Curbside Consult with Dr. Jayne 1/8/18

I read with interest the news item last week about the Vermont Health Information Exchange. While that state’s exchange is under the microscope for issues with spending and data quality, there are plenty of other HIEs out there that are struggling with being useful at the point of care. Since my work spans multiple states, I’m able to see what is available to clinicians and how well it integrates with clinical workflows. There are variables whether the exchange is truly an exchange – namely whether data can be pushed or pulled or whether it’s little more than a view-only repository.

In the Vermont situation, 91 percent of interviewed stakeholders think that the state needs an HIE, but only 19 percent of interviewees feel that it is meeting their needs. One of the major barriers cited is Vermont’s opt-in policy, which limits the number of patients whose data is present for sharing. At this point, only about 20 percent of patients have opted in.

I had my own adventure with opt-in in my early days as a CMIO, when we created a private HIE to share data among physicians affiliated with our hospital. Although there wasn’t a specific state law that forced us to be opt-in, there were case law citations that prevented us from assuming all patients gave us permission to share data. We were able to maneuver through it over time by having all participating practices add language to their new patient consent forms that permitted sharing through the HIE. The practices also had to go back and have new consents executed for existing patients, and that took time.

Our vendor was subsidizing the interfaces because we were a beta client for their new HIE platform. Our hospital was picking up the rest of the tab, so there was no cost to the community physicians. My staff and I did countless road shows trying to convince physicians that this was a good thing to be part of, but at the same time, our CIO spent a lot of time trying to kill it simply because it wasn’t his idea and it was being executed by clinical leadership rather than IT leadership.

We ended up being live for quite a few years until our state HIE began to take shape. In all, it was an exciting time, but very different from the environment we’re in now, where interoperability is at least a little bit easier.

Despite having been live for several years, my own state HIE still struggles. It doesn’t communicate with our state immunization registry, which reduces its utility for primary care and urgent care physicians. All the immunizations sent to the HIE are strictly added as read-only data element, and there is no mechanism for resolution of duplicates or for reconciling with the immunization registry. A physician looking to validate immunizations on the HIE also has to go to the registry, and since the registry actually functions as a source of truth, why not just go there in the first place?

Our HIE doesn’t store any diagnostic imaging, only PDF report documents. Sometimes these are useful when an existing finding is well described and can help serve as a comparison, but there are entirely too many radiology reports out there with “clinical correlation recommended,” which means the reading radiologist isn’t going to stick his or her neck out by providing a specific diagnosis. When we find unusual things on an x-ray or CT, we’re hard-pressed to understand whether they’ve changed from previous. Instead of being able to provide the patient with immediate reassurance, we’re left giving him or her a copy of our films on a CD for them to take to their primary physician or the pertinent specialist to get it sorted.

The consultants evaluating the Vermont HIE recommended that it provide quality reports to support data-driven care. Our HIE doesn’t do any kind of reporting either, which to me seems a waste of a good population management tool. We’re in the midst of the worse influenza season we’ve seen in the last decade and yet can’t leverage that data for real-time reporting or surveillance. We have to wait for data to be reported to the state health department, then for it to be parsed and sent back to us in static form.

The Vermont HIE review also revealed concerns about patient matching and the function of its master patient index. We struggle with that in my state as well. Our state HIE’s program for identifying potential duplicate patients and merging them feels like it’s virtually non-existent. Since the matching algorithm appears to use address as one of its criteria, when I search for patients I find records that are clearly the same patient but are treated as unique individuals because they have different addresses, even if the rest of the demographics are the same.

We don’t tolerate that level of records duplication in my current practice, and in my former life at Big Health System, we had aggressive policies in place to identify, validate, and merge duplicate patients in our system on a regular basis. There’s no reason the HIE can’t do the same, especially with subpopulations that are known to be transient, such as college students, migrants, and homeless persons.

Another general concern around HIEs that plays out across the country is the sustainability of their funding models. Many are heavily subsidized with state funds and others are cobbled together with a variety of funding sources.

I worked with a practice recently whose HIE is struggling with funding. Practices are either required to do a full integration with the HIE at a cost of more than $40K and then pay a couple hundred dollars per provider per year to stay connected, or if they don’t want to do a full integration, they can pay a steep annual fee for providers to have web portal access. My client’s practice has a residency program with many rotating providers along with a number of locum tenens providers who fill in at their rural clinics. The fee for portal access is strictly per provider, with no regard to resident, full-time, or part-time status. For residents who are only in clinic for a couple of half days a week during a four- to six-month rotation, it’s too costly. For part-time physicians and those who are functioning in a job share situation, it’s not cost effective. We attempted to negotiate a break with the HIE, but were unsuccessful.

In my own practice, where I’m surrounded by Epic hospitals, I’m waiting for the advertised Share Everywhere functionality to start making an appearance. Although it was to be included in their November release for MyChart, I haven’t been inundated with patients whipping out their phones to give me access codes so I can see their records and send a note pack to their Epic-based care team. I’d be interested to hear from anyone who has seen it in the wild or used it to access patient information.

How satisfied are you with your HIE options? Email me.

Email Dr. Jayne.

HIStalk Interviews John Fleming, MD, Deputy Assistant for Health Technology Reform, ONC

John Fleming, MD is deputy assistant for health technology reform for the Office of the National Coordinator. He served in the US House of Representatives (R-LA) from 2009 until 2017.

Describe your role within the Office of the National Coordinator.

I’m a board-certified family physician. I practiced for a number of years, going back to 1979 when I completed my family practice residency. I did six years of service in the Navy and then went into private practice in Minden, Louisiana. I ran for Congress in 2008 and served from 2009 through last year. I was appointed to this position, deputy assistant secretary of health IT reform, in March. I’ve been serving here ever since.

We have two major areas that we are working on going forward. One is interoperability. Genevieve Morris is the lead on that and that’s her specialty area. Mine is in physician burden, administrative burden, and provider burden in general. But particularly physician burden is critical and crucial at this point. Of course I work with the interoperability issues as well, but my major emphasis is on physician burden.

We’ve been doing a lot of stakeholder input. We’re continuing that process. Then, we’re going to begin working on deregulatory actions as well as fulfilling a requirement in the 21st Century Cures Act that we report to Congress or the Secretary or both. We’re still trying to elucidate that issue on the current state of things, which incidentally is not good on physician administrative burden, and recommendations on how we can move forward on that.

How do you see ONC’s role, especially since some of the burdens of documentation were imposed by the federal government and systems vendors design their products both around those requirements and what they believe the market has demanded?

In the mind of most providers out there, the burden is in some way connected to, if not caused by, the electronic health record. But the plain truth is that the electronic health record is not the fundamental cause of administrative burden. But it does, I think, worsen it to some extent, and it has not yet been capable of fixing some of the problems with administrative burden that you might expect a computer to do. 

I think it makes sense that ONC is involved. In the 21st Century Cures Act, it calls out for collaboration between ONC and CMS, because CMS is a major payer for healthcare across the nation. I’ve heard estimates that as much as 40 percent of healthcare is paid for through CMS, mainly through Medicare and Medicaid. It calls out a collaboration between ONC and CMS to do these things.

We have four work groups that are currently working in collaboration between the two agencies on the various aspects. Yes, the electronic health record does have its issues in terms of usability. The interface, we certainly think, needs improvement. But to be honest with you, it is not the fundamental problem. The fundamental problem with physician administrative burden has been an accumulation of regulations, requirements, and restrictions going back over three decades. To solve the problem, we need a combination of regulatory reform as well as improvement and enhancement of the EHR interface.

Do you see the burden of documentation that was introduced as an improvement framework within Meaningful Use unwinding, or will it just be changed to reflect contemporary practice?

I don’t think it’s going to change on its own. If left untouched, it’s going to continue. In fact, it’s actually going to get worse, because in the 2016 MACRA bill, there is brought forward the quality measures and quality reporting into the electronic health record space. Those requirements actually started up maybe six or eight years before, but they were streamlined and brought up to date into the MACRA  bill and set up for implementation.

As of last year, we began to see the implementation of quality reporting, and then payments are going to be adjusted based on scores. But the problem is, how do you work that into the electronic health record workflow without causing additional administrative burdens? The truth of the matter is it’s quite a challenge and there’s a lot written about it. MedPAC has made some very interesting comments about it as well. I would say to you that in the current trend line, it’s going to get worse before it gets better, which is all the more reason why we need to begin addressing these things.

One thing that you mentioned — I would like to adjust back on the facts a little bit. The documentation guidelines that I think are a big source of the physician administrative burdens actually began in 1995 in the pre-EHR period. The electronic health record in some ways has made that worse as an unintended consequence. In 1995, the rules and regulations came out and they were somewhat changed or added to in 1997, so there are two sets of guidelines and physicians can use either one of them. Evaluation and management codes – which are what most non-surgeons use, a set of codes as far as what level of service was provided — determine the pay to that physician. The level of payment is determined by how much documentation is provided in that visit. The point is, the more you document, the more you’re paid.

That doesn’t necessarily mean that doctors are being paid more for better service, longer time spent with patients, or even better care. Simply, the more they document about what they did, the more they’re paid. The problem that we see in the electronic health record era is that now these systems are often designed where you can click boxes and dump a lot of data or text into the progress note, much of it normal description, which then creates a huge document that becomes virtually unreadable and actually camouflages important findings. We call that note bloat.

As a result of the documentation guidelines in 1995 and 1997, which at that time required either dictation or handwriting, then you fast-forward into the higher adoption rates we have today, which are about 85 percent for ambulatory care, 97 percent for hospitals. Instead of improving that, the unintended consequence is that the way systems are designed, it creates larger and more unreadable notes. That has become quite a pain point for providers to the point that oftentimes a doctor simply refuses to read progress notes that other physicians created because they simply don’t have the time to dedicate to reading what is a lot of normal text. Often it’s a syntax that’s very hard to follow because it’s a cut-and-paste kind of creation.

Hopefully that gives you a little better idea of what seems to be the most crucial pain point. There are others, but that seems to be the one that you hear the most from physicians.

How do you see the recommendations of those committees being operationalized?

The documentation guidelines evaluate a progress note in terms of how the physician is paid based on three areas — the complexity of the history, the physical exam, and then the decision-making process. It’s very specific and arbitrary about how many systems are examined and discussed, how many tests are ordered, and that sort of thing.

The stakeholder input that we get — and a lot of discussions that we have internally from those like myself who’ve practiced medicine for a number of years — is that that needs to be reformed and streamlined. Just a couple of example ideas that we’re hearing. One is to do away with the requirements on the physical exam and the history and simply base that on the complexity of the decision-making. That can be somewhat arbitrary, too. How do you really score that? How do you determine what’s complex and what isn’t?  For instance, you may have one person with a serious disease that requires a lot of discussion and decision-making, or you may have somebody with five different simple problems. Which is considered more complex? That’s a matter of debate.

Another option that’s been discussed — and again, no decisions have been made whatsoever — would be to simply pay the physician a blended rate for the encounter and assume that some encounters are going to be more complex than others, but that by doing away with the extensive amount of unnecessary documentation that’s more red tape than anything, that the physician would have more time to spend with the patient and provide better quality care.

That’s just some of the discussion. We’re not even close to making a decision on that.

You said once that you would like everyone in America have a single, cloud-based health record under their control. Is that possible, and what would it take to make it a reality?

It is possible. There are some barriers. There are some challenges before us, but they’re technical and they can be overcome. For instance, how do you get that information to that location? That’s where we’re working on interoperability. Genevieve Morris is working on the TEFCA program – Trusted Exchange Framework and Common Agreement. We’ll have regulations that come out that are compliant with HIPAA, which will promote and implement some standards and also enforcement such that providers will be better able to share information with permission of the patients.

As we do that, there are companies out there already that have data banks, or patient record banks. They’re already accumulating those to some extent. It’ll simply be a matter of how they collect these from various providers, how they organize these records, and how they put them under the control of patients. That’s where the discussion about APIs comes in, which we talk a lot about here. Then, how do they give permission to other providers to access those records and at what security levels?

This is all coming together pretty rapidly, although we don’t have a specific goal here at ONC to create a patient-centered record. Both patients and professionals alike have a huge stake in this outcome. We’re facilitating the intermediate process of sharing that information, making sure the data is readable and transferrable so that ultimately it can be put into one single location.

That’s not to say that providers wouldn’t also have a version of records as well, but there would be a stockpile, or a single location that a patient could point someone to so that all care can be accessed to the extent that the patient gives permission. For instance, if you’re traveling in another state or another location and you have an acute illness, you could simply give a temporary password or code and that physician could access all of your records that have accumulated from a number of providers over a span of time.

How much is the lack of interoperability due to technology rather than the business problem of providers not necessarily wanting to share information?

It’s totally a mixed bag. Both of those are factors. I don’t think I have enough information to decide which is worse or which is the bigger problem. They’re both big problems.

I think that the policy side of it and the business model side is a lot easier to fix than the technical side, because what you’re looking at is all sorts of syntax issues. For instance, some programs may be set up to measure weight in kilograms, some in pounds, some may write out “pounds” and others might use a symbol instead. All of these things have to be unified in a way that when you send that information, it means what it’s supposed to mean when it gets to the other end.

There’s a huge complexity to all of those issues. We’re trying to bring everyone to a consensus on how that information is reported and what format we use, such as the FHIR standards, which seems to be the way most people are going nowadays. The standardization is something that we’re working on so that it’s easier to move that along.

The other part of it is, how do you build the highways out there for that information to flow? Then more importantly is the on-ramp to that information highway. Let’s say a solo physician wants to be interoperable with a local hospital, maybe other medical clinics, ambulatory centers, or other physicians. They may have to sign a number of different contracts in order to be able to do that with different standards, different requirements. Some may cost money in order to build APIs, an interface where one program can share information with another.

What Genevieve is working on is on-ramps where a given provider could — either through the vendor or through a local information exchange organization — get on that information highway with one login that’s sustainable. They can go wherever they need to go to get their information, whether it’s a one on or whether it’s a bulk download or upload.

All of that’s in the works. We’re trying to be not overly prescriptive about it because we want to be sure innovation continues. Sometimes too much regulation can hold that back.

But there’s also is the business model, the business case. Currently, or certainly in the past, there are vendors out there who felt it was in their best business interest not to share information or the capability of sharing information except within their own system. That gives them, in their view, some advantage in order to sell their system and its capabilities.

But I think with the evolving regulation requirements — and certainly the very stiff penalties against those who don’t create the capabilities to share information — there’s going to be a totally different business case out there that will be in the best interest of all vendors. That is to say, if you’re not able to communicate with all of the systems available out there through the pathways given, then you’re not going to have a sustainable business. I think that’s going to change rapidly over the next year or two.

How has ONC’s mission and operation changed with the leadership changes in HHS and the White House?

I can only speak for leadership as of this current administration since I really had no interaction with ONC prior to that time. The changes in leadership that we’ve had have really had no impact. Certainly the three political appointees in our agency are the same from Day One and our mission has been the same. We haven’t missed a step. We may report to a different person from time to time than we did before, but nothing’s changed about our activities or was really impacted whatsoever from the change of leadership, certainly at the Secretary level.

As a former number of Congress and a physician, what are the most significant opportunities to improve American health?

First of all, that we put patients or consumers back in the driver’s seat so that they can make decisions about their own healthcare and their healthcare coverage. Where we come in is the liquidity of data, so that information can go where it’s supposed to go and certainly for the benefit of the patient or the consumer. The reason I say “consumer” sometimes instead of “patient” is that a lot of times people want to maintain good health rather than getting well from ill health. It’s important to think of everyone in America as having the need for data liquidity for their health, even if they’re fully healthy.

We’ve  been through quite a cycle of healthcare reform, which I think continues to evolve. Whether you are very much in favor of government being in control of the healthcare system or whether you believe that the free market should be in control, I think we all agree that better access to care and lower cost and higher quality care should be the goal. That is really the goal ahead of us. We’re trying to create that data liquidity in order to help patients and professionals to delivery higher quality and lower cost.

Then on the physician burden side, if you look at it from a macroeconomic standpoint, there’s a lot written about the fact that physicians spend at least half their time and perhaps more — and we think that this is happening with nurses and other healthcare professions as well — on administrative duties. They’re spending half of their professional activity functioning below their license. What we really have is a pent-up productivity in America.

Think about the physician shortage that we have across America, particularly in primary care. If we were to unleash doctors, if they were practicing up to their full license status — that is, functioning as healthcare providers at least 90 percent of the time, much less 100 percent of the time — just think how much more care and how much time they could spend with patients, how much better quality of care would be, and how much lower the cost would be.

That’s the ultimate goal I have in the physician administrative burden space — to unleash, unlock that pent-up lack of productivity that has been created over three decades of regulations on top of regulations. I’ve only named two or three. There’s quite a number of them that sometime I’ll be happy to go through it with you to show you just how much has been done in the regulatory space over the many years that has created what is, at this point, a critical juncture in this time of healthcare such that doctors, at the highest rate ever, are having burnout or retiring early, going into other professions, and certainly not practicing to their ultimate capabilities. That’s what I hope to achieve on the productivity side of things.

Do you have any final thoughts?

Other than the ongoing regulatory responsibility that we have at ONC — which is the follow-through on Meaningful Use, which is now wrapped into MIPS, which is part of the quality measurement and quality reporting space going forward and through statute — what we are dedicated to do here in addition to supporting HHS in all of its goals and missions is to create data liquidity, lowering healthcare cost and increasing quality by way of improved interoperability and the end of information blocking. Then also to unleash physician productivity, which is at an all-time low. That is, in a nutshell, what we’re all about here at ONC.

Morning Headlines 1/8/18

2017 US Healthcare Breaches Involving Ransomware Increased 89% Year-Over-Year

A new report from Cryptonite finds that ransomware attacks on healthcare institutions increased by 89 percent from 2016 to 2017.

Denver-based health care ratings site Healthgrades confirms employee layoffs

Provider ratings and reviews business Healthgrades confirms an unspecified number of layoffs across the company.

Trusted Exchange Framework and Common Agreement

ONC publishes a draft of its Trusted Exchange Framework as directed by Congress in the 21st Century Cures Act.

Monday Morning Update 1/8/18

Top News

ONC publishes a draft of its Trusted Exchange Framework as directed by Congress in the 21st Century Cures Act.

ONC hopes to create “a single on-ramp to interoperability for all.” Click the graphic to enlarge.

The public comment period is open through February 18. ONC expects to publish the final version late this year.

Reader Comments

From Chip McFlaude: “Re: Meltdown and Spectre CPU bug. The software patch will likely degrade performance on all IT systems. We’re waiting for benchmarks from Epic.” The near-certain performance hit that the patch will cause – and the possible need to add computing horsepower to offset it – is something providers and vendors should be paying attention to. Application of the patch isn’t optional even if hardware upgrades can’t be done first. Needless to say (hopefully, anyway), health systems need to apply the patch to every computing device – smartphones, desktops, servers, etc. — now that the flaw’s existence has been globally publicized and malware authors are rushing their new releases to market. 

From Just Another Healthtech Insider: “Re: KLAS. I founded a very successful health IT consulting firm that was always highly ranked in KLAS, but we never made the official list because we refused to pay KLAS for consulting services to be moved up from ‘not statistically relevant.’ Healthcare organizations rely on this information not realizing that moving up on the list may involve paying KLAS for their advice on how to rank higher. It may well be that KLAS helps vendors improve in general to also improve their scores specifically and that’s OK, although mixing vendor consulting with vendor ranking will always create suspicion, justified or otherwise. But has been observed many times, KLAS isn’t exactly either Consumer Reports or Black Book in transparently selling statistically validated customer reports that were collected on a large scale via transparent methods. Whether KLAS has a high impact on purchasing decisions or not, the possibility that it might has created an ever-expanding , KLAS-enriching vendor demand and relationships that are far from arm’s length. I don’t expect KLAS to ever publicly list how much it is paid annually by each vendor it ranks, but they fact that they’re paid at all serves as a reminder that it’s a consulting firm, not an influence-free industry watchdog. Unfortunately, the steps KLAS would need to take to achieve the latter would destroy its lucrative business model, so you either accept them as-is or not.

From Press Hangry: “Re: public relations firms. Our company needs PR services and would be interested in your recommendations, from boutique firms to larger ones.” I don’t have a good company-facing view of who does what, but PR folks are welcome to complete this form about their firms and I’ll forward the information to those companies that occasionally ask for help.

HIStalk Announcements and Requests

Most poll respondents say their 2017 was better than 2016, although commenters reported that they experienced personal illness, loss of family members, and concerns about the country’s direction.

New poll to your right or here: what makes a newly filed lawsuit newsworthy? My opinion is that accusations mean zero until a jury weighs the evidence and renders a verdict, but that’s just me not wanting to waste time on the vast majority of lawsuits that don’t result in a decisive victory either way.

HISsies nominations are still open.

HIMSS18 is just eight weeks away. Like every year, I’m getting a lot of post-New Year’s Day sponsorship information requests and new sponsors who are anxious to get started. I greatly appreciate the interest and the support. Lorre will be thrilled to get on a call to make it happen before March when we’re all hearing slot machines 24×7.

We provided three video cameras for Mrs. S’s third grade class in Pennsylvania in fully funding her DonorsChoose grant request to enrich her scientific methods unit. She reports, “My students are already planning out the science experiments that they want to conduct at home and record. There are so many possibilities of things to record and fun lessons to do with these video cameras!”

Thanks to the following companies that recently supported HIStalk. Click a logo for more information.

Last Week’s Most Interesting News

• A study finds minimal use and outcomes improvement of patients using a hospital’s patient portal while admitted as an inpatient.
• A report finds that one of many problems at VC-backed, four-state Medicare Advantage insurer Clover Health is that an analytics bug caused its outreach employees to call its healthiest members instead of its sickest to offer health advice.
• Doctors at the VA hospital in Roseburg, OR say administrators anxious to fudge their quality data ordered them to discharge sick ED patients and steer chronically ill patients to hospice care to avoid having them die in-house.

Webinars

January 24 (Wednesday) 1:00 ET: “Location, Location, Location: How to Deploy RTLS Asset Management for Capital Savings.” Sponsor: Versus Technology. Presenter: Doug Duvall, solution architect, Versus Technology. Misplaced or sub-optimally deployed medical equipment delays patient care and hampers safety-mandated preventive maintenance. It also forces hospitals to buy more equipment despite an average utilization that may be as low as 30 percent, misdirecting precious capital dollars that could be better spent on more strategic projects. A real-time locating system (RTLS) cannot only track asset location, but also help ensure that equipment is properly distributed to the right place at the right time. This webinar will provide insight into the evaluation, selection, and benefits of an RTLS-powered asset management solution.

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

Acquisitions, Funding, Business, and Stock

The price of the world’s best-selling drug, Humira, has doubled in the past five years to $38,000 per year and accounts for two-thirds of its manufacturer’s $26 billion in annual revenue. It costs multiples more in the US than in the rest of the world and so far the company has done a good job squelching competing biosimilars.

Sales

Adventist Health outsources management of its revenue cycle and clinical applications employees to Cerner.

Decisions

• Cherokee Medical Center (AL) will switch from Medhost to CPSI Evident in February 2018.
• Merit Health-Batesville (MS) will go live with Medhost inpatient EHR in March 2018.
• Siloam Springs Regional Hospital (AR) replaced Medhost with McKesson’s inpatient EHR in September 2017.

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

Announcements and Implementations

Glytec’s software-as-a-medical-device for outpatient insulin titration earns a US patent.

Government and Politics

VA Secretary David Shulkin says in an interview that the VA has held off signing a contract with Cerner because the company’s definition of interoperability includes only the exchange of CCDAs, adding that, “To say it wasn’t a good meeting would be an understatement.” I doubt it was a intended as a shrewd VA contracting strategy to announce Cerner as its no-bid EHR vendor and then drag the publicly traded company along until it agrees to the VA’s terms under the threat of killing the golden goose, but at least the VA didn’t sign first and ask questions later as they seemed desperate to do just a few weeks ago. Having VA and DoD both using Cerner is not a guarantee of interoperability, but the bigger challenge might be connecting the VA to its many community-based providers, who use every EHR on the market. Going live without that capability when spending $10 billion or more is ludicrous. This is the first evidence I’ve seen that the VA might be listening to skeptical members of Congress instead of its White House selection committee who displayed questionable expertise in declaring Cerner the only viable choice. You have to wonder if Cerner could wangle out of the scrutiny more easily if they were working with a big government contractor used to making problems go away.

Other

An 18-year-old who pretended to be a doctor – running his own clinical and urgent care and strolling hospital halls in a white coat – is sentenced to 3 1/2 years in prison after pleading guilty to charges that also include stealing $35,000 from an 86-year-old “patient.” The fantastically named Malachi Love seems indignant that he was caught: “I’m just a young black guy who opened up a practice who is trying to do some good in the community. If that is a negative thing, we have a lot more work to do in the community than to single out me … Just because someone has the title doctor in front of their name does not necessarily imply MD.”

Sponsor Updates

• Optimum Healthcare IT creates an infographic titled “Formulary Management: Effects of Standardized Vs. Non-Standardized.”
• The American Heart Association names Sphere3 CEO Kourtney Govro a co-chair of the Kansas City Go Red for Women Luncheon on April 18.
• Surescripts will exhibit at the ASAP Annual Conference January 10-12 in Naples, FL.
• Visage Imaging will exhibit at the ACR-RBMA Practice Leaders Forum January 12-14 in Chandler, AZ.
• ZeOmega’s Jiva tackles major challenges surrounding population identification and stratification.

Blog Posts

• Crucial Lessons for Successful IT Transitions (Santa Rosa Consulting)
• Smart Hospitals and Future Technology Today (The SSI Group)
• Two Ways PRM Software can Increase Patient Satisfaction (Solutionreach)
• New Year Resolutions: Improving Transitions of Care (Summit Healthcare)
• See Voalte Platform at HIMSS18! (Voalte)
• How to Build a Single Customer View (West Corp.)
• Technology Brings Laser-Like Focus to Claim Status Monitoring (ZirMed)

Contacts

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

Morning Headlines 1/5/18

Power restored for Henry Ford Health’s computers

Henry Ford Health System (MI) recovers from a power outage at its data center early Thursday morning that shut down phones, email, and IT systems, including Epic.

VETS Act of 2017

Following in the House’s November footsteps, the Senate unanimously passes the Veterans E-Health & Telemedicine Support Act of 2017, giving VA providers the ability to care for patients via telemedicine at any location in any state.

Patient portal use and hospital outcomes

A Mayo Clinic Jacksonville study finds that only around 20 percent of inpatients who had previously registered for its patient portal actually used it during their stay, concluding that inpatient portal use probably doesn’t improve outcomes.

VillageMD Announces $80 Million Growth Financing from Athyrium Capital Management

Primary care management and technology company VillageMD raises $80 million in a financing round led by Athyrium Capital Management, bringing its total funding to $116 million.

News 1/5/18

Top News

A Mayo Clinic Jacksonville study finds that only around 20 percent of inpatients who had previously registered for its patient portal actually used it during their stay, concluding that inpatient portal use probably doesn’t improve outcomes.

Mayo’s portal provides a real-time view of lab results, admission notes, consultation reports, and operative notes. It does not, however, give patients access to progress notes or provide electronic messaging with care teams, which might help explain why they didn’t bother to log on (or the fact that they were busy being sick). There’s also the question of whether Mayo’s inpatients are representative of the populations of other health systems.

It may also be that staff communication there was good enough that patients didn’t have to chase down news about themselves on the portal.

What I would want in an inpatient portal, or more specifically, a custom app running on a tablet:

• An integrated call system that allows me to indicate what I want or need and have my request prioritized and routed appropriately (just more ice at some point or a pain med now?)
• A schedule of my meds due, a photo of each dose to double-check employees who might screw up, and a link to a standard medical reference so I remember what it’s for.
• Two-way video would be nice for employees who otherwise have to make their way to my room for something that isn’t critical (maybe I want to ask a pharmacist a question, for example).
• The ability to create tasks for staff (like fix my TV) and for staff to create tasks for me (like get out of bed and walk down the hall twice a day), with completion times noted and stored for accountability.
• A Bluetooth-powered hospital badge that would flash the name and title of the person on the screen along with their photo and then record it so I could review it afterward.
• A list of ordered but not yet performed tests or procedures, ideally with the dates and times they are scheduled.
• Some idea of my care plan, success metrics, and expected outcomes.
• A display of every line item being charged for my stay in as near real time as possible.
• The usual hotel-like options for requests involving food, entertainment, and housekeeping.
• The ability to record what a caregiver is telling me so I can review it afterward to avoid missing something important.
• The Bluetooth badge-powered ability to display a giant, flashing red dollar sign when a hospital-sent caregiver enters my room who – despite my explicit instructions — isn’t in-network with my insurance.

Reader Comments

From Glory Basking: “Re: solutions, platforms, systems, applications. What’s the difference?” You would need to ask the marketing folks who love these terms and use them interchangeably. I remember an insistent email from a company’s marketing VP who was appalled that I had described its programmer utility (not the VP) as a “tool” instead of its preferred, overarching “platform.” That made me think of old-school techies would reference “a piece of software” — which was odd indeed since software is neither physical or divisible – or when an IBMer urged me in my short time as a vendor employee to always refer to our software as “solutions”or the even more grandiose “solution set” because it lulls the prospect into overlooking its many faults in picturing it as a reliable problem-solving appliance activated by writing a large check.

From Spinnaker: “Re: health IT podcasts. Which ones do you recommend?” I’ve never listened to any podcast – health IT or otherwise – but readers are welcome to make a recommendation. I would much rather skim the news visually for a minute or two (like on HIStalk) than sit through a real-time audio recording whose pacing I can’t control, but then again my attention span is so short that when I listen to the car radio (which isn’t often), I usually leave it on scan.

From Festivus: “Re: more EHR vendor lawsuits. See link.” Newly filed lawsuits are fun to write about, but I’ve mostly stopped because you’re just hearing one side of the story. Anybody can sue anyone for any reason in the good old United States of Litigious Peoples, so it’s journalistically lazy to write about a newly filed lawsuit as though it contains verified facts. Wait for the outcome – that’s the actual news.

From Thank You: “Re: HIStalk. It’s critical to my job and so valuable. I just wanted to drop a note and say thank you for all the hard work and effort you put into maintaining it and keeping the content fresh!” Thanks. I don’t have any time-suck hobbies other than starting with an empty screen and filling it up the best I can, so this is my golf or Facebooking.

From Spam in a Can: “Re: EHRs. Epic’s ‘we make you more money’ claims are erroneous, if not disingenuous, according to this journal article.” I’m not sure it says that. A JAMA Ophthalmology article recaps a survey of ophthalmologists about EHR use. My takeaways:

• The very long survey drew 348 respondents from a random sample of 2,000 AAO members invited, which isn’t a fantastic sample size or response rate (the US has about 18,000 practicing ophthalmologists). Only one respondent was selected within a given ZIP code and the survey was delivered via email. Of those respondents, only 265 reported using an EHR, so hopefully the authors discarded the 83 responses of those who don’t (but thus leaving the sample size even tinier).
• Epic was the most-used EHR, although only a vendor ranking was provided rather than actual numbers.
• 77 percent of EHR-using ophthalmologists say their practice is owned by physicians and only 6 percent by hospitals, which raises an interesting question – why the heck are so many of them using Epic instead of a specialty-specific EHR/PM? That seems suspicious.
• The 72 percent of respondents who use EHRs say their net revenues and productivity have declined while their practice costs have increased.
• Only 9 percent said net practice revenue increased with EHR use, while 35 percent said it stayed the same and 41 percent said it decreased. That seems odd since most of them also said coding levels and charge capture were unchanged or higher, leaving only reduced productivity as a possibility. Or that changes were associated with EHR implementation but not caused by it since time passed and situations changed either way.
• 36 percent of ophthalmologists said they would go back to paper if given the chance.
• A great majority of respondents said practice costs went up after implementing an EHR, but the study demographics also noted that most practices were running their first EHR. Obviously EHRs are more expensive than paper and the study didn’t ask respondents how much they thought costs rose, only whether they did, which again could have been due to unrelated factors over time.
• Many respondents were pushed into using EHRs because of Meaningful Use incentives, which brought their own burdensome EHR documentation requirements.
• It’s a perception study, which means that while practicing doctors rendered an opinion about cost, revenue, and profits, their participation was not vetted by role (so they aren’t necessarily involved in practice management) and their actual numbers weren’t reviewed.

HIStalk Announcements and Requests

The frantic Post-New Year’s, pre-HIMSS housekeeping is underway. Sponsors who want to be featured in my HIMSS guide will be receiving a link to the data collection form (anxious ones can contact Lorre). It’s also time to open the HISsies nominations, recalling that it’s like a political primary – the candidates with the most votes will appear for voting on the final ballot, so don’t complain later if you don’t nominate now.

Ms. M’s pre-K class in New York City received the science kits that HIStalk readers provided in funding her DonorsChoose teacher grant request. She reports, “We have been talking about volcanoes for the past few weeks. Many of the children didn’t even know what a volcano was. We are excited to start using these items within the next few weeks. You have made a tremendous impact on our class. Happy New Year.”

Listening: Garner, NC-based Sarah Shook & the Disarmers, a rare glimpse at what country music could be if devotees would stop throwing money at (a) throaty, big-city pretty boys inexplicably wearing cowboy hats indoors, and (b) privileged, bespangled warblers hiding their shiny pop ambitions behind a faux front of populism. This band is classic country meets sneering punk, unpolished and and full of hard-life experience, which is what country music used to be before big corporations took it over with harmless mannequins who would flee the studio in confusion if confronted with an actual pedal steel guitar or upright bass. I like that Sarah is an angry activist who chose as her band mates experienced (meaning: kind of old) musicians who really round out the sound.

Webinars

January 24 (Wednesday) 1:00 ET: “Location, Location, Location: How to Deploy RTLS Asset Management for Capital Savings.” Sponsor: Versus Technology. Presenter: Doug Duvall, solution architect, Versus Technology. Misplaced or sub-optimally deployed medical equipment delays patient care and hampers safety-mandated preventive maintenance. It also forces hospitals to buy more equipment despite an average utilization that may be as low as 30 percent, misdirecting precious capital dollars that could be better spent on more strategic projects. A real-time locating system (RTLS) cannot only track asset location, but also help ensure that equipment is properly distributed to the right place at the right time. This webinar will provide insight into the evaluation, selection, and benefits of an RTLS-powered asset management solution.

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

Acquisitions, Funding, Business, and Stock

VC-backed, four-state Medicare Advantage insurer Clover Health is not only losing money, failing to negotiate lower-cost provider contracts, and leaving patients on the hook for bills it won’t pay, it is also struggling with its highly-touted analytics technology. A bug in its algorithm that was supposed to rank members from sickest to healthiest for outreach calls had reversed the order with nobody noticing for several months, wasting the time of reps who called its healthiest customers first in chasing the high-hanging fruit.

Enterprise telehealth platform vendor InTouch Health will acquire direct-to-home telehealth platform vendor TruClinic.

AMA-backed Akiri, which offers a secure subscriber data transport network for healthcare, raises $10 million in a Series A funding round.

Sales

The US Army expands its use of Vocera communications technology, adding a new hospital and expanding the rollout of two others.

Capital Region Medical Center (MO) chooses CloudWave’s managed, cloud-based disaster recovery services for Meditech.

LA County Department of Health Services renews its revenue cycle management software and services contract with Harris Healthcare’s QuadraMed Affinity Corporation.

Hospital Sisters Health System (IL) chooses Health Catalyst’s Data Operating System analytics system for its ACO and PCIN.

People

Mike Ruotolo (Inovalon) joins PatientSafe Solutions as regional sales VP.

Announcements and Implementations

A new KLAS report on population health management identifies six functionality areas (data aggregation, data analysis, care management, administrative and financial reporting, patient engagement, and clinician engagement) and finds that HealthEC and Forward Health Group lead the pack, with feedback coming mostly from ACOs. Health Catalyst, Arcadia, and Philips Wellcentive topped satisfaction for IDNs/CINs. Narrowly-focused PHM solutions offered by EHR vendors scored surprisingly poorly in clinician engagement compared to leaders Forward Health Group and Enli. 

Government and Politics

HIMSS adds VA Secretary David Shulkin to a Friday morning session at HIMSS18 called “It Takes a Community – Delivering 21st Century Coordinated Care for Those In and Out of Uniform” that also features Defense Health Agency Director Vice-Admiral Raquel Bono. I assume the VA will have signed its Cerner contract by then, but you never know. I noticed that HIMSS will also need to change the title of fellow keynoter Eric Schmidt, whose credential as executive chairman of Google parent Alphabet will end at company’s board meeting this month when he assumes the less-keynoterly title of “technical advisor.”

Other

A fascinating article by oncologist and author Siddhartha Mukherjee, DPhil, MD describes “the dying algorithm,” a 2016 Stanford project that mined EHR data retrospectively to create a deep neural network that could accurately predict whether a given patient would die within the next year. Interestingly, the algorithm works well but remains a black box because it’s not easy to figure out what it learned or how it applies its information to individual cases. It’s also interesting that despite sounding coldly high tech, the algorithm was developed with a nobler, more humane purpose – to identify terminally ill patients within the 3-12 month survival “sweet spot” in which palliative care is most effective in not wasting resources too early, but allowing patients enough time to settle their affairs.

New versions of the cell-enabled Apple Watch are randomly rebooting in hospitals, apparently affected – as its documentation acknowledges is possible – by pacemakers, defibrillators, and other medical equipment. Users report that switching the watch to airplane mode while in the ICU prevents rebooting.

I enjoyed this video from Brad Nieder, MD, a practicing doctor and comedian whose “The Health Humorist” website invites folks to, “Put on a paper dress. Grab a magazine from 1987. This won’t hurt a bit!”

Sponsor Updates

• Healthfinch is mentioned in KLAS’s emerging companies report.
• AssessURhealth joins Greenway Health’s online marketplace.
• Formativ Health renovates new space with sustainability in mind.
• Ingenious Med staff volunteer with Open Hand Atlanta to deliver meals to the homebound.
• KLAS highlights Health Catalyst as a high performer in a new population health management report.
• Kyruus will exhibit at the JP Morgan Healthcare Conference January 8-11 in San Francisco.
• ZeOmega adds identification and stratification tools to its Jiva population health management solution.

Blog Posts

• CIO Chat – John Kravitz, Geisinger Health System (Huntzinger Management Group)
• Singletrack: Small is Beautiful, and it Just Might Last (EClinicalWorks)
• 2018 Predictions from Healthcare Leaders Across the Country (Hayes Management Consulting)
• Identifying Cybersecurity Threats in Healthcare IT (The HCI Group)
• DrFirst Response to The President’s Commission on Combating Drug Addiction and the Opioid Crisis Report (DrFirst)
• Hunt Regional Medical Center Improves Patient Experience with Vocera (Vocera)
• Cost Savings from Standardizing the Formulary (Optimum Healthcare IT)
• Virtual Desktop Infrastructure – Drivers, Security, Costs and Benefits (Huntzinger Management Group)
• One Hospital, 62 Lives Saved: Our Work Gets Real (Iatric Systems)
• 2017: A Year in Review of Our Most Popular Content (Kyruus)
• When compliance dashboards and annual audits are not enough (Impact Advisors)
• 3 New Year’s Resolutions to Push Payers Into the Digital Age (InstaMed)
• InterSystems Healthcare Leadership Conference: Sun, sand and the future of health IT (InterSystems)
• Digital Transformation in Healthcare and Life Sciences Wrap Up: Have you defined your path? (Liaison Technologies)
• In Mammography, History Matters (LifeImage)
• How Advisory Services Helps Value-based Care Organizations Reach Their Goals (Lightbeam Health Solutions)
• How EHRs give time back to nurses (Meditech)
• If it’s 2018, it must be time for interoperability, data dumping, and changing chart ownership (Medicomp Systems)
• One Organization’s Journey to Whole-Person Care: Landis Communities (Netsmart)
• Happy New Year from Nordic (Nordic)
• With SayIt from NVoq, your Cloud-Based Speech Recognition is not just accurate, but always HIPAA compliant (NVoq)
• Reduce hospital readmission rates through tech-driven care coordination (Experian Health)
• ONC Speaks Up for Physicians (PatientKeeper)

Contacts

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

EPtalk by Dr. Jayne 1/4/18

The New Year has started out with a bang and a reminder that for some IT organizations, old habits die hard. I tried to log in to my flexible spending account website to submit a receipt for the contact lenses I put off purchasing until 2018, only to be locked out. I wasn’t able to do an online password reset, so had to call customer service. There I was told that my password (which I just set back in December) was expired and that it has to be changed “every 90 days because of HIPAA.” I guess they missed the memo that HIPAA doesn’t require a specific password expiration interval, and also the one where NIST and other organizations are advising against forcing regular password expiration without reason. HIPAA remains one of the most incorrectly cited regulations I can think of and there’s not much hope for improvement.

I also tangled with a pharmacy that insists on calling our office to request verbal authorization to change prescriptions from capsules to tablets and vice versa, even when our electronic signatures are placed squarely on the “substitution permitted” signature line as required by state regulations. This particular pharmacy is the only one who calls and I can’t imagine that their business is so slow that they don’t have anything else to do than to make unnecessary phone calls to physicians.

I’ve always been a bit annoyed at the fact that most EHRs display a dizzying array of formulations that prescribers have to sort through. For many medications, it doesn’t matter if the dosage form is a tablet or capsule, but we have to select one or the other nevertheless. Of course it matters if it’s a liquid or a chewable when you have a patient who doesn’t swallow pills, but otherwise it’s just one more thing we have to assess when we’re clicking through the day. I had to play bad cop and threatened to report them to the State Board of Pharmacy if they continue harassing us.

I’m looking forward to the day when I have robust clinical decision support in my EHR that takes the diagnosis I just loaded and the drug I’m selecting and only shows me the dosage forms and instructions that are pertinent for the clinical situation given the most current clinical recommendations and local antibiotic resistance. To do that in our current system, we manage order sets that each client has to build and maintain. I know there are more integrated solutions out there, but I don’t think they take the local resistance rates into account. At least not yet.

For the vendor with whom I was on the phone the other day troubleshooting an issue with MIPS calculations, I’m going to recommend a New Year’s Resolution: if you’re going to bother being on a call, make sure you’re paying attention. This call was the culmination of efforts to manage multiple support tickets around several interrelated issues. At first I was impressed by their SWAT approach to getting the right teams on the call to try to solve the issue. My confidence flagged the first time that someone had to be asked a question twice due to “being on mute,” which we all know is a (somewhat illogical) euphemism for “not paying attention.” This happened again not five minutes later, with the second support rep at least admitting that he “was multitasking.” I would question the judgment in play when you multitask while you have a disgruntled client on the phone along with five or six of your peers who all have other (if not better) things to do. I used to work with a guy at Big Health System who would routinely be “on two conference calls at once.” I could never figure out why anyone would think that was a good idea.

I had a bright spot in my week when I was orienting a new physician to our group. He wasn’t aware of Clinical Informatics as a subspecialty, but having been a computer science major, was very interested in hearing more about the path to board certification. He had been doing informatics work at his previous employer but didn’t see himself as much more than a super user. When we talked through some of his work, it was much broader than he thought. It’s always good to see the sparkle in someone’s eye when you discuss something they find exciting rather than thinking that conversations about EHR workflow are a chore. We’ll definitely include him in our clinical champion group and see how much he wants to participate now that he’s with us.

I read with interest the reader comment from Sick Doc about urgent care centers being closed on holidays. Now that my practice is approaching 20 locations, we did some modifications of our holiday hours this year. Normally we are open 365 days of the year, but staffing every holiday in a practice that size was taking its toll on staff morale. We remained open, but not at every location, consolidating operations within a 10-mile radius of identified “core” locations. Signage and directions were placed at closed locations with matching website modifications.

We piloted this approach with Thanksgiving and it was successful, so we continued it into the Christmas and New Year holidays. Overall patient volume was down but only slightly, and I think the decrease was within what you could reasonably attribute to people not wanting to miss out on family gatherings or to venture out into the bitterly cold weather we’ve been experiencing. We’re proud to offer care 16 hours a day, which is the most any urgent care in our area provides. Our staff definitely appreciated the greater odds of being able to spend time with family. They’re running pretty ragged with the spiking volumes due to influenza, which we’re countering by having lunch delivered for the staff every day, at least in the short term.

Urgent care is definitely a growing market segment, with an announcement today that Mercy is partnering with GoHealth Urgent Care for Midwest operations. GoHealth already partners with health systems in New York, Portland, Hartford, and San Francisco. I hadn’t heard of them prior to the announcement, but got a kick out of their website’s picture of innovative facilities “engineered for your comfort and privacy” that appears to show a fishbowl-like exam room with glass walls along with a glassed-in vitals station where everyone in the waiting room can watch you step on the scale and get your blood drawn in the phlebotomy chair.

The press release mentions that these are “smart glass” rooms, which I assume means they become opaque when people are in them. For a profitable urgent care, that should be most of the time, making the technology’s value somewhat questionable. The terrazzo floors look nice, though.

Basic visits at the Bay Area clinic start at $250 (cash price paid in full at the time of service) and are $150 in Portland, $120 in Hartford, and $125 in the Big Apple. I wonder what Mercy’s existing urgent care physicians think about the announcement and whether their clinics will remain open?

According to the release, charting will be transparent on wide screen monitors in each room using Mercy’s Epic EHR. GoHealth didn’t have great reviews on Glassdoor, so I’ll be watching this one closely.

What do you think about smart glass exam rooms? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 1/4/18

Carrollton Family Clinic vs. EClinicalWorks

Carrollton Family Clinic (MS) files a class-action lawsuit against EClinicalWorks in an effort to recoup lost Meaningful Use incentive money and related IT expenses.

Medical E-Records Co. Files $30M Suit Against Rival

Kipu Systems sues Sanomedics subsidiary ZenCharts for allegedly stealing the intellectual property behind its EHR for behavioral health providers.

Data Incident

Emory Healthcare (GA) experiences a data breach when a former employee dumps Emory patient data onto a Microsoft Office 365 OneDrive Account associated with his or her new job at the University of Arizona College of Medicine.

CMS Launches Data Submission System for Clinicians in the Quality Payment Program

CMS develops a new online performance data submission tool for physicians participating in the Quality Payment Program. The 2017 submission period runs through March 31.

HIStalk Interviews Dennis Dowling, CEO, Formativ Health

Dennis Dowling is CEO of Formativ Health of New York, NY.

Tell me about yourself and the company.

I’ve been working in healthcare most of my life and my entire career. I have spent probably 42 of 45 years working in an organization now known as Northwell, which is a healthcare system in metropolitan New York. I held a a variety of responsibilities. I was executive director of two of their flagship hospitals, North Shore University Hospital and Long Island Jewish Medical Center. I was more recently responsible for the strategy and the management of their ambulatory care network, which now comprises over 3,000 physicians and multiple joint ventures in dialysis, imaging, urgent care, ambulatory surgery, and so forth. 

In January 2017, I became as chief executive officer of a commercial, for-profit joint venture known as Formativ Health.

How hard it was to turn Northwell’s management services into an investor-backed joint venture company?

There are clearly differences between a not-for-profit, community-based organization and its culture and that of a for-profit, commercial enterprise. The difficulty is in having both of these organizations understand the culture of the other and figure out how to adapt their cultures, missions, and objectives together.

It’s not the business so much as the personality and character of the organizations that have to be understood. If you have a community-based organization, no matter how large or complicated — a not-for-profit, mission-driven organization like most of healthcare — to understand how to function and operate in a for-profit, commercial world is a challenge. Similarly, these commercial, for-profit organizations don’t get it when they’re dealing with a community-based organization like most of healthcare.

In what areas are physician practices least prepared to meet current and future expectations?

I would start with consumerism, the advent of transparency, convenience, and the expectations that most of the population has of other industries. Whether it’s banking, retail, or airlines, when you interact with any of those industries as a consumer, you have certain expectations about service and convenience. Healthcare is way behind in having that transparency, convenience, access, and service as part of its DNA.

Hospitals, physician groups, and practices need to adapt quickly. As you can see recently with Amazon, Google, and CVS, a myriad of industries and organizations are moving into the healthcare space. If the current healthcare providers don’t understand and adapt quickly, they’re going to get overrun and pushed aside.

How will practices and hospitals that are accustomed to staying busy and profitable just by opening their doors market their services and improve the patient experience?

Just as you asked the question, that’s the challenge facing healthcare today. Some are going to be able to understand the challenge, recognize it,and adapt to meet it. Others will be swept aside.

The new patients of today and tomorrow will accept nothing less than transparency, ease of access, convenience, and good service. They will no longer accept sitting in a waiting room with a 300-page novel that they can read while they’re waiting for their physician. They won’t accept that any longer, nor should they. That’s the new expectation.

Technology is going to have a lot to do with it, just like it does in other industries. This is another challenge for healthcare — to quickly develop and adapt the technology that the consumers of today are going to expect and demand. Technology that allows them to interact with their provider without going through a phone tree and filling out dozens and dozens of forms in a waiting room multiple times. This is an antiquated system.

There are good, understandable explanations as to why healthcare has been slower than other industries to react. A lot of it is regulatory. A lot of it is privacy concerns. Nevertheless, for whatever reason, it is what it is. It’s going to have to change and change very quickly.

Hospitals have been acquiring physician practices and are now merging with each other to form what could be just a few dozen national health systems. That gives them scale to improve communication, engagement, and patient satisfaction, but with the risk of being seen as a faceless corporation that doesn’t value people as individuals. Will patients see the situation getting better or worse?

What is transpiring now in healthcare has been experienced by many other industries throughout this nation. It could be the airline industry, banking, or accounting. There used to be the Big 8, now I think there are three accounting firms left. There used to be airlines like TWA, Pan American, and Eastern. They’re all gone. They were all swept aside. Either for some of the reasons we’ve already mentioned – adaptation, meeting some of the challenges that they faced, and they weren’t able to have that flexibility to adapt — or they were swept aside through this consolidation. 

Healthcare is going through that as we speak. There are no longer these little community-based hospitals that were the local equivalent of the YMCA and a Main Street mom and pop store. They’re now all being brought together into these massive health systems. At the end of the day, there will be some number.  We can guess the number of jellybeans in the jar, but there will be very fewer healthcare organizations. Not only are they consolidating as hospitals to each other, their physicians are consolidating into large medical groups and then again into hospitals to create these health systems.

There’s also now the trend where insurance companies are acquiring providers and providers are creating insurance companies. I think the latest trend is going to be the commercial market, like the CVSs and the Amazons, getting into healthcare. You’re having the retail meets the healthcare providers and vice versa. I don’t know who’s going to be left standing at the end of the day, but the landscape is going to be dramatically different than it was yesterday.

What’s that going to mean for the patient? I’m going to be optimistic. I think what they will have is a much more open, transparent, and accessible healthcare system than they had yesterday, notwithstanding the Marcus Welby image of the kind, gentle healthcare provider — whether it was a hospital or a physician — of the past.

People need ease of access. They need high levels of service. Competition for access and service is a good thing. Healthcare needed a prod to become more convenient and more focused on the patient, satisfying their needs for both service and access. This will ultimately be a good thing. It will be disruptive to the providers, but I think it will ultimately be very positive for the patients.

What service and technology improvements do you recommend to practices?

That’s the focus and objective of Formativ. We’re looking to fill this gap — I consider it a gap — between connecting the patient with the physician. Right now, it’s a very frustrating experience for both physicians and patients. Walk into virtually any physician’s practice and it’s like walking into a three-ring circus. There are all kinds of activities. You’ve got phones ringing. You’ve got people standing and waiting to make a new appointment. You’ve got these poor people behind the desk trying to juggle and balance handing out paper and moving patients back into the exam area. The organizational skills these poor receptionists need to balance and manage are incredible.

We go in and say, there’s no need for all of this. Like in other industries and other experiences, you can take that noise out of the waiting room and out of that day, moving it to the day before. Get it done in a more relaxed and more manageable setting. You can pre-register. You can get all the patient demographic and insurance information before you walk into the waiting room. You can do it electronically. When the patient walks into that waiting room to see their physician, it becomes a clinical experience, not an administrative nightmare.

When they’re leaving and need care coordination, follow-up care, or prescription refills, you can all do this electronically or over the phone by someone who is dedicated to help that patient navigate the system rather than trying to cram it all in to the same time you are there to have a clinical experience. You can do this through technology and dedicated service.

We refer to that as our patient access service. Individuals who are sitting anywhere are interacting with the patient, have the ability to see into the electronic health record of that patient, can communicate with the clinical providers through the electronic health record, can answer patient questions, can get schedules and appointments made, can answer insurance questions, and can help coordinate that whole experience for that patient.

Do you have any final thoughts?

It’s an exciting opportunity for those that recognize the challenge and the need that the population is demanding from their healthcare providers. For those who are willing to step up and to meet that challenge, it can be a very exciting and rewarding opportunity.

I’ve been doing this for well over 40 years. It’s been a pleasure and an honor to try and meet the needs of the community of patients — who, more often than not, experience some hardship or problem with healthcare – and try to relieve them of some of the frustration and the anxiety. Through technology and  personalized service, there’s this incredible window where those that are willing can step through. I believe the receptivity of patients is going to be extraordinary.

I’m just blessed to be able to have the opportunity to see the transformation and be part of it. It is coming, make no mistake about it. Don’t think it’s not. There is a wave of consumerism that will engulf healthcare. I hope and expect that most of the healthcare providers will be able to step up to meet the challenge.

Morning Headlines 1/3/18

At Veterans Hospital in Oregon, a Push for Better Ratings Puts Patients at Risk, Doctors Say

Doctors at the VA hospital in Roseburg, OR point to shady administrative efforts to boost quality ratings, including discharging sick ED patients and steering the chronically ill to nearby hospice care to avoid in-hospital deaths.

Computer downtime update 1-2-18

Jones Memorial Hospital (NY) notifies patients of the continued IT systems downtime after a December 27 cyberattack.

Promoting Telehealth in Rural America

The FCC seeks comments on a proposed rule that would increase and potentially reallocate funding for the Rural Health Care Program.

SSM Health Reports Privacy Breach of Medical Records

SSM Health (MO) notifies 29,000 patients of a November data breach involving inappropriate employee access. The call-center employee honed his activities in on a small group of patients with controlled substance prescriptions from a particular PCP in St. Louis.

News 1/3/18

Top News

Some systems of Jones Memorial Hospital (NY) – including Meditech — remain down following an unspecified December 27 cyberattack.

The hospital is asking patients to bring in their insurance card, meds list, and whatever medical history they have.

Reader Comments

From Debtor: “Re: news article calling American Well a start-up. What’s the shelf life? That company was founded in 2012. Or is it just a more-hip way to say ‘small business’ with no implicit time constraint?” I agree. I posit that a “start-up” will possess these characteristics, the absence of any meaning it’s just a less-sexy “business”:

• Founded within the past five years.
• Has not been acquired. 
• Founders are still running the show.
• Annual revenue is under $50 million and headcount under 100.
• Implicit valuation is less than $500 million and funding is via bootstrapping, angel investors, and early funding rounds.
• The business model is uncertain and stability is absent.
• Growing quickly while remaining unprofitable.

From Sparsely Populated: “Re: hospital construction. All those publish or perish authors should consider trying to correlate big health system construction expense with patient satisfaction and improved outcomes.” That would be interesting, as is the fact that some are questioning why health systems are building Taj Mahospitals while proclaiming themselves fit for purpose as benevolent overseers of declining public health. It’s a Pandora’s box of trying to tie non-clinical hospital overhead to their effect on the only metric that matters – patient outcomes. Locals, however, don’t understand or don’t care that health system costs sap the national economy even if they boost the local one, so they’re proud to show off fancy buildings to visitors.

From Deal Watcher: “Re: wondering about EHR decisions. Singapore docs want Epic and the CIOs want Allscripts in a decision that was supposed to be made by December 31. Nova Scotia has been out on RFP and it’s between Allscripts and Cerner, perhaps on hold since the entire Canadian Maritime was considering collaborating on a single integrated EHR. The VA is still delayed despite strong rhetoric from Secretary David Shulkin – if interoperability is their goal, why invest $10+ billion in a new EHR that won’t get them very far instead of waiting a few years for MU3 and mandated APIs that will allow interoperability initiatives like the Carin Alliance go mainstream?” Singapore will announce its decision in the next 2-4 weeks, I hear. I haven’t heard about anything new from Nova Scotia. I’ve also never heard of the CARIN Alliance, an apparently for-profit member organization convened by former government officials as a Leavitt Partners project to facilitate consumer-directed exchange.   

From MD Professor: “Re: prescription drug monitoring programs. In my state, the focus on reducing opiate prescribing has seen skyrocketing rates of IV heroin use and overdoses even as available treatment programs have been reduced in number and insurance covers less of the high cost. Prescribing of even non-opiate controlled substances requires five minutes to deal with the state’s website. It only works with some browsers and enforces rigid password and reset rules that encourage poor security practices. The hospital says EHR interfacing is too expensive. I personally think the state makes the process cumbersome on purpose to dissuade clinicians from prescribing, so I don’t expect improvements to PDMP integration or usability any time soon.” You’ve identified four significant problems: (a) reducing the supply of legally manufactured opiates has raised their street cost and pushed users to less-reliable products that may kill them or steer them to crime to pay for their habit; (b) we are mired in the never-ending “war on drugs” that cannot be won by Darwinism, incarcerating users or dealers, fining drug distributors, or trying to limit access to drugs; (c) addicts trying to quit have few affordable treatment options; and (d) the use of PDMPs is creating unintended consequences even as it sucks up provider time. I don’t know the answer, but I’m pretty sure PDMPs specifically and technology in general aren’t it. A public health expert would tell you that few chronic conditions can be resolved by shaming or punishing those who have them, even if their own choices contributed.

From Jennifer Coons, RN: “Re: Seiling Municipal Hospital (OK). I know there have been lots of comments and rumors on HIStalk about my hospital and our decision to change vendors and I wanted to take time to address them and put them to a close. I appreciate your consideration in posting this letter to your readers.” Jennifer is administrator of the hospital. Click the graphic above to enlarge her letter explaining why the hospital recently reversed its decision to replace CPSI/Evident Thrive with Athenahealth and is now back on the former.

From Sick Doc: “Re: urgent care centers. I became ill with a high fever on New Year’s Day. All the urgent care centers were closed for the holiday.” I’ve often said that it’s no wonder that people show up in the ED for non-emergent issues. Private practices are nearly always closed outside of what used to be called bankers’ hours, urgent care centers set their own hours, and health system clinics stick to a university-like schedule, with only the ED offering the certainty that the lights will be on and the desk staffed. You would think a provider business case exists for being available for the other 14 or so hours each weekday plus weekends and holidays. I wonder if telemedicine providers similarly limit their availability?

From Banner Downgrade: “Re: Banner – University Medical Center, Tucson, AZ. A patient writes to the paper to complain about the EHR.” The letter writer says that following Banner’s “downgrade’ from Epic to Cerner:

• His 30-minute appointment took more than 3.5 hours.
• Banner’s Cerner system doesn’t receive his information his local doctors are sending.
• Automated paging is no longer offered, so waiting patient names are called out by nurses.
• He received a 13-page printout (sounds like a visit summary and/or patient education handout) that previously he could have accessed online.
• He no longer receives telephone appointment reminders.

HIStalk Announcements and Requests

Most poll respondents celebrate a winter holiday and most of those observe Christmas. Either way, the days are getting longer; we’re back in the post-holiday, pre-HIMSS frenzy; and it’s just 76 days until spring in the Northern Hemisphere.

New poll to your right or here: was 2017 an overall better year for you than 2016? You can elaborate further in the poll’s comments (click its “comments” link after voting).

Some reader survey respondents suggesting eliminating some sections of HIStalk. I decided to let democracy rule – vote on which of the listed sections I should keep or drop in a survey I call “HIStalk Hot or Not.” I’ll be making a few more changes in response to feedback from survey respondents, one of whom received a late Christmas present in the form of an Amazon gift card (check your junk mail, folks, since all I had was an email address and the emailed gift card hasn’t been claimed yet).

Anonymous Epic Developer’s DonorsChoose donation funded math games for Ms. M’s first-grade class in Goldsboro, NC and solar energy study materials for Mrs. Z’s elementary school class in Brooklyn, NY. Anonymous made a donation that paid for a STEAM center (resources and furniture) for Ms. M’s elementary school class in Albuquerque, NM and a laptop and case for Mrs. H’s high school class in Fayetteville, NC. The teachers took the time to email me on New Year’s Day to say thanks.

This may be the last DonorsChoose update based on responses to the “keep or drop” survey above. One reader survey respondent dismissed the DonorsChoose updates as undesirable “virtue signaling,” a term (made up by a magazine in 2015) that I had to look up and found to be incorrectly applied since it indicates saying but not actually doing something virtuous (like helping teachers in need). Not to mention that I’m celebrating reader financial support of students, not bragging on my own. I admit that while most of the 570 reader survey responses were constructive and/or supportive, others ranged from dismissive to downright hostile and that always stings for awhile.

Last Week’s Most Interesting News

• A consultant says Vermont’s HIE is not meeting the needs of its stakeholders and advises it to improve its services and financial sustainability.
• A physician says missed meds are due to complex psychological issues rather than just patient forgetfulness, raising the question of whether a Big Brother-like pill tracker can improve outcomes.
• The Indian Health Service issues and RFI for help in planning an IT future that will likely not involve the VA’s VistA, on which its RPMS systems are based.

Webinars

January 24 (Wednesday) 1:00 ET: “Location, Location, Location: How to Deploy RTLS Asset Management for Capital Savings.” Sponsor: Versus Technology. Presenter: Doug Duvall, solution architect, Versus Technology. Misplaced or sub-optimally deployed medical equipment delays patient care and hampers safety-mandated preventive maintenance. It also forces hospitals to buy more equipment despite an average utilization that may be as low as 30 percent, misdirecting precious capital dollars that could be better spent on more strategic projects. A real-time locating system (RTLS) cannot only track asset location, but also help ensure that equipment is properly distributed to the right place at the right time. This webinar will provide insight into the evaluation, selection, and benefits of an RTLS-powered asset management solution.

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

Acquisitions, Funding, Business, and Stock

Cancer informatics vendor Inspirata acquires Toronto-based Artificial Intelligence in Medicine, whose product uses AI/NLP to extract oncology information from clinical documents.

Sales

Union General Hospital (GA) chooses Cerner to replace McKesson Paragon and Athenahealth, planning a CommunityWorks deployment of Millennium, RCM, and HealtheIntent.

Decisions

• Slidell Memorial Hospital (LA) will switch from McKesson to Epic in 2018.
• Lavaca Medical Center (TX) will replace Healthland with Cerner in 2018.
• Merrick Medical Center (NE) will replace Healthland with Epic.
• Wayne Medical Center (TN) will switch from Meditech to Cerner in June 2018.

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

Announcements and Implementations

Sweden-based telemedicine and care center operator Doktor.se opens a clinic in a Swedish county where primary care is free, meaning that under Swedish law, everyone in Sweden can now access free virtual visits.

Black Book launches a mobile survey app.

Government and Politics

Doctors at the VA hospital in Roseburg, OR say metrics-obsessed administrators ordered them to discharge sick ED patients to make sure the hospital’s VA quality ratings (and administrator bonuses) didn’t suffer even though more than half its beds are always vacant. The hospital is also alleged to have told doctors to avoid listing congestive heart failure as an admitting diagnosis (since the hospital would be penalized for poor preventive care) and to steer chronically veterans to hospices to avoid having them counted as an in-hospital death.

Other

How cold it is? It’s so cold that exhibitionists are flashing drawings of themselves. It’s so cold that lawyers are putting their hands in their own pockets. It’s so cold that systems at IU Health Ball Memorial Hospital (IN) have gone down due to a shattered fiberoptic line.

Here’s Vince’s 30-year look back at the health IT landscape of January 1988, when long-timers might have been distracted by the latest episode of “The Cosby Show,” the end of the war in Iraq, or the scramble to get Michael Jackson “Bad” concert tickets.

Sponsor Updates

• Leidos Health publishes a white paper titled “Ready or Not, It’s MACRA Time.”
• Meditech announces its support for several STEM-related school initiatives.
• Audacious Inquiry’s Julie Boughn is recognized as a 2018 FedHealthIT100 awardee for contributions in modernizing enterprise health IT.
• AssessURhealth announces several 2017 company milestones, including a 170-percent increase in customer growth.
• Besler Consulting releases a new podcast, “American Healthcare: Worst value in the developed world?”
• CoverMyMeds celebrates its 2017 North American Visionary Innovation Leadership Award from Frost & Sullivan.
• KLAS recognizes CTG as Best in KLAS for Partial IT Outsourcing.

Blog Posts

• MACRA Quality: A step-by-step beginner’s guide (AdvancedMD)
• New Hypertension Guidelines (Arcadia Healthcare Solutions)
• Actionable Content: A Framework for Better Decision Making (Change Healthcare)
• Free Up Your Staff Time to Help Improve Patient Reviews (ChartLogic)
• How to Grab the Attention of Hiring Managers and Recruiters (Direct Consulting Associates)
• The Future of Data and Analytics in Healthcare (Dimensional Insight)

Contacts

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

Morning Headlines 1/2/18

Meuhedet Signs Giant Telemedicine Agreement With US Startup

Israel-based HMO Meuhedet inks a deal with American Well valued at between $50 million and $60 million. The company, which is the country’s third-largest HMO, will be the first non-US business to work with American Well. Israeli-born brothers Ido and Roy Schoenberg – both physicians – founded the telemedicine company in 2006.

US medical device tax back in effect after two-year pause

A medical device sales tax of 2.3 percent goes back into effect after a two-year hiatus, a development the Advanced Medical Technology Association believes will stifle innovation and lead to the loss and/or creation of jobs.

FDA chief: I’m surprised it took big tech this long to get into health care

FDA Commissioner Scott Gottlieb, MD shares his thoughts on the ways in which Amazon, Apple, and Alphabet will transform the healthcare industry.

New year set to bring overhauled electronic health records system to Newman Regional Health

In Kansas, Newman Regional Health deploys Meditech 6.16 – its first medical records upgrade in 21 years.

The 20 Most Important Health IT Takeaways of 2017

1. Hospital Consolidation Ran Amok, Benefiting Cerner and Epic

The big are getting bigger and more profitable among both health systems and their technology vendors. The resulting rip-and-replace projects are offsetting the first wave of post-Meaningful Use demand slack-off. That trend will continue as health systems use their favorable billing rules to acquire not only medical practices, but nursing homes. The industry marches toward a few multi-state, legally non-profit but hugely profitable operators controlling their freshly expanded markets.

The EHR vendor market has consolidated into:

1. Epic and Cerner for US inpatient, as Epic announced plans to move down-market with a less-expensive basic system and Cerner held its advantage among large health systems that are contemplating merging into mega-systems.
2. Epic for health system-connected private practices.
3. Meditech for small health systems and those in Canada.
4. CPSI for cash-strapped rural and safety net hospitals.
5. Allscripts for hospitals in Australia and Europe, with newly acquired Paragon remaining an unknown.

2. Ambulatory Vendors Faced Reduced Post-MU Demand

Most practices that want an EHR already have one, and even some of those are being forced to displace their preferred system after being acquired by big health systems using Epic and Cerner. Ambulatory EHR vendors face several negative market pressures: complaints about poor usability and interoperability, technologically outdated products that still have to be maintained and enhanced, and lack of demand. The Department of Justice’s $155 million False Claims Act settlement with EClinicalWorks could portend similar charges against its competitors.

The bright spot for ambulatory EHR vendors is revenue cycle services (which they are well equipped to provide) and population health management technology (which they are not).

3. Value-Based Care Sounded Good, But Had Minimal Impact

Everybody likes the idea of paying for value instead of services performed — until they look at the work required and the potential profit lost. Heads in the beds and butts in the waiting room seats will continue to be the main driver as long as Medicare keeps paying for them.

4. The Press Exposed Questionable Business Practices

Theranos, Outcome Health, and NantHealth had their bubbles burst by dogged investigative reporting. Those exposés will likely continue as the shrinking journalism industry finds that those stories sell.

5. ONC Was Mostly Irrelevant

Much of the work around hot topics such as interoperability, EHR safety, and cybersecurity happened outside of ONC’s sphere of influence as it faced personnel changes and threatened budget cutbacks in a vastly different political environment.

6. The VA Rushed to Judgment

The VA — pushed by the White House to choose Cerner with the general thesis that running the same system as the VA will be good for veterans — announced to Congress that it will quickly sign a VistA-replacing Cerner no-bid contract despite unanswered questions around cost, DoD interoperability, and information exchange with the community-based providers that serve veterans.

The VA’s contract signing deadline of November was missed as Congress failed to move the VA’s money around to fund the deal, with the resulting extended timeline allowing Congress to pressure the VA into developing an actual plan on interoperability outside the federal government’s walls.

7. New Inpatient EHR Entrants Quickly Hit a Wall

The inpatient aspirations of EClinicalWorks and Athenahealth were dampened not only by complexity, the market’s preference for broad and mature product suites, and entrenched competition, but also by a DOJ settlement and activist investor pressure, respectively. ECW remained characteristically quiet, but the cost-cutting and executive-shedding Athenahealth was reduced to publicly sparring with CPSI over the decisions of tiny hospitals instead of with Epic over the large ones.

8. Allscripts and Greenway Announced Plans to Streamline Their Ambulatory EHR Portfolios

Both companies said they will develop a single system to replace their multiple aging ones.

9. Drug Companies Suddenly Became Interested in EHR Data That Technology Allowed Them To Obtain

Pharma needs to justify high drug prices and analyzing individual patient outcomes is one way to do that. They also found value in performing virtual clinical studies, recruiting clinical trials participants, and detecting adverse effects.

10. AI Hype Became Rampant as IBM Watson Health Turned Into a Marketing Term

Already-inflated expectations for artificial intelligence and machine learning expanded further, but the lack of results from IBM Watson Health, the paucity of transparency on exactly what Watson is doing and how, and Watson’s high-profile failure at MD Anderson encouraged moderating expectations even as Google and other technology firms look for healthcare nails to pound with their profitable hammers.

11. FHIR, APIs, and the CommonWell-Carequality Linkage Decreased Interoperability Barriers In Meeting The Minimal Market Demand For It

It predictably turned out that technology wasn’t the biggest barrier in exchanging patient information with competitors – it was that providers are fiercely protective of their business. Interoperability always works when demand exists, such as among multiple hospitals and practices within the same health system.

Providers will make interoperability happen quickly only if their profits depend on it. Perhaps the “data blocking” standard should be applied to health systems that manage to exchange information with disparate systems only within their own organization.

12. Population Health Management Presented Promise Without Many Definitive Results

Population health management and its associated technologies are an inherently good thing to patients, but the business model is marginal and slipping as the federal government steers the reimbursement ship back to fee-for-service. Implementation models vary widely, it’s early to publish definitive results, and providers whose profit comes from traditional services show reluctance to kill their golden goose. The track record of innovation whose only benefit is to patients is unfortunately poor.

13. The Federal Government’s Anti-ACA Efforts Threatened Provider Incomes

The federal government’s efforts to kill the ACA without an alternative in place will increase the number of uninsured patients who will still show up in the ED knowing they won’t be turned away, putting pressure on health system bottom lines that look great now only because their non-operational investments are killing it in a booming stock market.

The disrupted risk pool will continue to hamper insurers and the lack of political will to address exorbitant US healthcare charges guarantees that healthcare will be a mess for a long time except for deep-pockets consumers who can afford boutique care.

14. Big Companies Once Again Showed Their Health IT Short Attention Spans

McKesson sold out and GE mulled its healthcare IT exit as both companies chased the next shiny object in the face of sliding profits. Historical precedents are ample that buying health IT products from a company whose toes are dipped in other industries – especially if, as is nearly always the case, they turn out to be crappy health IT vendors — will nearly always leave customers stuck with a far-worse product turfed off hastily to a new owner at a devalued fire sale price.

15. Potential New Entrants Like CVS and Amazon Worried Health Systems As Hopeful Consumers Cheered

Health systems realized that despite the political clout that allowed them to become the default but questionably well-suited profiteer for everything from oncology practices to population health management, the market is becoming attractive to potential competitions such as CVS and Amazon that are not burdened by inefficiency and consumer indifference. The question of “who owns the patient” is valid, even if insulting to the patient who shouldn’t be “owned” by anyone.

16.  Cyberattacks Mostly Spared Hospitals, But Hit For-Profit Company Bottom Lines Hard

WannaCry and NotPetya malware caused temporary disruption of the operations of a handful of US hospitals, but publicly traded Merck and Nuance took big but temporary financial hits due to crippled operations.

17. The Federal Government Chased the Tip of the Healthcare Fraud Iceberg

Medicare’s pay-and-chase practices have created a ton of fraud and a few ounces of penalties that haven’t deterred the large number of scammers who make fortunes working the system’s many holes. A few high-profile settlements and prosecutions showed the risk to criminals, but the reward remains infinitely larger and the risk of actually serving prison time is minimal.

18. HIMSS Kept Getting Bigger

Cash-flush HIMSS has to spend its vendor-provided money somewhere, with competing publications and conferences topping its acquisition list and increasingly making it the all-controlling industry voice.

19. Technology Did Little to Improve the Opioid Crisis

Doctor-shopper databases have done little to improve the opioid situation, which remains a people rather than a technology problem due to user demand, doctor willingness to supply it due to questionable prescribing practices and sometimes outright fraud, and the ever-growing and ever-cheapening illegal drug supply that is happy to take up the slack if legal prescribing declines. Continuing demand with reduced supply does little except to raise prices and encourage customers to seek out more dangerous alternatives.

20. Digital Health Had a Few Bright Spots Among Unproven Apps

Consumer health apps and platforms continue to seem like good ideas even in the absence of evidence that they positively impact outcomes, they have minimal mainstream uptake outside of the quantified selves, and providers show no interest in looking at piles of self-captured information (especially when they aren’t being paid to do so) that provides little basis for intervention.

Patient engagement technologies offer promise in improving outcomes for a narrow subset of consumers, although definitive proof is mostly lacking. Technology vendors see the market opportunity in under-diagnosis, the extent and societal health value of which is questionable.

As an uplifting New Year’s bonus for “year in review” honors, I look back at the best health IT-related video ever created. The “Hamilton”-inspired production of Mary Washington Healthcare (VA) was appropriate to its location, magnificently written and performed by its employees, and reflective of the aspirations of a hospital implementing a new EHR.

Morning Headlines 12/29/17

State’s $44.3M health data system ‘at a crossroads,’ study says

A review of Vermont’s statewide HIE finds financial and administrative issues and an erosion of end user confidence.

CMS Appears to Forbid All Forms of Text Messaging

A health law firm reports that CMS has been issuing warnings hospitals that any form of texting PHI is unacceptable, even through secure text messaging applications. UPDATE: only ordering via text message is prohibited, as confirmed with CMS.

Swallowing a Spy — The Potential Uses of Digital Adherence Monitoring

A NEJM perspective article questions the usefulness of digital medicines, specifically the ingestible sensor manufactured by Proteus Digital Health to track and improve medication adherence. In the article, author Lisa Rosenbaum, MD opines that for digital monitoring to improve adherence rates, “lapses would probably need to reflect pragmatic rather than psychological obstacles, particularly for diseases for which medication taking isn’t associated with relief of symptoms.”

Some Doctors Still Billing Medicare for the Most Complicated, Expensive Office Visits

A ProPublica investigation questions the billing patterns of providers that almost exclusively bill CMS for the most expensive and complex visit type.

News 12/29/17

Top News

A consulting firm’s review of Vermont’s HIE finds that 91 percent of its stakeholders think the state needs such a service, but VHIE is meeting the needs of only 19 percent of them.

VHIE gets 95 percent of its funding from public sources, which raises a sustainability red flag. It has spent $44 million, most of that provided from federal Meaningful Use funds.

The report says data quality is a problem; VHIE’s “cumbersome” opt-in policy has limited enrollment to 20 percent of the state’s population; and most users have view-only access.

The consulting firm recommends that VHIE:

• Provide search capability for extracted portions of the full record of patients
• Allow providers to submit public health reports and registry data
• Implement a master patient index and provider directory that can link patients to providers or ACOs
• Provide quality reports to support data-driven care
• Allow providers to submit Meaningful Use reports directly from their EHRs
• Coordinate with the state’s all-payer claims database to allow analyzing cost at patient and population levels

The HIE is run by Burlington-based Vermont Information Technology Leaders, which agreed with the consultant’s findings. John Evans, VITL president and CEO, will retire on January 1, 2018.

Reader Comments

From Mordecai: “Re: Renaissance Weekend. I received an invitation – have you heard of it?” I haven’t heard of it. According to its website, Renaissance Weekend  — not to be confused with those goofy Renaissance Faires where historically accurate / BDSM attired attendees frequently exclaim “huzzah” and “good morrow” while they waveth a smoked turkey leg in one hand and cell phone in the other — is an invitation-only retreat of diversely accomplished folks who get together to talk about public policy, innovation, science, and other heady topics. I’m interested in hearing from anyone who has attended or was invited. The idea of going someplace fun for brainy discussions is pretty cool, although interested folks would probably need a connection to be invited and a good supply of extroversion to make it worth going. Maybe there’s something similar with bar lowered for the rest of us. I knew a guy once who convened his own retreat sort of thing, where he invited interesting and diverse people to join him for a day (or maybe it was a weekend) of freewheeling, friendly discussion, although I can see that devolving into a beer bust.

HIStalk Announcements and Requests

An anonymous reader’s contribution to DonorsChoose, with matching funds applied from my anonymous vendor executive, fully paid for these teacher projects:

• Science books for Ms. C’s elementary school class in Provo, UT.
• Programmable robots for Ms. M’s elementary school class in Clermont, FL.
• A programmable robot for the Robot Coding Club of Mrs. J’s elementary school class in Cleveland, OH.
• STEAM kits for Mrs. K’s elementary school class in Winnetka, CA.
• A document camera for Mrs. W’s elementary school class in Elm City, NC.
• Six tablets and a printer for Mrs. J’s elementary school class in Forest Park, GA (it tugged at me when she mentioned that three of her students are homeless)
• Math activity centers for Mrs. S’s pre-kindergarten class in Hillsville, VA.

I was working early and funded the projects at around 4 a.m., but the apparently also early-rising Mrs. W got in touch almost immediately to say, “WOW! What a wonderful surprise! I can not thank you enough for your generosity! I am so excited to be able to give all of my students the ability to watch and interact with my daily lessons. This document camera will allow my students to be in the moment as I model lessons. This will also help students to be more engaged. Thank you!”

Webinars

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

Acquisitions, Funding, Business, and Stock

I realized this morning that it has been nearly six months since Neal Patterson died on July 9, at which time Cerner said its longstanding succession plan meant that “the process to select a new CEO is nearing a conclusion.” CFO Marc Naughton said in the October 26 earnings call that the board would “take their time and go through the process in a very careful manner.” Co-founder Cliff Illig remains as chairman and interim CEO. I don’t know how long the average publicly traded company takes to name a permanent CEO, but six months with an interim seems like a long time.

Sales

Shepherd Center (GA) will implement Epic in a Community Connect agreement with Piedmont Healthcare (GA).

People

Kyruus hires Chris Gervais (Threat Stack) as SVP of engineering.

Government and Politics

A health law firm says CMS is warning hospitals that they cannot send patient information by text messaging in any form since secure texting systems are unreliable. That seems unlikely other than for using messaging to transmit orders, which Joint Commission has raised as a potential problem because of the inconsistent workflow involved in entering them into EHR. I’ve reached out to CMS for a response. UPDATE: per the response I received from CMS, my suspicions were correct. Texting patient information among healthcare team members remains OK as long as the platform is secure, while texting patient orders is prohibited in all cases.

A ProPublica report finds that CMS has done little to investigate private practice doctors who nearly always bill at the most complex visit rate. One Alabama doctor coded 95 percent of his visits at the highest intensity vs. 5 percent of his peers, for which Medicare paid $450,000. An expert blames EHRs that assign billing codes based on which boxes are checked, saying, “Those programs tend to upcode.”

Privacy and Security

Systems at Jones Memorial Hospital (NY) go down due to an unspecified cyberattack. Amusing to me is that the hospital is located in Wellsville.

21st Century Oncology will pay a $2.3 million HHS OCR settlement for potential HIPAA violations involving a hacker using remote desktop protocol to penetrate the company’s network SQL database.

Other

The Peoria, IL newspaper describes the planned February 1 complete IT switchover of two hospitals that OSF HealthCare has acquired, which the IT team hopes to complete in just the seven hours between the 12:01 a.m. agreement effective time and the day shift’s start at 7:00 a.m. The OSF team has staged equipment on rolling carts, practiced assembly and testing, labeled 2,000 cables with their destination, and created training videos for non-technical employees and volunteers who will help with the conversion. CTO James Mormann says OSF is considering using its expertise to spin off a new IT system switching business.

Apple apologizes for intentionally slowing down older IPhones that have diminished battery capacity in an attempt to avoid unexpected shutdowns, offering as a mea culpa a price reduction on batteries for the IPhone 6 or newer from the usual $79 price to $29. The company will also provide a battery health meter in an IOS update in early 2018.

The latest Gallup poll of most ethical professions ranks nurses at the top, with doctors and pharmacists coming in at #4 and #5 even as the honesty ranking of pharmacists fell to its lowest score since 1994. Finishing dead last were members of Congress, car salespeople, and lobbyists.

Only a small fraction of Washington doctors are using the state’s prescription drug monitoring program database, leading one legislator to advocate making their participation mandatory. The state medical association blames standalone PDMP software that doesn’t connect to EHRs. Epic integrates with the state’s system, but only one hospital has turned it on. An expert recommends that the state double the PDMP’s technology budget, integrate the system with EHRs, and pay doctors to use it to avoid resistance to yet another unfunded mandate that takes up their time.

A New York Times article notes the new healthcare possibilities of the latest-generation Apple Watch, which connects directly to cellular networks instead of requiring tethering to an IPhone. It mentions the AliveCor KardiaBand for capturing EKGs, but observes that such devices can flood doctors with questionably useful information that they don’t know where to store. The company has responded by developing a software platform for doctors.

A NEJM op-ed piece questions the psychology behind patients who don’t take their prescribed medications and the role of the Proteus “digital pill” that monitors their medication adherence. The physician author says the problem is rarely caused by patients forgetting to take their meds – despite what they tell their doctor – but rather the psychology in acknowledging their mortality. Some snips:

Understanding takes time, and it’s often easier to tell people what to do than explore why they don’t do it. Even having studied the psychological factors driving non-adherence among patients with coronary disease, I often lapse into check-the-box mode with my patients … For those of us who struggle, the most effective adherence booster may be giving doctors and patients the time to explore the beliefs and attributions informing medication behaviors. These conversations can’t happen in a 15-minute visit. Given how little our health care system seems to value such interactions, it’s no wonder that skepticism often greets these new, unproven, and costly technologies. But though this skepticism may be warranted, it may also reflect a fear that the technology is intended to replace our efforts, rather than facilitate them.

A Froedtert Hospital (WI) anesthesiology resident with a history of depression kills himself on Christmas day by barricading himself in the OR, withdrawing fentanyl from the computerized dispensing system under a patient’s name, and administering it to himself.

Contacts

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

EPtalk by Dr. Jayne 12/28/17

I’ve been following the reader comments regarding the recently-opened $1.2 billion Stanford Children’s Hospital. There is plenty of cynicism about whether the expenditure will lead to better outcomes or a healthier community. I see this in my own community with several multi-state health systems competing to have the most beautiful and indulgent facilities, with far less advertising of their actual patient care.

My own hospital experience earlier this year was in a lovely private room with a flat screen TV four times larger than what I have at home, along with on-demand dining in a brand-new hospital wing. It was also accompanied by lackluster nursing care, delayed antibiotics, and failure to use bar-code medication administration systems as required to ensure patient safety. There was also a missing pathology specimen and a weeks-long delay in seeing my discharge summary in their patient portal. At least the hospital in question was spared a penalty under the Hospital-Acquired Condition Reduction Program. 

Although I received belt-and-suspenders prevention against deep vein thrombosis with both heparin injections and pneumatic compression devices, I’m not sure whether it was as effective as my early-morning ambulation, as I got dressed and packed up as quickly as possible to avoid staying any longer than absolutely necessary.

I caught up with some grad school friends who were in town for the holidays. A summary of our get together reads like the opening line of a bad joke — a doctor, a drug rep, and a hospital administrator go into a bar… All of us have worn many different hats over the last two decades, so it was interesting to hear each other’s perspectives on the evolution of Meaningful Use, the current state of this mess we call a healthcare system, and whether physicians are hanging in there or readying themselves to retire or pursue second careers.

I go back and forth in the latter category. Although my work is rewarding when I can help organizations make meaningful change, it can be depressing as frontline primary care groups struggle with trying to deliver more to sicker patients with fewer resources. Although value-based care is supposed to “fix” this, the learning curve can be steep and it’s hard for many organizations to figure out how to spend money they don’t have to make money they may or may not actually receive.

Many of the physicians I work with experience less satisfaction in their work lives than even a few years ago. Some of my former family medicine colleagues have moved into niche practices such as cosmetic treatments and vasectomy reversals. I know already that a couple of my favorite clients are planning to pursue early retirement in 2018. I’m sorry to see them go since they’re not even in their sixties, but given the diminishing returns on their professional labors, they feel backed into a corner.

As solid members of Generation X, we did have some common thoughts on what we think we’ll see in healthcare’s next decade. First, practices, hospitals, and health systems will continue to compete with each other to some degree even when it would make sense to collaborate. We see health systems that refuse to participate in collaborative ventures that would help not only patients but their own bottom line, out of fear of losing control. At least in our respective parts of the country, we don’t see this changing.

Second, there will be continued focus on profitable service lines despite the push to steer patients to enhanced primary care models. Community-based exercise and weight loss programs aren’t profitable, but knee replacements certainly are. It’s challenging for primary care physicians in the trenches to motivate patients for the months and years needed to solidify lifestyle changes (assuming the same provider even continues to be in your network) and the US population will continue to ask for high tech interventions where there is a possibility for a quick win.

There isn’t any excitement around funding the major cultural changes needed to truly transform how we live, what we eat, and how we manage our health, although we will continue to see glimmers of hope with greater patient engagement and patient empowerment.

Third, the cost of healthcare will continue to be a hot button issue. When left with the individual decision of investing in their health through preventive care or to purchase insurance against major health expenses, many people will lack the money to fund those choices. Others will choose to spend their money on other priorities. Since healthcare isn’t going to get any less expensive, this will continue to cause medical bankruptcies and significant hardship. The cycle of unfunded care and cost shifting to insured patients will continue.

As we chatted, we wanted to be hopeful about things such as machine learning, diagnosis algorithms, and predictive analytics, but it’s difficult to support the bluster from the reality in many cases. The next year or so will be very telling for these technologies and I think we’ll get some real data for how they’re going to play on a broader scale.

The reality, though, is that non-sexy interventions such as public health projects and simply getting people to move more and eat less are going to be increasingly important as we continue to try to reduce the burden of chronic disease. I think often of one of my favorite shows “Call the Midwife” and the untapped potential of community health interventions. At least one health system in my city is working towards greater community outreach, establishing new school-based clinics that not only provide healthcare, but serve as food pantries and distribution sites for clothing and other necessities.

Hopefully the New Year will bring continued focus on corporate stewardship as we continue to figure out how to make something sustainable out of dysfunctional systems that seem constantly on the brink of collapse. Healthcare impacts such a great deal of our economy and daily lives, so I was excited to read about a large health system that was willing to look at issues outside their “normal” areas of activity and consider other impacts such as water use, greenhouse gas emissions, and plastic waste. Healthcare organizations employ an increasing percentage of the US workforce and may be uniquely poised to transform workplace culture over the next decade as we evaluate how we care for aging Baby Boomers and whether we will put systems in place to reverse some of the negative health trends we’re seeing.

What challenges do you think we’ll see in the New Year? Is your organization looking to lead change? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 12/28/17

Federal Exchange Open Enrollment for 2018 coverage, most cost effective saving Americans millions of dollars while improving customer service and access to care

CMS reports that 8.8 million consumers used Healthcare.gov to buy health insurance during this year’s enrollment period, down from 9.2 million last year. CMS spent $10 million on marketing and outreach this year, compared to the $100 million spent last year.

CMS to relax reporting rules for ACOs impacted by hurricanes, fires

CMS publishes an interim final rule adjusting the reporting requirements of the Medicare Shared Savings Program to provide leniency to ACOs that were impacted by natural disasters this year.

Ransomware focus limits healthcare IT progress in 2017

Modern Healthcare looks back on 2017 and concludes that the onslaught of ransomware attacks overshadowed any gains made in health IT this year.