie, where employees go through a nine-hour program to identify their best times for creativity vs. low-energy tasks. Employees are encouraged to mesh their work and professional lives to harness those periods as well as to work around family commitments, leading to a dramatic increase in employee satisfaction with work-life balance. I’ve worked in several clock-punching organizations where even salaried employees were expected to put on a show of being at their desk at certain times regardless of whether they were actually doing anything productive.

Has your employer done any investigation into harnessing people’s most productive periods during the day? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 1/3/19

HL7 Publishes FHIR Release 4

Health Level Seven International publishes the FHIR Release 4 standard.

Bristol-Myers Squibb to buy Celgene in $74 billion deal

The merger, if approved by shareholders and regulators, will create the US’s fourth-largest drug company.

Jvion Secures Significant Strategic Growth Investment to Expand Application of Its Healthcare AI and Prescriptive Analytics Platform

Healthcare AI vendor Jvion raises a growth equity investment of an unstated amount, led by JMI Equity.

Machine Learning Primer for Clinicians–Part 10

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

While previous articles have described supervised ML models of regression and classification, in this article, we’re going to detect anomalies in antibiotic resistance patterns using an unsupervised ML model. 

By definition, anomalies are rare, unpredictable events, so we usually don’t have labeled samples of anomalies to train a supervised ML model. Even if we had labeled samples of anomalies, a supervised model will not be able to identify a new anomaly, one it has never seen during training. The true magic of unsupervised learning is the ML model capability to identify an anomaly never seen.

The Python code and the dataset used for this article are available here. 

Data

The data for this article is based on a subset of MIMIC3 (Multiparameter Intelligent Monitoring in Intensive Care), a de-identified, freely available ICU database, Using SQL as detailed in my book , a dataset of 25,448 antibiograms was extracted.  The initial dataset includes 140 unique microorganisms and their resistance / sensitivity to 29 antibiotics arranged in 25,400 rows:

• +1 = organism is sensitive to antibiotic
• 0 = information is not available
• -1 = organism is resistant to antibiotic

Summarizing the above table by grouping on the organisms produces a general antibiogram:

A view perpendicular to the organisms axis on the above chart becomes the projection of all the organisms and their relative sensitivity vs. resistance to all antibiotics:

The view perpendicular to the antibiotics axis becomes the projection of all the antibiotics and the relevant susceptibility of all the organisms:

The challenge is to detect an anomaly that may manifest itself as a slight change of an organism susceptibility to one antibiotic, for example, along the black dashed line in the diagram below. During testing of the ML model, we’ll gradually modify one organism susceptibility to one antibiotic and test the model on F1 score, repeatedly, at different levels of susceptibility:

Let’s focus on the most frequent organism in the data set – Staph Aureus Coag Positive (Staph). 

Staph has 6,925 samples out of 25,400 (27.2 percent of the whole dataset) and its average antibiogram in a projected 3D view:

The above chart projected on 2D and rotated 90 degrees clockwise depicts the average antibiogram of Staph:

Note that in the above diagram, zero has an additional meaning besides “information not available.” Zero may be also the result of averaging a number of sensitive with the same number of resistant samples and thus and average of zero susceptibility.

Model

• Task: unsupervised anomaly detection in antibiograms, a binary decision: normal vs. anomaly
• Experience: 25,400 antibiograms defined as normal for model training purposes
• Performance: F1 score at various degrees of anomalies applied to the average antibiogram of one organism (Staph) and one antibiotic at a time

Local Outlier Factor (LOF) is an anomaly detection algorithm introduced in 2000, which finds outliers by comparing their location with respect to a given number of neighbors (k). LOF takes a local approach to detect outliers about their neighbors, whereas other global strategies might not be the best detection for datasets that fluctuate in density.

If k = 3, then the point A in the above diagram will be considered an outlier by LOF, as it is too far from its nearest three neighbors.

A comparison of four outlier detection algorithms from scikit-learn on various anomaly detection challenges: yellow dots are inliers and blue ones are outliers, with LOF in the rightmost column below:

The LOF model is initially trained with the original antibiograms dataset, which the model will memorize as normal.

After the model was trained, we gradually modify the Staph susceptibility to: 

• Vancomycin only: from the original +0.5 to 0.4, 0.2, 0, -0.2,… -1.0
• Gentamicin only: from the original +0.8 to 0.4, 0.2, 0, -0.2,… -1.0
• Both antibiotics at the same time: 0.4, 0.2, 0, -0.2,… -1.0 sensitivity / resistance

Below is a Staph antibiogram with only 13 percent sensitive to gentamicin compared to the normal Staph antibiotic susceptibility at 83 percent for the same antibiotic:

And the same comparison as above, but with a Staph population that is 13 percent resistant to gentamicin:

Performance

The last example, Staph susceptibility to gentamicin significantly shifting from (+0.83) to (-0.13) creates a confusion matrix with the following performance metrics:

• Accuracy: 87.3 percent
• Recall: 82.6 percent
• Precision: 91.3 percent
• F1 score: 0.867

At each antibiotic sensitivity / resistance level applied as above, the model performance is measured with F1 score (the harmonic mean of precision and recall detailed in previous articles). The model performance charted over a range of Staph susceptibilities to vancomycin, gentamicin, and both antibiotics:

The more significant an anomaly of an antibiogram, the higher the F1 score of the model. An anomaly may manifest itself as a a single large change in the sensitivity of one organism to one antibiotic or as several small changes in the resistance to multiple antibiotics happening at the same time. A chart of LOF model performance over a range of anomalies can provide insights into the model capabilities at a specific F1 score. For example, at F1 = 0.75, Staph sensitivity to gentamicin declining from (+0.83) to (+0.2) will be flagged as an anomaly, but the same organism changing its vancomycin sensitivity from (+0.53) to (-0.2) will not be flagged as an anomaly. 

There are no hard coded rules in the form of “if…then…” when using an unsupervised ML model. As there are no anomalies to use as labeled samples, there is a need to synthetically create outliers for testing the model performance by modifying samples features in what (we believe) may simulate an anomaly.

In all the testing scenarios performed with the LOF model, these synthetic anomalies have always been in one direction: from an existing level of sensitivity towards a more resistant organism, as this is the direction the bacteria are developing under the evolutionary pressures of antibiotics. A microorganism developing a new sensitivity towards an antibiotic is practically unheard of, as it dooms the bacteria to commit suicide when exposed to an antibiotic to which it was previously resistant.

Unsupervised anomaly detection is a promising area of development in AI, as these ML models have shown their uncanny, magic capabilities to sift through large datasets and decide, under their own volition, what’s normal and what should be considered an anomaly.

Next Article

Basics of Computer Vision

Morning Headlines 1/2/19

Epic Systems adds dentists, life insurers to its software network

Epic’s VP of population health says the company is “moving beyond the walls” in creating a single repository for all of a patient’s electronic health records – dental, on-site clinics, drugstores, specialty clinics, and potentially home health and hospice providers.

When Doctors Serve on Company Boards

Cancer centers are responding to the perceived conflicts of interest that arise when their researchers and doctors serve on the boards of drug, lab, and medical device companies.

In Screening for Suicide Risk, Facebook Takes On Tricky Public Health Role

Facebook has deployed suicidal thoughts detection algorithms without tracking their outcomes even as the company faces global scrutiny for its privacy practices.

Malware attack disrupts delivery of L.A. Times and Tribune papers across the U.S.

Several newspapers are left unable to print editions after Tribune Publishing is taken down by an attack of Ryuk ransomware, a potent strain spread via malicious emails that was the subject of an HHS Cybersecurity Program warning in August 2018.

Morning Headlines 12/31/18

CenturyLink outage knocks out 911 calls, hospital’s patient records

A CenturyLink outage left several hospitals without Internet service Friday, also taking down phones, 911 access, and ATMs all over the country.

Cranky comments: detecting clinical decision support malfunctions through free-text override reasons

A JAMIA-published study of comments that clinicians enter when overriding clinical decision support warnings finds that the text can be mined to identify system shortcomings about 26 percent of the time.

‘Bleed Out’ Shows How Medical Errors Can Have Life-Changing Consequences

A filmmaker’s new HBO documentary covers what he says was a medical error that left his mother with permanent brain damage, for which he primarily blames Aurora West Allis Medical Center’s use of E-ICU coverage.

Stanley Black & Decker Debuts Healthcare And Security Innovations At CES 2019

The company will launch a voice-controlled, smartphone-integrated medication management and caregiver communication tool that supports independent living.

Monday Morning Update 12/31/18

Top News

A CenturyLink outage left several hospitals without Internet service Friday, also taking down phones, 911 access, and ATMs all over the country.

North Colorado Medical Center was forced to go back to paper documentation, while its parent organization Banner Health had phone problems since the outage also affected Verizon Wireless.

FCC has launched an investigation since 911 calls couldn’t get through.

Reader Comments

From Soccer Mom: “Re: hospital price lists. Will they really be posted online by January 1 per that new requirement you mentioned?” Not in a way that will make the slightest difference to healthcare costs. The “requirement” carries no punishment that I’ve seen for non-compliance, so I will predict that approximately one hospital out of 100 will comply by January 1 (it will be easy to check this week). My reaction to the administration’s toothless, well-intended, but fake healthcare price transparency PR move:

• Hospitals will at best bury an Excel version of their charge master in some obscure website location where patients can’t readily find it.
• Charge master prices are meaningless and provide zero consumer competitive shopping value.
• You as a paying health insurance holder can’t see the negotiated prices under which you will actually be billed since those companies and health systems delight in keeping that information secret, even from (maybe especially from) patients.
• Patients who suddenly start seeing stories about posted prices (even though the original requirement was announced in April) will question what the fuss was all about when they see that the information is useless, other than to raise their hackles that their big-building, high-employment hospital is charging $5 for an easily recognizable aspirin.
• Having worked in hospitals forever, I can say with certainty that hospitals intentionally make their charge masters hard to understand. I won a certain amount of admiration from an early hospital employer for being able to obfuscate the entire charge master’s descriptions so that only employees could figure the items out – we got a lot fewer patient complaints about our $10 boxes of Kleenex after the description was changed to “absorbent wipes.”

From Mike: “Re: DonorsChoose. Thanks for doing what you do (and to Mrs. HIStalk for putting-up with it). Here’s a donation. My nieces and nephews are getting used to this idea of me donating instead of buying them more stuff.” Thanks. I’m holding Mike’s DonorsChoose donation since I’m expecting fresh matching funds from my generous anonymous vendor executive (UPDATE: the extremely generous matching funds just arrived, so see below). Mrs. H was happy to see your comment, if for no other reason than because I had to leave my solitary spare bedroom – aka my HIStalk writing place – to show her your message.

From Wandering Eyeballs: “Re: the medical resident who hung himself after struggling to use the hospital’s computer system. I’d love to know what system it was.” The website of NHS University Hospitals Birmingham says they use OceanoPAS, which was recently developed specifically for the trust by Servelec. I doubt they’ll be adding this particular user experience to their marketing material, although a competitor could certainly milk it.

From Big Orange Marble: “Re: our executive hire press release. Why didn’t you list that he came from [high-profile company name omitted]?)” Because he didn’t – he took a crappy, short-lived job after leaving the impressive company but before joining yours. I report where someone worked last, not where they worked best. Your career isn’t going so well if its high point came three jobs back.

From Spittle Slinger: “Re: designing software with doctors. This article says engineers should work with them directly.” No doubt, but while acknowledging these factors:

1. Doctors and their workflows are not universal. Location, practice setting, specialty, and education all influence why every doctor thinks their way is the best way. Pleasing them all with a single product design is not possible.
2. Design isn’t the same as design validation. Ask a single doctor to design a new system and it will probably miss the mark in many ways. I’ve seen some truly awful, shortsighted, and dangerously presumption-driven software that was proudly proclaimed to have been “developed by a practicing doctor for his own use.”
3. Software sales are often scotched by deep functionality and workflows that violate an individual clinician’s reality rather than failing to embrace it. It’s safer to keep it general if you want to sell broadly.
4. What doctors say they want isn’t the same as what they would actually use. Doctors who think they are smarter than most of their peers (and that’s a lot of them) often think software needs to protect patient from their less-gifted colleagues (see: clinical decision support).
5. EHRs that doctors proclaim as unfriendly or unhelpful were often designed by doctors whose vision was limited to what was in front of them, i.e. the paper chart. You won’t get a lot of innovation asking a user what they want. Apple was at one time the boldest, most innovative company in the world because they gave people capabilities they didn’t even know they needed. Build to user spec would have given us slick-looking cassette players.
6. The best way to incorporate doctors in software design is to observe them, note their challenges and their lack of having the right information at the right time, and then go offline to come up with creative solutions. Have doctors validate the design. Doctors are good at poking holes in clearly visible, faulty assumptions and that’s the best use of their time.
7. Don’t forget that not all clinicians are doctors. A lot of clinical system use is by nurses, therapists, and other professionals and doctors are clueless about their requirements and workflows.
8. It’s easy to be lured into the idea that clinical software can be as easy and fun to use as Facebook, Twitter, or Amazon. The fact that such software is not available is not because the rest of us are missing how cool that would be, but because it won’t work.
9. Selling to health systems means meeting the needs of hospital executives who are mostly in charge. Making doctors happy is incidental.
10. A given doctor’s idea of a great work environment might be the freedom to be a sometimes-illogical cowboy who disregards everybody else’s data needs and quality oversight. Their perfect system has been around for years – a clipboard and underlings who obey tersely barked orders. Doctors weren’t the ones crying for that to change.

From Organized Chaos: “Re: HBO’s ‘Bleed Out’ documentary. It’s fascinating and frustrating on many levels, although some of the content feels unnecessary. It is being promoted as being about medical errors, which seems like an incorrect and unsatisfactory label. Still, it should remind us about the fragile, fragmented nature of healthcare system delivery.” I don’t have HBO and haven’t seen it, but “Bleed Out” — which is getting good early reviews — is a “citizen’s investigation” by a filmmaker whose mother was left with permanent brain damage after an operation that he claims went wrong. The patient lost all her life savings due to medical bills and the filmmaker sued for malpractice, so he’s not exactly an unbiased researcher. The movie PR piece cites a Hopkins estimate that medical errors kill at least 250,000 people in the US each year as the third-leading cause of death, although I worry that, like every time Joe Public sees a video and immediately renders a verdict, an N-of-one family story about a complicated care episode isn’t the best way to address the problem (but it’s good at creating a rallying cry). I’ll also note that the “third leading cause of death” conclusion of the research paper wasn’t backed by good methodology since it was mostly intended to convince CDC to use more than just ICD-10 codes on death certificates. Much of the movie’s focus is on E-ICU at Aurora West Allis Medical Center, which a now-retired surgeon labeled on-camera as “plain goddamn sloppy medicine” and which the filmmaker claims wasn’t effective because his mother’s deteriorating vital signs either weren’t noticed or weren’t reported by the remote staff. Advocate Aurora Health told employees a couple of weeks ago when the movie came out that it regrets the patient’s outcome, but noted that juries found no negligence by the hospital or doctors in the malpractice case. The movie’s tagline of “The American healthcare system just messed with the wrong filmmaker” reeks of sensationalistic propaganda instead of unbiased investigation.

HIStalk Announcements and Requests

Just over half of poll respondents who claim to work for provider organizations say their EHR vendor has refused to integrate with a system they wanted to implement from a small vendor. Frank Poggio says the big vendors know better than to refuse outright – they just give a far-off implementation date or an unrealistic price tag. Dave says Epic has never refused integration requests from his IT department, while Adam says his small vendor employer was shut down by the clinic’s large health system parent rather than Epic. People who’ve never worked in health IT often miss the nuances in play here – integration is a risky pain point for the IT department, departments that want a particular system often don’t have the clout to get it budgeted or implemented, and vendors often ignore user requests that haven’t been pushed up the health system’s C-level food chain. In other words, lack of cooperation among competing entities isn’t limited to vendors.

New poll to your right or here, reflecting further on what I would ask Epic CEO Judy Faulkner in the unlikely event that she agreed to be interviewed: what do you like reading most in an executive interview? I’ve interviewed a ton of CEOs and always strongly urge them to avoid spouting the marketing-pushed boilerplate and show some personality and humor in a genuine conversation, which works about one time in 10. I only interview CEOs since VPs play it too safe in worrying about getting themselves fired with a flip comment, but I’ve also learned from experience that consulting firm CEOs are inexplicably the hardest to bring to life, riding banality relentlessly even when I ask them provocative, off-the-wall questions.

My anonymous vendor executive replenished the very substantial fund he or she created for me to use for DonorsChoose project matching. This and other matching allowed me to fully fund these projects with Mike’s donation last week:

• Three Chromebooks and wireless mice for Ms. G’s high school science class in Panama City, FL, which was out of school for five weeks after Hurricane Michael
• Physics study materials for Ms. B’s high school engineering class in Cleveland, OH
• 12 sets of headphones for Ms. B’s elementary school class in Cass Lake, MN
• A white board for Ms. G’s high school chemistry class in Darlington, SC
• Composition notebooks for science journals for Ms. O’s middle school class in San Antonio, TX
• A wireless microphone system for Mr. H’s elementary school class in Salinas, CA
• Linear equation graphing tools for Ms. K’s elementary school class in West Peoria, IL
• Math manipulatives for Ms. M’s elementary school class in Griffin, GA
• Wobble chairs, whiteboards, lapboards, and book bins for Ms. S’s elementary school class in League City, TX

I know we all can’t wait for the serious education, demonstrated non-profit budget responsibility, and extreme patient focus of HIMSS19, so you’ll be thrilled to know that it starts in just 42 days.

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

Stanley Black & Decker launches Pria, a voice-controlled, smartphone-integrated medication management and caregiver communication tool that supports independent living.

People

Revenue cycle management firm Access Healthcare Services hires David Tassoni (Brimstone Consulting Group) as president of US operations.

Other

A JAMIA-published study of comments that clinicians enter when overriding clinical decision support warnings finds that the text can be mined to identify system shortcomings about 26 percent of the time. Interesting examples: (a) a low-potassium warning that was issued for a patient taking digoxin, caused by techs entering “hemolyzed” instead of a number in the K result; (b) a rule that didn’t identify carvedilol as a beta blocker and thus warned that one had not been ordered; and (c) a cyclosporine level warning that was triggered by an order for the ophthalmic form. I’ve written a lot of clinical decision support rules and analyzed both the override rates as well as the comments and it was always informative, even when doctors used the freeform space to lash out against the world. Here is the most important lesson I’ve learned – you have to look at how often the rule changed behavior, i.e., the problematic order was abandoned or the suggested entry or discontinuation of another order was performed as expected. That’s the only true measure of whether the doctor found the information useful. Although I had some doctors told me that they intentionally avoided immediately doing what the computer recommended just to prevent giving it the satisfaction of finding their mistake (they changed it afterward hoping our analysis wouldn’t notice their near-miss). I’ll add another item from experience – sometimes doctors think a human is reading their free-text comments in real time, as they might have with paper orders, and thus enter enter critical information such as a conditional or corollary order, expended instructions, or an order for an item they couldn’t find using the search box.

Kaiser Health News finds that hospices don’t always have staff available to meet the needs of patients, are rarely being punished for failing to respond to family calls, sometimes don’t have someone to answer questions about new drug and equipment orders, or skip skilled visits because of to understaffing. I’m really frustrated with a health system in which everybody and his brother makes fortunes off sick patients, yet the only place open after weekday business hours is the ED.

In India, Apollo Hospitals complains that the depositions of doctors that were presented to a panel investigating the hospital death of Tamil Nadu’s former chief minister (who was also an award-winning actress) contain significant court transcription errors, such as “incubation” instead of “intubation.”

The Bangor, ME newspaper profiles 68-year-old Frank Bennett, who is working through his bucket list in the five years since he was diagnosed with Lou Gehrig’s disease, apparently caused by Agent Orange exposure in Vietnam – choosing a dog, buying a Model A Ford, skydiving, taking family vacations to the Caribbean, and proposing all over again to his wife of 46 years. He’s receiving care from a ALS coordinated care program. He says,

We’re all dying, some at a different rate. I’m not afraid of dying. I fear the process. And my caregivers and family — what they have to see and go through. That bothers me the most. I want people to remember me the way I used to be.

Contacts

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

Weekender 12/28/18

Weekly News Recap

• Movie tough guy Carlos “Chuck” Norris warns against short PCP visits in which prevention topics are missing in action and doctors spend too much time entering EHR documentation.
• The New York Times predicts that Alphabet-owned DeepMind’s AlphaZero machine learning platform will facilitate science and medicine breakthroughs because it appears to learn why its solutions work rather than just applying brute force to detect and apply patterns.
• Rep. Jim Banks (R-IN), chairman of the House’s VA technology subcommittee, questions the VA’s plan to implement Cerner patient scheduling, noting the VA hasn’t said what it will cost to move to Cerner scheduling, the timelines required, and the benefit to veterans.
• New York Times Health notes that more than half of older Americans can’t understand the medical information providers give them.
• Christmas happened and not much else.

Watercooler Talk Tidbits

Readers funded the DonorsChoose teacher grant request of Ms. F in California, who asked for programmable robots for her kindergarten class. She reports, “These Bee-Bots are even more amazing than I had imagined. The kids LOVE using the Bee-Bots and have learned so much. We began with using the Bee-Bots at centers to help us identify letters, and then beginning letter sounds, then we were able to build CVC words with the Bee-Bots. We are currently learning about shapes and the Bee-Bots have been helping us to do that. The Bee-Bots have been a great introduction to coding/computer science! Thank you for your support!”

The Wall Street Journal describes how primary care doctors who are employed by health systems are pushed hard to avoid sending lucrative referrals outside the system.

A small Columbus, OH church that refused to sell its property to Nationwide Children’s Hospital finds itself dwarfed by a $50 million, six-story parking garage that is part of the hospital’s $730 million expansion.

A four-year-old girl who has spent her entire life in Ranken Jordan Pediatric Bridge Hospital (MO) after being born prematurely goes home for the first time. It’s a feel-good story as long as you don’t think about the cost and who pays.

University of Iowa Hospitals and Clinics holds a retirement party for 13-year-old top caregiver Maggie, a shelter dog who has for the past eight years snuggled with ill patients in the hospital’s Furry Friends program. In related news, Finn the therapy greyhound, a former racing dog who graduated from a training program run by prison inmates, is among the 16 therapy dogs that spend time with patients of Riley Hospital for Children (IN).

In Case You Missed It

• News 12/28/18
• EPtalk by Dr. Jayne 12/27/18
• Monday Morning Update 12/24/18

Get Involved

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

Morning Headlines 12/28/18

Livongo Focuses on Government and Labor Segment with Proven Executive

Former Livongo sales executive Randy Forman returns to head up the company’s government and labor division following an eight-month stint at Vida Health.

Can medical devices be hacked? Arizona doctors prepare for possibility of cyberattacks

University of Arizona College of Medicine – Phoenix convenes CyberMed Summit, led by two ethical hackers who are graduates of the medical school.

After nearly five years lawsuit against Flowers Hospital is over

The Alabama hospital sets aside $150,000 to cover claims that a since-jailed lab employee sold 1,200 patient records for filing fraudulent tax returns.

Hospital prices: full cost lists must be published from January 1, new federal rule says

A rule announced in April requires hospitals to post “what they have online” in the form of annually updated, downloadable price lists.

News 12/28/18

Top News

Cinematic butt-kicker Chuck Norris, who is a shocking 78 years old, talks about physician burnout in his monthly health column.

He says PCPs have only an ever-shortening 7-22 minutes to spend with each patient, meaning that health and lifestyle counseling get pushed aside.

Chuck also notes that insurance company and government requirements force doctors to spend half their time documenting in the EHR as “medical clerks.”

In an unrelated item suitable for a slow news day, Chuck’s real name is Carlos.

Reader Comments

From Carbon Dating App: “Re: BS in healthcare. Check out Wharton School’s list.” The Ivy League school’s tongue-in-cheek report bluntly labels as BS many recent healthcare examples of “deceptive, misleading, unsubstantiated, and foolish statements,” even including medical literature in which a self-appointed expert considers only a single theory in performing studies that cannot be replicated. The authors cite a major BS problem in trying to improve healthcare quality while reducing costs, in which programs are launched based entirely on political appeal and the optimistic idea that their skimpy details can be refined on the fly. The article includes a BS Checklist Manifesto to identify these major forms:

1. Top-down solutions in which C-level executives come up with visionary ideas and then move on to the next shiny object as their underlings are forced to try to implement complex change without their involvement.
2. Consulting firms that pitch one-size-fits-all solutions for healthcare that have saturated the market in other industries and thus require fresh sales.
3. Silver bullet solutions with little evidence to back them up, such as EHRs and care coordination, that make incrementalism seem meek in comparison.
4. Following self-appointed gurus such as Don Berwick, Michael Porter, or Michael Hammer, with programs such as the Triple Aim receiving widespread endorsement even though nobody can define the numerator, denominator, or desirable ratio and people continue to confuse ”health” with “healthcare.”
5. The faddish idea of disruption, which has never really taken off in healthcare, partly because consumers don’t like the idea of healthcare change and neither do the companies and people making fortunes from it.
6. Stage-based models (of which Meaningful Use is an example) that support models that are often simplistic or wrong.
7. Excel-driven assumptions that prove wildly incorrect over the long term, such as the prediction that Medicare would cost $12 billion by 1990 instead of the actual $110 billion or that ACOs would save big money.
8. Fashionable bandwagons, such as hospital mergers and vertical integration that don’t improve performance, as health systems “get the bug that has infected your competitor.”
9. The idea that best practices such as those of Cleveland Clinic and Mayo Clinic will work for everyone else as consultants claim.
10. Buzzwords such as “scale,” “synergy,” “population health,” and the worst offenders of three-letter acronyms such as ACO and EHR.

From Academic Health System CIO: “Re: HIStalk. I am a long-time reader and appreciate your very reasonable list of questions to Judy Faulkner and balanced comments about the New York Times article. Thanks for the site, the balance of topics, and approach to the field.“ Thanks. The most fascinating aspect of the Epic story involves the company’s culture and its ability to identify and train bright new college graduates to function effectively in healthcare technology. I can’t imagine any other industry in which a 24-year-old employee with no relevant non-Epic work experience can command the attention of highly experienced health system clinicians and executives and actually get them to complete a painful project as defined by agreed-on metrics. I can assure you that is almost unheard of, as most significant health system endeavors devolve into endless debates and deflected responsibility (everybody is empowered to say no, but nobody can say yes). I would also love to know more about architecture and technology deployment – when’s the last time you heard of an Epic site going down due to Epic’s software (rather than hardware, network, or remote access middleware)? Most of us in the industry have never attended UGM and the company’s close-to-the-vest culture means we don’t really know how Epic works or how its success might be replicated, which I suppose is a good thing from Epic’s perspective but bad for those of who want to understand the legacy of what Judy built. 

From Split Pea: “Re: big data. What do you think of this article?” Van Halen’s concert rider required promoters to provide dressing room M&Ms with the brown ones removed, not because they were self-entitled prisses (which they were, but still …), but so they could assess the likelihood that the promoter had read the agreement carefully and followed through on their commitments. Likewise, when I see that a paid author can’t spell the possessive “its” correctly, I assume their abilities are limited and I stop reading. I also avoid Facebook because it’s depressing to see so many comments that sound like they were written by an angry, bitter six-year-old. We might have been better off as a pre-social media society when you had to earn the ability to influence by first passing the scrutiny of a responsible editor or event organizer.

From Mister Bittermuch: “Re: HIPAA. I planned to use the light week to catch up on risk assessment work, but with the lapse in government funding, the NIST regulatory resources supporting HIPAA are unavailable. Maybe HHS will, as it has for recent disasters, issue a temporary emergency guidance suspending HIPAA because we can’t get to the necessary resource material (just kidding). Google and file reposting will keep us secure.” The positive aspect of having a dysfunctional government is that things can’t get much worse in its absence.

HIStalk Announcements and Requests

I rarely use the term “it will change your life” in describing a technology purchase, but I’m happy to say that Mrs. HIStalk’s brilliant Christmas gift to me of a Sonos Play:1 speaker will do exactly that for just $149. The 5x5x6 inch, four-pound speaker connects over WiFi to your mobile device using the Sonos app, which you then use to tune the Play:1 in a couple of minutes by walking around the room with your phone or tablet. The sound is incredibly powerful and rich and the app integrates your streaming music choices (Spotify premium, Pandora, and TuneIn Radio in my case) into a single user interface from which you can choose individual Spotify tracks or playlists, a Pandora station (like jazz for dinnertime or hair band screaming for household chores), or live radio from all over the country. The app works over WiFi rather than via Bluetooth or infrared, so you can control everything from anywhere as long as you’re on the same WiFi. She gave one to a relative as well and has already ordered a second one so they can use them as wireless surround sound rear speakers, while we’re getting a second one for ourselves so we can cover the whole house with music (either the same or different sources). It sounds and works a lot better than old-school speakers-in-the-ceiling home audio and is actually fun to set up in just a couple of minutes, not to mention that you can just unplug the power cord, move it to another room, and plug it back in to get back to the music. I’m pretty sure it has plenty of kick for a patio or back yard gathering, too. Meanwhile, I got Mrs. H an Apple Watch (the Series 3, which was a steal on Black Friday and offers nearly every benefit of the Series 4) and she’s trying to figure out how to incorporate it into her lifestyle beyond the obvious fitness tracking 

It’s a slow holiday time until after New Year’s Day, but even so, two companies have signed up as new HIStalk Platinum sponsors in the past week, obviously using their quieter time to reflect on their need to bolster their expensive HIMSS presence with a timely announcement, not to mention exposure that lasts a full year instead of three days and that reaches decision-makers rather than just booth booty seekers. Thanks for the support.

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.

Sales

• FirstCare Health Plans will offer a virtual care program powered by MDLive.

Other

Odd: a study of 400,000 ICU patients in the UK finds that short men die at a higher rate than tall ones. The author has no idea what this means or what ICUs should do differently (if anything), but speculate that maybe it’s related to incorrectly sized equipment or erroneous drug dosing, providing this unhelpful advice: “The message from this research is for doctors to be more aware of people’s height.” I’ll also say that I’ve seen a few cases in which critical drugs were incorrectly dosed by doctors who failed to take into account a patient’s missing extremity due to amputation or birth defect.

A study finds that the vision of students in Japan is the worst it has ever been, which the government says is due to excessive time spent staring at smartphones and mobile games.

In India, a patient’s three sons trash the ICU and beat up security guards after she dies of lung disease. One of them says her treatments were performed incorrectly, the hospital pressed them to pay her bill every day, and employees as well as doctors demanded cash bribes to check on her.

Sponsor Updates

More than 1,000 Meditech employees in its Georgia, Massachusetts, and Minnesota offices participated in the company’s Holiday Giving program to help 60 underprivileged families.

First Databank employees volunteered at the South San Francisco Holiday Toy and Food Drive.

Definitive Healthcare and its employees donated $100,000 in cash and and hundreds of volunteer hours to 30 charities in its home state of Massachusetts in 2018.

Contacts

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

EPtalk by Dr. Jayne 12/27/18

The holidays tend to bring out the best (or the worst) in people, depending on whether you work in the customer service sector and how harried your clientele might be. Healthcare has become less of a vocation and more of a transactional situation, where the customer is always right and ratings drive salaries as much or more than clinical outcomes might.

Our urgent care practice is open 365 days per year, although some of the locations close on Thanksgiving, Christmas, and New Year’s Day if they’re within five miles of another site that is open. We used to have every location open on those holidays, but it wasn’t an employee satisfier and closing a portion of the locations made a huge difference for our teams and their families. For those who do work on the holidays, we have catered meals delivered the day before so that staff can at least reheat something for lunch or dinner that might be marginally more interesting than a brown-bag from home.

My holiday rotation put me on Black Friday this year and also the day after Christmas. I knew I was in for a wild ride this morning when there were 10 people waiting outside my door before I even arrived. The situation must have been even worse at other locations, because my scribe was immediately redeployed to another site to work as a patient care tech and another tech was pulled to a third location. Several of our sites broke the records for most patient visits in a day.

I’m always glad that we’re there to help patients, but the unpredictability of surge volumes can wear out a staff pretty quickly. We had some patients who weren’t happy about the wait time and a couple who stormed out of the office because of it. Those are always difficult situations and the team took them in stride, although it always leaves a lump in your stomach when you know someone was unhappy.

The holidays also brought out some examples of the challenges we face in trying to coordinate care based on the way that healthcare is financed in the US. I saw one gentleman who had a work-related injury that occurred last Saturday. He wasn’t able to be seen because we have a worker’s compensation contract with his company and no one was there to authorize the visit. The practice couldn’t see him on his personal health insurance because he had already declared it to be work related and it would therefore be denied.

He wasn’t willing to pay out of pocket, so he went back to work. He couldn’t reach anyone in the authorization department on Sunday or Monday and the office was closed on Tuesday, so today was the first day he could be seen. Although he had tried to treat himself the best way he could, I suspect that he’s going to have a poor outcome because appropriate care was delayed.

I had a patient who required some specific follow up and I wanted to contact his physician through the after-hours exchange. Usually to accomplish this I ask a staffer to call the practice, listen to the after-hours message and get the exchange number, then have them put out a page for the physician to call my cell phone. It can take an hour or more for this process to happen, and in today’s care coordination non-event, it didn’t happen at all.

When my assistant called the practice, they hadn’t switched their phone system over from the usual “we are unable to take your call” message to the “we’re closed, please call the exchange at the following number” message. There was no voice mail available and the patient said he had driven past the office and found it closed. Without an exchange number, we weren’t able to reach his physician or another covering provider.

I had flashbacks from my days as a solo physician when I was the person who had to make sure the phones were switched over. I would call the office before I left to confirm it worked. I sent a task in the EHR to have tomorrow’s team try to do the follow up, but I’m sure that physician’s office is going to be slammed with calls tomorrow and I don’t envy my colleague in trying to take care of it.

We also had a patient come in late in the evening for a preoperative clearance visit, only to find out that her surgery was scheduled for the morning. Good thing that all of her labs were normal and her medical history didn’t have any concerning elements or that surgeon would have had a surprise on his schedule tomorrow. His office was working today, however, because they had called the patient and let her know that they hadn’t received her labs and x-rays, which prompted her visit to us.

We did see some genuine emergencies, including a patient who fell carrying a glass ornament that caused a fairly serious laceration when it broke and a patient with dehydration due to foodborne illness. We also saw some self-inflicted damage, including someone who was seriously ill after trying to “cleanse toxins” with a recipe she saw on the Internet. What she did was to partially cleanse her body of electrolytes, which we were happy to replete. Another gentleman had a raging fever, shaking chills, and poor oxygenation after failing to adequately treat his bacterial pneumonia with a vitamin B12 infusion given at a local spa.

We had two family members who were waiting with patients and decided to be seen “while we’re here.” They didn’t have urgent issues, but figured that since they were waiting already, why not? Neither of them had tried any over the counter or home remedies and both had minor problems that could have been treated for less than $10 at the drugstore. Convenience is king, however, and they both left with prescriptions so that insurance would cover it rather than spending the money out of pocket. They’ll also generate multi-hundred dollar urgent care bills.

It’s moments like that which become a bit depressing, when you are silently screaming that there is a patient in the room next door with an ornament shard stuck in their body, and instead of dealing with it, you’re writing scripts for athlete’s foot and cold sores. We also had patients themselves adding on medical problems after check-in, including one who wanted refills on all her maintenance medications while she was there for an ice-skating related fracture. The reason: “My doctor went on vacation the week before Christmas and never responded to the refill request.”

I felt sad for the nonagenarian who hasn’t felt good in a decade and whose chief complaint was, “I used to climb 14,000- foot mountains and now I’ve felt crummy for a couple of years” and who was brought in by his daughter. There’s not a lot we can do about that at the urgent care other than to offer sympathy, rule out any life-threatening issues, and arrange follow up care. I was grateful for the occasional strep throat visit or sinus infection and even the fractures since they didn’t involve family disharmony or complex psychosocial issues. I’m privileged to have elders in my own family who are generally in good health, and based on what I see at work, I don’t take it for granted.

There’s virtually no consulting work between Christmas and New Year’s, so I’ll be back in the trenches again tomorrow and then over the weekend. Let’s hope for primary care docs who have their phones set up, offices that are open, and sidewalks that aren’t slippery. My New Year’s wish is that the folks who concocted the influenza vaccine nailed it and that everyone has a happy and safe 2019.

Email Dr. Jayne.

Morning Headlines 12/27/18

One Giant Step for a Chess-Playing Machine

The New York Times describes Alphabet-owned DeepMind’s AlphaZero machine learning algorithm that not only became unbeatable in chess, it also appears to have used psychology to actually learn the game rather than choosing from pre-programmed moves, which may lead to development of novel solutions in science and medicine.

Misconceptions About Health Costs When You’re Older

End-of-life spending is often declared wasteful after the fact, but predicting who is likely to die to save the cost of heroic intervention isn’t accurate.

Massachusetts Stroke Patient Receives ‘Outrageous’ $474,725 Medical Flight Bill

A woman whose doctor and insurer agreed that her stroke symptoms required emergency transportation via private air ambulance to Massachusetts General Hospital, an hour’s drive away, is shocked to learn that she’s on the hook to pay the nearly $500,000 portion of the bill that isn’t covered by insurance.

Humana Announces Inaugural Hospital Incentive Program Participants

Cleveland Clinic, Jackson Health System, TriHealth, and WellStar Health System will participate in Humana’s coordinated care program that emphasizes access to screening, avoiding health complications, using analytics to coordinate care, and paying doctors based on outcomes rather than volume.

Morning Headlines 12/24/18

Banks Asks VA to Adopt Modern Appointment Scheduling System

Rep. Jim Banks (R-IN), chairman of the House’s VA technology subcommittee, questions the VA’s plan to implement Cerner patient scheduling, noting the VA hasn’t said what it will cost to move to Cerner scheduling, the timelines required, and the benefit to veterans.

BayCare Hospitals Go Mobile with Wayfinding

BayCare (FL) goes live on indoor patient way-finding powered by Connexient’s MediNav.

With incubators, hospital systems tread ethical boundaries

Politico points out the ethically shaky ground hospitals find themselves on when developing sometimes sub-par technology through on-site incubators, often as a means to firm up finances.

Monday Morning Update 12/24/18

Top News

Rep. Jim Banks (R-IN), chairman of the House’s VA technology subcommittee, questions the VA’s plan to implement Cerner patient scheduling, noting:

• The VA’s Epic Cadence pilot under the MASS contract worth up to $624 million has been successful even though VA leaders keep stopping and restarting the project, decided at one point that the VA didn’t need resource-based scheduling, and then said that a VistA scheduling enhancement (VSE) would suffice.
• The Epic implementation would be nearly finished if the VA hadn’t slowed the project down, which made VSE look favorable.
• The VA hasn’t said what it will cost to move to Cerner scheduling, the timelines required, and the benefit to veterans.
• The VA should consider using FHIR to connect Cerner to Epic scheduling.

Reader Comments

From Archie Tech: “Re: NYT’s Epic piece. Didn’t really get into the gist of the company’s success.” Epic’s campus is cool, but writers tend to fawn over the architecture and bucolic location to the exclusion of finding out more relevant facts about the company, possibly because Judy doesn’t really want to be interviewed at all, much less about the secrets of Epic’s success. I worry that her PR recalcitrance is depriving the industry of the chance to understand how, against all odds, a nerdy, introverted computer science professor created a mammoth tech company in an unlikely location by breaking every rule in the book. Writers who have earned a rare, brief audience with her invariably ask dopey, fawning questions whose answers don’t provide much insight.

From Amish Avenger: “Re: Centra Health’s first loss in a decade, blamed on unexpected Cerner costs and hiring hundreds of trainers. So they planned to install a new EHR + rev cycle system across an entire health system and didn’t anticipate a need to train people? There must be more of a story here. Did Centra believe that Cerner would train everyone or that a new EHR would be as intuitive as a cell phone?” Centra spent double the $33 million it expected for implementing Cerner this year, then was hit after its September 1 go-live with lower productivity that reduced net revenue by 10 percent. It “unexpectedly” hired 400 consultants for two months to help with the go-live. The health system had other revenue-impacting problems (a nursing shortage, executive turnover, and reduced payments) that might have been conveniently blamed on Cerner, but surprise costs for training suggests that the health system either missed something or got bad advice. I think they were replacing a hodgepodge of systems that included McKesson and Allscripts.

From Silicon Valley Geek: “Re: Health 2.0 API survey. It’s got a lot of great data despite all the Epic bashing. I’m a big fan of your astute and objective survey credibility analysis. I’ve love to know if you see methodology flaws or red flags in this one.” My observations on the survey, which was apparently targeted to unnamed and undefined “small health tech vendors”:

• Only 64 respondents completed the survey, but it was not stated how those respondents were chosen, whether multiple respondents work for the same vendor employer or what jobs they hold, or what defines a “small health tech vendor.”
• I’m not sure that all small health tech vendors are created equal in terms of expertise, market success, information they need or provide, or their product’s competitive position with EHR vendors.
• The responses aren’t too surprising and pass the common sense test, but the premise of asking small vendors if the big ones are holding them back incorporates inherent bias.
• The poll’s bottom line is that EHR vendors are improving in allowing API and other access to their systems, but pricing (especially app store) remains an issue, Athenahealth and Allscripts are easiest to work with while Epic trails the pack, and small vendors are worried that big ones are trying to steal their intellectual property.
• The poll also raises the question of whether health system EHR customers contribute to the problem by their lack of interest in working with small vendors.
• Perhaps more insight could have been gleaned by asking health systems which systems they want to use from small vendors and whether their EHR vendor has said yes or no to integrating with them. It’s easy for a startup to blame EHR vendors for their own lack of market success, but I don’t hear health systems complaining that their EHR vendors won’t support the integration those health systems need. The “one throat to choke” health system business imperative, along with ridiculously long and imitative procurement processes, are perhaps most responsible for small-vendor market challenges rather than their involuntary reliance on other vendors.

From Spikes High: “Re: doctor EHR complaints. We need to catalog them for the public good.” It wouldn’t be all that useful given the variables involved:

• The doctor’s background and experience with competing products is always going to drive their perceptions. Complaints about a particular EHR may in fact be complaints about all EHRs.
• Much of what a physician sees and is required to do is defined by their employer, the patient’s insurer, government regulations, or malpractice requirements, not the EHR vendor.
• Complaints about usability can be caused by poor training or lack of experience rather than the product itself.
• Doctors sometimes unrealistically expect off-the-shelf EHRs to mimic their own highly individualized workflows or specialty-specific preferences.
• The all-over-the-place complaints about a particular product mean any problems aren’t black and white, and every vendor has clients who happily use its systems.
• The benefits of an EHR don’t necessarily accrue to those who are forced to use it and thus dissatisfaction is inevitable. Complaints about EHR productivity loss, mandatory data entry, or unwelcome administrative oversight could easily be made about unwelcome paper processes as well. Doctors struggle with the idea that they’ve willingly given up their autonomy to self-enriching businesspeople armed with EHRs and an indifference to their factory workers, including those who wear white coats.
• Here’s how to tell what parts of the EHR doctors find useful. Survey solo concierge practitioners who pay for systems out of their own pockets and who use only the functionality they need to achieve good outcomes and productivity. Mine is implementing Elation EHR, he told me last week, and he practically spat on the ground when describing his previous job working for a hospital that mandated Epic (but mostly because he didn’t like working for a hospital whose executives were making millions while reducing his income).

HIStalk Announcements and Requests

A reader who wishes to remain anonymous made a generous donation to my DonorsChoose project, asking that I choose elementary and middle school STEM projects. Those are my favorite as well because we’re losing ground globally in STEM and I think it’s important to generate interest in younger students. This donation, along with matching funds, fully funded these teacher grant requests:

• Science and weather learning activity sets for Ms. C’s elementary school class in Shepherd, TX
• Math manipulatives for Ms. A’s pre-kindergarten class in Washington, DC
• Hands-on science kits for Ms. D’s elementary school class in Kansas City, MO
• A Chromebook for STEAM studies for Ms. G’s elementary school class in Bronx, NY
• STEM creative materials for Ms. K’s middle school class in Bridgeport, CT
• An interactive quiz gaming system for Ms. K’s elementary school class in Milwaukee, WI
• STEM creative building toys for Ms. B’s pre-kindergarten class in Washington, DC

Ms. B responded quickly in emailing, “My students are truly going to feel like January is gift-opening time all over again!”

Poll respondents communicate with their PCP by sending patient portal messages (which was surprising to me as by far the #1 answer), filling out online forms, and visiting the office to obtain or deliver paper forms. Almost unheard of are texting, using electronic signature such as DocuSign to complete forms electronically, and (thankfully) faxing. Selection Bias correctly notes that my readers may not be representative. Two readers love communicating by portal and one just calls the office.

New poll to your right or here, for provider IT folks – has your EHR vendor refused your request to integrate with a small vendor’s system? Vote and then explain what you asked for and how your EHR vendor responded.

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.

Sales

• Community Regional Medical Center (CA) chooses Phynd for provider enrollment, management, and reporting, to be integrated with Epic.

People

Tenet Healthcare hires Christopher Walden, RN, MHA (Health First) as VP/east region client services leader.

Announcements and Implementations

BayCare (FL) goes live on indoor patient way-finding powered by Connexient’s MediNav. The hospital’s visitor app includes detailed floor maps, department and clinic locations, real-time location, points of interest, and driving and parking directions.

Other

A New York Times health article says that more than half of older Americans – the population in whom medical care is most complex — can’t understand medical information such as the purpose and interpretation of a particular test, weight graphs, and insurance coverage. It recommends that providers stop using abbreviations with patients, make forms and instructions more easily understood, and communicate more clearly while encouraging patient questions. Commenters also blamed provider reluctance to write things down instead of just reciting them orally, assigning non-clinical employees to respond to emailed patient questions, and the economic reality of short appointments and lack of follow-up that cause patient misunderstandings or questions to be missed. One reader’s insightful comment urged that patients be given the NNT (number needed to treat, which is the number of patients who would have to be treated with a given drug to prevent one bad outcome) and NNH (number needed to harm, the number of patients who take a drug before one of them is harmed). Informaticists, what say you on the NNT/NNH issue?

In England, a medical resident hangs himself in his first week on the job after struggling to use the hospital’s computer system. If that’s not bad enough of a computer testimonial, (a) his body wasn’t found for two days because of a scheduling mix-up; and (b)hospital employees told his frantic parents to call the police instead of them because they couldn’t find him in their computer — it turns out that his name had been entered incorrectly.

Inc. lists 10 words and phrases used in business that really need to go away (I wasn’t convinced until I saw “curate,” which ranks near the top of my list of perfectly good words that have been ruined by idiots trying to make “making a list” seem impressive):

• Digital transformation
• Disruption
• Synergy
• Crushing it
• Superstar
• Curate
• Girl boss
• Open the kimono
• Move the needle
• Reach out

A reader forwarded a link to Episode 1 of “Chiefs in Carts Getting Coffee,” in which Arkansas Children’s Hospital SVP/CIO Jon Goldberg interviews EVP/COO Chanda Chacon while riding in a golf cart (“I think she’ll appreciate the subtleness of this blue, boxy beast.”) Goldberg also sends a “Fone Free Friday” message to the entire organization every week that has developed a cult following.

Sponsor Updates

• Pivot Point Consulting’s Seattle team wraps presents for the Forgotten Children’s Fund.
• OpenText completes its acquisition of Liaison Technologies.
• Lightbeam Health Solutions publishes a new case study, “The South Bend Clinic: Using Analytics to Thrive Under Value-Based Contracts.”
• The local paper covers LogicStream’s app to prep hospitals for drug shortages.
• More providers sign on for Meditech Expanse in 2018.
• NextGate announces a milestone year with significant market growth and achievements.
• NVoq publishes a new Meditech use case featuring Alliance Community Hospital.
• PatientPing publishes a coordinated care success story featuring Houston Methodist.
• The “Winning in Health” podcast features Sansoro Health CEO Jeremy Pierotti.
• ZappRx will work with global biopharma company Genentech on idiopathic pulmonary fibrosis, allergic asthma, and chronic idiopathic urticaria.
• Zen Healthcare IT welcomes Guardian Health Service to its interoperability community.
• ZeOmega achieves NCQA PHM Prevalidation for its Jiva PHM platform.

Blog Posts

• Gift Guide for the Data-Focused Enterprise (Liaison Technologies)
• 3 Key Principles to Prevent Nurse Burnout (LiveProcess)
• Meditech celebrates 50 years of bold innovation (Meditech)
• A Personal Journey to Recovery (Netsmart)
• Nordic gives back 2018: A roundup of causes to consider supporting (Nordic)
• 5 Predictions for Healthcare and Health Outcomes in 2019 (PatientBond)
• Two Machine Learning Models Your Revenue Cycle Should Experiment With (Patientco)
• How to make health IT the ally (vs. the enemy) of physicians (PatientKeeper)
• “Advocate First” Case Manager Expands Services at Home Health Agency (PreparedHealth)
• 2019: The Year of AI Operationalization in Healthcare (Qventus)
• What makes healthcare integration so complex? (Redox)
• Top Four Mistakes Hospitals Make When Capturing Data for Medicare Reimbursement (TransUnion)
• Clinical communication is the foundation of quality care. (Voalte)
• 5 Easy Steps to Create High-Quality Videos for Your Practice (WebPT)

Contacts

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

Weekender 12/21/18

Weekly News Recap

• The VA considers terminating its patient scheduling contract with Epic and Leidos in favor of buying a similar system from Cerner.
• 3M will acquire MModal’s physician documentation technology business for $1 billion.
• Epic’s 75-year-old CEO Judy Faulkner tells The New York Times that she will probably never retire, but has instructed shareholders that when they choose a new CEO, they should replace her with an Epic software developer.
• GE firms up plans to spin off its healthcare business via an IPO.
• Teladoc’s COO/CFO resigns over an incident in which he shared stock trading tips with a Teladoc employee with whom he was having an affair.
• Livongo hires former Cerner President Zane Burke as CEO.
• HHS OCR issues an RFI for help reviewing how HIPAA impacts data sharing, how long it takes for patients to get copies of their own medical information, and how often providers refuse to share PHI for treatment purposes.
• Change Healthcare acquires the API and blockchain assets of interoperability vendor PokitDok.
• FDA names Flatiron Health Chief Medical Officer Amy Abernethy, MD, PhD as principal deputy commissioner.
• A federal judge in Texas rules that the Affordable Care Act is unconstitutional.

Watercooler Talk Tidbits

Reader donations provided the first-grade class of Ms. L in Indiana with math games and activity centers by funding her DonorsChoose teacher grant request. She reports, “My students love getting to play with and use math tools at home. Families particularly like the games so that they are getting to learn and practice with their child during the week as well! Thank you so much for your generosity and helping my students be able to gain confidence in math and get more practice at home!”

Donations from Deborah and Vicki this week, supplemented by generous matching money, fully funded these DonorsChoose requests:

• A wireless color printer for Ms. P’s second grade class in Morehead City, NC (impacted by Hurricane Florence)
• Makerspace technology for Ms. B’s high school library in Houston, TX
• Five laptops for Ms. H’s second grade class in Havelock, NC (her class was out for 5.5 weeks due to Hurricane Florence)
• Four tablets and cases for Ms. S’s third grade class in Fresno, TX
• Art supplies for Ms. W’s healthcare STEM high school class in Conway, SC (her school was impacted by both Hurricane Florence and Hurricane Matthew)
• A molecular modeling set for Ms. G’s fifth grade school class in Tracy, CA (she is a first-year teacher)
• LEGO bricks for Ms. W’s elementary school class in Balch Springs, TX 

A reader tells me that industry long-timer and friend of HIStalk Ford Phillips of River Bend Marketing passed away this week in Cape Girardeau, MO at 73.

Customer service reps for consumer DNA testing companies are finding themselves in the awkward position of shocking customers with news that their sibling doesn’t share the same parents, that their child was fathered by someone else, or that their DNA matches that of a previously unknown family member. Ancestry.com prepares employees with a months-long training program that includes role-playing and empathy.

A woman settles for $1 million her lawsuit against a plastic surgeon who she claims implanted an unapproved breast reconstruction device that injured her, then falsified her paper medical records to make it look as though she had approved. The doctor had been paid nearly $500,000 over five years by the device’s manufacturer and owns company stock.

Researchers analyze Sweden’s national cardiac patient database to find that while heart attacks happen more often in early mornings and on Mondays, the year’s peak happens at 10 p.m. on Christmas Eve. The study, along with others, finds that heart attack incidence rises during the week between Christmas and New Year’s Day, perhaps due to the stress caused by money issues, family gatherings, and increased consumption of food and alcohol.

Cigarette maker Altria will pay $13 billion in cash for a 35 percent state in vaping vendor Juul, valuing the three-year-old company at $40 billion. $2 billion of the sales price will go to Juul’s 1,500 employees as bonuses (that’s $1.3 million each, although individual payouts will be based on years of service and shares owned). Juul, which had vowed to make cigarettes obsolete, will benefit from Altria’s legal and marketing muscle as it tries to avoid FDA crackdowns on what some experts say is the top public health crisis in teens. Altria is also diversifying its declining tobacco business by making investments in cannabis and beer manufacturers.

Former President Barack Obama visits Children’s National hospital to sing Christmas songs and give gifts to children. He also thanked employees for working over the holidays.

In Nigeria, a financial consultant regularly visits a government hospital in Lagos to pay the bills of patients who have been discharged, but who aren’t allowed to go home until their bill is paid. Only 5 percent of the country’s residents have health insurance and hospitals sometimes even hold the bodies of deceased patients until relatives pay their bill. The man doesn’t want publicity or thanks for what he calls The Angel Project, where he advocates that “you be the angel you hope to meet.”

In Case You Missed It

• News 12/21/18
• EPtalk by Dr. Jayne 12/20/18
• Machine Learning Primer for Clinicians–Part 9
• News 12/19/18
• Curbside Consult with Dr. Jayne 12/17/18
• HIStalk Interviews Kevin MacDonald, CEO, Kit Check
• Monday Morning Update 12/17/18

Get Involved

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

Morning Headlines 12/21/18

DrChrono Raises $10M from SQN Venture Partners

Tablet-based EHR vendor DrChrono raises $10 million in funding.

Cerner could snag another big VA contract

The VA is considering terminating its $624 million Epic-Leidos patient scheduling system pilot project and buying a similar system from Cerner.

Medicare Program: Accrediting Organizations Conflict of Interest and Consulting Services; Request for Information

CMS issues an RFI asking for feedback on whether or not the consulting practices of hospital accreditation agencies like The Joint Commission pose a conflict of interest.

This Health Startup Won Big Government Deals—But Inside, Doctors Flagged Problems

An exposé on Babylon Health finds that, despite raising $85 million and convincing the NHS to use its chatbot-powered diagnosis app, its software wasn’t tested anywhere else and didn’t work.