Monday Morning Update 5/29/17

Top News

In Canada, a report by Alberta’s auditor general says the government’s $1.2 billion proposed project to replace the clinical and administrative systems of Alberta Health Services with a single system is not likely to generate the expected $900 million in cost savings because it doesn’t include primary care practices.

The project, announced a year ago, would replace 1,300 individual AHS systems.

The report notes that Albertans pay the highest healthcare costs of all provinces in Canada, yet the quality and integration recommendations of previous reports have been mostly ignored. It observes that despite claims of how good healthcare is in Canada, it’s almost as bad as in the US, which finishes dead last among 11 developed countries despite spending far more than any of them.

The Auditor General also notes that fee-for-service payments have hampered accountability and integration. It also says that health leader turnover is high due to political cycles, with the average AHS hospital CEO lasting just 1.2 years.

Province physicians use at least 12 incompatible EHRs. Canada-wide, 94 percent of hospitals use IT only for administrative tasks.

The report observes that if banks used IT like Alberta Health Services:

• Each branch bank would have its own systems that can’t communicate with other branches.
• Systems at some branches would be so prone to failure that paper files would be kept ready.
• Tellers, mortgage officers, and investment specialists wouldn’t be able to access each other’s information.
• The only access to banking information would be via faxing.
• Customers would be required each time they visit a branch to fill out the same form asking for name, address, employment information, and financial history.
• Traveling customers could not withdraw money without opening an account first because the branch would not know who they are.
• Applying for a mortgage would require visiting each prospective lender individually and completing their proprietary application package.
• Online banking would not exist.
• Obtaining an account balance would require making a written request and waiting two weeks for the mailed information to arrive.
• Bank managers would not have enough information to understand the performance of individual branches.
• The banks would spend $600 million per year to maintain IT systems but without a plan to standardize them and keep them up to date.

Reader Comments

From More Math: “Re: CommonWell’s 60,000 documents downloaded. Looking at the latest from Epic’s website, it appears that Care Everywhere hits CommonWell’s lifetime exchange number every 15 minutes. Sounds like Epic is willing and able. Bigger question is whether the CommonWell is drying up.” CommonWell’s March 2017 fact sheet says that 5,100 provider sites have gone live and have generated 85 million queries, although I don’t know how “queries” translates into “documents.” The quoted figure of 60,000 documents retrieved doesn’t indicate the time frame involved, but if that’s all of them since CommonWell’s beginning in 2013, that’s a pretty anemic number. Cerner said in a HIMSS16 presentation that it had 4,000 providers live on CommonWell, which suggests that almost all live CommonWell members are Cerner users; that those providers enrolled only an average of 50 patients each; and that only eight documents per provider were actually retrieved. EHR vendors pay a per-transaction cost to CommonWell and providers don’t really like sharing their patient information with competitors, so there’s not a lot of economic incentive for anyone other than the patient to use CommonWell’s services.

From Laura Palmer: “Re: Cure Forward. Has shut down, according to its site.” The Boston startup offered a platform that matched patients with clinical trials, although previous announcements suggest that its system may never have graduated from beta testing status. The company raised $19 million in a June 2015 investment and nothing since. Sole investor Apple Tree Partners has expunged Cure Forward from its website, omitting the company from its “legacy investments” section and removing previous Cure Forward press releases (thereby practicing the investing world’s legendary 20-20 hindsight). Cure Forward founder Martin Naley, who launched the company as a entrepreneur in residence at Apple Tree Partners, says on his LinkedIn profile that the company “ceased operations at the end of May 2017 due to financing difficulty.”

HIStalk Announcements and Requests

Readers funded the DonorsChoose grant request of Mrs. M in Ohio, who requested math fluency games and fitness-related “brain breaks.” 

Two-thirds of the 247 poll respondents who say they have certification or fellowship credentials don’t list them on their business cards or in their email signatures. KG says credentials should be listed only on CVs other than for practicing clinicians, while Sue says her earned credentials are important to her work and her clients use them as well. John opines that healthcare people deploy “a fruit salad of acronyms” such that the more of them someone lists, the less he believes what they say.

New poll to your right or here: to what extent has CommonWell benefited patients since its 2013 founding? I appreciate your vote and, even more so, your comments explaining it.

Gregg Allman died Saturday at 69, leaving zero of the two brothers who founded the Allman Brothers Band in 1969 still alive (also making Cher the ex-wife of two deceased celebrities). I’m not a fan at all of the retired band’s music since I really dislike Southern boogie and country music even when it’s bluesy (other than Lynyrd Skynyrd, anyway), but it’s apparent that hard living took its toll on the founding members — Duane Allman died at 24 in 1971 in a motorcycle accident, bass player Berry Oakley died a year later in the same manner and location, and drummer Butch Trucks killed himself earlier this year. That leaves guitarist Dickey Betts (73) and drummer Jaimoe Johanson (72).

I’ve had problems for years where I leave the laptop running and Firefox is open to pages that refresh (like Twitter or news sites) – Firefox gets sluggish and Windows Task Manager shows it eating up a huge amount of memory and CPU, requiring me to hard-cancel it. The solution – I finally switched to Chrome for everything browser related, which makes even more sense now that I’m using a Chromebook and an Android phone. My only non-Google technology is an iPad Mini and the Windows laptop, both of which will move to a Google platform when it’s time to replace them.

In Flanders Fields
By John McCrae, MD (1872-1918)

In Flanders fields the poppies blow
Between the crosses row on row
That mark our place; and in the sky
The larks, still bravely singing, fly
Scarce heard amid the guns below.

We are the Dead. Short days ago
We lived, felt dawn, saw sunset glow,
Loved and were loved, and now we lie
In Flanders fields.

Take up our quarrel with the foe:
To you from failing hands we throw
The torch; be yours to hold it high.
If ye break faith with us who die
We shall not sleep, though poppies grow
In Flanders fields.

This Week in Health IT History

One year ago:

• Forbes revises its estimate of the net worth of Theranos founder Elizabeth Holmes from $4.5 billion to zero.
• An ONC study finds that 84 percent of US hospitals are using at least a Basic EHR, a nine-fold increase since HITECH’s adoption in 2009.
• DrFirst acquires Meditech-focused consulting firm The IN Group.
• CHIME awards $30,000 each to the two finalists in the concept round of its national patient ID challenge, with those contestants moving to the final $1 million round.

Five years ago:

• Allscripts caves in to a proxy fight and adds three new board members advocated by key shareholder HealthCor Partners, which had publicly called for Allscripts to fire CEO Glen Tullman.
• Three-fourths of respondents to my poll disagree with Neal Patterson’s assertion that Cerner and Epic will end up being the only hospital EHR survivors.
• Fired HCA doctors say the hospital chain hired huge numbers of physicians to prepare for an ACO environment, then terminated those whose practices weren’t profitable.

Ten years ago:

• A research article finds that few hospitals are using bedside barcode-checking of medications and that nurses bypass those systems frequently.
• An article describing problems with Kaiser Permanente’s shuttered kidney transplant program blames information management problems and its paper-based systems.
• A rumor suggests that Misys is trying to sell its hospital systems.
• Former National Coordinator David Brailer launches the $700 million private equity fund Health Evolution Partners.
• MED3OOO takes a majority ownership position in InteGreat.

Weekly Anonymous Reader Question

Last week’s results: job promotion factors.

This week’s survey: what is the role of the person you most value as a mentor and/or professional peer, how did you connect with them, and how do you maintain the relationship?

Last Week’s Most Interesting News

• The Wall Street Journal notes that uncertainty surrounding the Affordable Care Act has forced some health IT startups to change their strategies.
• Five hospitals in Australia experience an IT incident cause by applying security patches to protect against WannaCry ransomware.
• Apple acquires sleep monitoring sensor and app vendor Beddit.
• The Congressional Budget Office estimates that the Affordable Health Care Act would increase the number of uninsured Americans by 23 million by 2026 in reducing the deficit by $119 billion.
• The Bipartisan Policy Center calls for private-public efforts to improve health IT safety, but does not mention ONC’s proposed EHR safety center.
• The director of Denmark’s equivalent of the FDA warns that big US tech companies like Google and Apple are rolling out health apps without demonstrating their efficacy and safety and that those companies are gaining permanent access to patient data.
• The local paper says that Erie County Medical Center’s ransomware infection is still affecting the hospital six weeks after the hospital decided not to pay the demanded $44,000 ransom, also running a screenshot provided by a hospital employee that suggests that the culprit was Samas, the same malware that took down MedStar Health in 2016. 

Webinars

June 22 (Thursday) 1:00 ET. “Social Determinants of Health.” Sponsored by Philips Wellcentive. Presenter: David Nash, MD, MBA, dean, Jefferson College of Population Health. One of the nation’s foremost experts on social determinants of health will explain the importance of these factors and how to make the best use of them.

June 29 (Thursday) 2:00 ET. “Be the First to See New Data on Why Patients Switch Healthcare Providers.” Sponsored by Solutionreach. As patients pay more for their care and have access to more data about cost and quality, their expectations for healthcare are changing. And as their expectations change, they are more likely to switch providers to get them met. In this free webinar, we’ll look at this new data on why patients switch and what makes them stay. Be one of the first to see the latest data on why patients leave and what you can do about it.

July 11 (Tuesday) 1:00 ET.  “Your Data Migration Questions Answered: Ask the Expert Q&A Panel.” Sponsored by Galen Healthcare Solutions. Presenters: Julia Snapp, manager of professional services, Galen Healthcare Solutions; Tyler Suacci, principal technical consultant, Galen Healthcare Solutions. This webcast will give attendees who are considering or in the process of replacing and/or transitioning EHRs the ability to ask questions of our experts. Our moderators have extensive experience in data migration efforts, having supported over 250+ projects, and migration of 40MM+ patient records and 7K+ providers. They will be available to answer questions surrounding changes in workflows, items to consider when migrating data, knowing what to migrate vs. archive, etc.

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

Acquisitions, Funding, Business, and Stock

Debt-ridden Florida-based clinic operator 21st Century Oncology – which was breached by hackers in 2016 in exposing the records of 2.2 million patients and resulting in at least 13 federal class action lawsuits – files Chapter 11 bankruptcy. As companies tend to do, 21st Century calls the bankruptcy a “positive development,” brags that it is “fundamentally strong and profitable,” and claims that “very little, if anything, should change during the Chapter 11 process,” calling into question either the credibility of the company or of the US bankruptcy process that is often used as a shrewd corporate strategy to legally screw employees and creditors for the benefit of executives.

Decisions

• Fitzgibbon Hospital (MO) will replace Meditech and GE Healthcare with Cerner in November 2017.
• Pinnacle Hospital  (IN) will go live with Prognosis Innovation Healthcare in June 2017.
• Illinois Valley Community Hospital (IL) will implement Athenahealth’s EHR in November 2017, replacing McKesson.
• Pioneers Medical Center (CO) will go live with Athenahealth in 2017.
• Riverside Tappahannock Hospital (VA) will replace Siemens with Epic in June 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

Vanderbilt LifeFlight develops an Uber-like app to allow first responders to request a helicopter, sending the service an the GPS coordinates and and requestor information while giving the emergency responder a real-time flight map and estimated arrival time.

Other

A co-founder of startup Iodine — which published patient-submitted experience with medications — says his company, as well as other digital health startups, were naive in thinking that their technology could create a healthcare revolution. Iodine quietly sold itself off to drug discount coupon publisher GoodRx a few months ago. Thomas Goetz says not only did disruption not happen, it probably never will, because:

• Healthcare regulation hinders rapid transformation.
• Entrenched players are huge and have their hands in multiple aspects of healthcare.
• Nobody cares about better-faster-cheaper in healthcare.
• There’s no ability to shop prices.
• The government is the biggest customer.
• Incentives are misaligned.

The Columbus, OH paper profiles prescription prior authorization system vendor CoverMyMeds, the first local startup to sell itself for at least $1 billion (to McKesson in January of this year for $1.1 billion, this case). CEO Matt Scantland says the company’s formula for success was, “Start with a big problem and solve it not by disrupting anything, but by finding a way that everyone wins,” adding that it wasn’t the first company to tackle the problem, but rather the first to develop a scalable solution. The article notes that CoverMyMeds has over 500 Columbus-based employees who get a free gourmet lunch each day and have a virtual reality room to play video games with peers in its Cleveland office. I interviewed Matt in September 2014 when the company had just 73 employees and $19 million in revenue, but he was predicting bigger things:

Prior authorization seems like a very niche thing. It kind of is, but at the same time, it’s also right at the intersection where a doctor is making a decision about the tradeoffs between the cost of a treatment and its efficacy. We think that that’s a fundamental problem in healthcare. We have built both the network and the connectivity and then also the relationships with pharma, payers, pharmacies, and providers. We think we can help doctors make more intelligent consumption decisions. We think is a very large opportunity, starting with drug, but helping to get to more personalized medicine in terms of prescribing, and then also other procedures as well. Because of the growth of the size now, we have a lot of interest from the financial and strategic partners. We’re always willing to listen. We think this is a very big standalone company on its own.

He went down, under. In Australia, a member of Parliament laughs so hard while watching the US TV show “Veep” that he chokes on his sushi, passes out, and stumbles through his house before falling face-down unconscious into his granite kitchen island, leaving him with a black eye, three stiches, and a get-well tweet from star Julia Louis-Dreyfus.

Sponsor Updates

• Encore, A Quintiles Company publishes a white paper titled “Care Management Framework – The Critical Path to Implementing a Care Management Strategy.”
• QuadraMed, a Harris Healthcare company, will exhibit at the NYHIMA Annual Conference June 4-7 in Rochester.
• Salesforce announces strategic agreement with Dell Technologies.
• Solutionreach expands leadership team with new promotions.
• Summit Healthcare and Access will exhibit at the 2017 International MUSE Conference May 30-June 2 in Dallas.

Blog Posts

• How IT Leaders will Guide Digital Transformation (Salesforce)
• Is Hospital Pricing Transparency Possible? (The SSI Group)
• Three Ways to Take Appointment Reminders to the Next Level (Solutionreach)
• How Secure are Your Backups? (Summit Healthcare)

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne, Lt. Dan.
More news: HIStalk Practice, HIStalk Connect.
Get HIStalk updates. Send news or rumors.
Contact us.

Reader Survey Results: Job Promotion Factors

I asked what factors affected a job promotion.

Being humble, but speaking up in meetings (especially with solution ideas for important problems).

Many factors worked together to promote me through three levels in five years. An ability and willingness to drive change and tackle challenges in areas traditionally labeled as “impossible” because they required revamping entrenched negative habits. An unflinching determination to get tasks done on time (with no short cuts) and work out compromises even with the most difficult stakeholders. The ability to get to the root cause of an issue and focus on how to avoid future snafus with education and documentation without dwelling on placing blame. Consistently keeping EVERYONE very well aware of a projects progress and problems – so everyone felt in the know. Taking copious and diligent notes so as to instill trust and confidence when making statements at meetings, allowing decision makers to move forward more quickly. It also didn’t hurt getting another master’s degree specializing in a key niche area! Never let your skills become stale or your attitude become obstinate.

Proving myself works in getting more responsibilities. Moving to a new company was required to get a promotion.

Paying attention. I don’t believe in random luck, I believe that if you keep your mind open, you will be able to see the opportunities that are all around you. Luck is the ability to see the doors that are already open, waiting for you to step through. Also, be kind and generous.

I do not seek a promotion as something to have, a title to add to my business card or resume. I do not seek a promotion as a reward for time served or deeds already done. I seek a promotion for the opportunity to connect with new people to share ideas, the ability to move forward with new kinds of projects, the ability to tap into new resources. If you can articulate your desire for promotion in the context of moving forward instead of looking backward (a reward) or appearance (new business cards), then your organization will see you as a part of their future as well.

Always doing what I think is the right thing,and the best things for my customers. Always be honest and when I see a problem or an opportunity for improvement, regardless if I am responsible for it or not, I try to identify a solution.

Not looking for the promotion and focusing on making my boss(es) look good. Supporting their ideas and approaches.

I’ve had three offers to get a significant bump in salary and/or role. Every time was when I threatened to quit.

Receiving offers from other companies willing to pay me more.

Job changes, willingness to take on new projects, show value and communicate it.

Building relationships and consistently delivering results.

Who you know and certifications. Also geographical location seems to be a factor — if the person who is doing the hiring is from the same area of the country as you, then that helps with a connection.

Being better at the job than all the other people around me.

I’m a white male. I am also smart, talented, and hard working. But judging from my colleagues, being a white male is often all that is needed to climb the ladder. Competency does not seem to be a requirement.

A good boss. There are ideas, and there is doing. Do. Prompt responses to your boss and your boss’s boss.

#1: Asking for them. Having competing offers (that helped with salary level). Having (at the time) a relatively unique background with IT and medical experience. Having the right networks of people who give your request credibility

Company laid off one-third of people. We all applied elsewhere, they begged us to stay. To stay, I requested improved salary, vacation, and title. They obliged.

Leaving.

Most of my promotions have occurred when I’m working for someone who gets things done and cares about my career. Lesson: Think about who you are aligned with professionally.

Self-sufficiency and a willingness to figure things out on my own.

The ability to lead others, even if not in an appointed leadership role. Last promotion to Lead Analyst role earned by demonstrating ability to assist new and current co-worker analysts to achieve positive results. Sometimes though one is born with an innate nature to lead and enjoy doing so (without be overbearing – i.e., “bossy”). One can always possess a technical ability to perform job duties, but needs guidance and mentoring to achieve success.

My ability to smile while professionally dealing with the jackasses that infest our fine HIT industry.

Being a woman. Just kidding!

My top 3: specific measureable business results from work. The ability to communicate effectively with both non-IT and IT people. Reasoned risk-taking.

Integrity, dedication to performing at the best of my ability, and respect for everyone’s role and contribution to delivering quality services.

Being in the right place at the right time. Having a track record of delivering results. Being helpful and useful. Thinking critically and anticipating my next action. Dressing nice, being well groomed and presentable, speaking clearly and confidently, having a sense of humor, and being able to relate to everyone, not just my peers.

Morning Headlines 5/26/17

Health-Tech Startups Pivot as Obamacare Uncertainty Mounts

The Wall Street Journal profiles health IT startups funded during the ACA boom, and how they are pivoting their business models to survive the ongoing legislative uncertainty around ACA’s repeal.

Townsville Hospital responds to major cyber incident

In Australia, five hospitals within Queensland Health suffer network downtime stemming from issues installing the WannaCry security patch.

Synopsys and Ponemon Study Highlights Critical Security Deficiencies in Medical Devices

A survey of medical device manufacturers finds that 67 percent believe that an attack on one of their devices is likely to occur in the next 12 months,  but despite the risk only 17 percent are taking significant steps to prevent cyberattacks.

Health Care Providers Must Stop Wasting Patients’ Time

Harvard Business Review profiles Kaiser Permanente’s efforts to coordinate care outside of the hospital setting effectively enough to discharge surgical patients earlier, in many cases on the same day of the patient’s surgery. .

News 5/26/17

Top News

The uncertain future of the Affordable Care Act is forcing some health IT startups – especially those that sell mostly to hospitals – to change their strategies, according to a Wall Street Journal report.

The political turmoil has also raised the funding bar as investors seek out companies with solid revenue and market validation, thereby putting their money into fewer but larger deals.

These companies are reported to have made changes due to ACA uncertainty:

• Smart pill bottle maker Pillsy is refocusing its sales efforts on consumers rather than providers.
• Diabetes management technology vendor Omada Health is increasing its sales emphasis on clinical evidence and return on investment.
• Pregnancy tracker app vendor Babyscripts is concentrating on large health systems instead of physician practices.
• Take Command Health, which helps people who can’t get employer-provided health insurance find coverage, is revamping its platform to target small businesses that reimburse employee healthcare costs.
• Amino, whose tools target specialty care, raised $25 million after changing its platform to analyzing the cost of preventive services that may no longer be free with ACA changes.

Reader Comments

From Ex Epic: “Re: CommonWell. In the Madison consultant community, it’s pretty much understood that CommonWell is/was a Cerner marketing campaign to win the DoD. They tweeted these numbers at their collaboration forum last week, with quick math showing they have roughly one document retrieved per customer facility.”

HIStalk Announcements and Requests

This week on HIStalk Practice: Solutionreach’s Jim Higgins highlights the importance of patient relationship management in attracting and keeping millennial patients. Qliance Medical Management abruptly shuts down clinics amidst financial and legal difficulties. Lemonaid Health raises $11 million. Harbin Clinic adds PrecisionBI analytics to its Athenahealth tools. School nurses up in arms over incentivized telemedicine consent. Femwell Group Health will offer HealthGrid patient engagement tech. ClearHealth Quality Institute looks for telemedicine committee candidates.

Webinars

June 22 (Thursday) 1:00 ET. “Social Determinants of Health.” Sponsored by Philips Wellcentive. Presenter: David Nash, MD, MBA, dean, Jefferson College of Population Health. One of the nation’s foremost experts on social determinants of health will explain the importance of these factors and how to make the best use of them.

June 29 (Thursday) 2:00 ET. “Be the First to See New Data on Why Patients Switch Healthcare Providers.” Sponsored by Solutionreach. As patients pay more for their care and have access to more data about cost and quality, their expectations for healthcare are changing. And as their expectations change, they are more likely to switch providers to get them met. In this free webinar, we’ll look at this new data on why patients switch and what makes them stay. Be one of the first to see the latest data on why patients leave and what you can do about it.

July 11 (Tuesday) 1:00 ET.  “Your Data Migration Questions Answered: Ask the Expert Q&A Panel.” Sponsored by Galen Healthcare Solutions. Presenters: Julia Snapp, manager of professional services, Galen Healthcare Solutions; Tyler Suacci, principal technical consultant, Galen Healthcare Solutions. This webcast will give attendees who are considering or in the process of replacing and/or transitioning EHRs the ability to ask questions of our experts. Our moderators have extensive experience in data migration efforts, having supported over 250+ projects, and migration of 40MM+ patient records and 7K+ providers. They will be available to answer questions surrounding changes in workflows, items to consider when migrating data, knowing what to migrate vs. archive, etc.

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

Acquisitions, Funding, Business, and Stock

Clinical trials software vendor Medrio receives a $30 million equity investment from Questa Capital Management.

Apple acquires Finland-based Beddit, which offers a sleep tracking app that uses mattress-attached flexible sensors.

People

Jessica Campbell (Leidos Health) joins Nordic as VP of client partnerships.

Announcements and Implementations

Elsevier will add its ClinicalKey clinical search engine to the World Health Organization’s Research4Life journal access program for developing countries. 

The DiamondView HIE of South Country Health Alliance (MN) goes live with Medicity Notify, which provides electronic notification services for population health management that will be rolled out across its 11 counties.

Government and Politics

ProPublica reports that some Republican lawmakers who are being called out on social media for their support of the American Health Care Act (and their sometimes incorrect statements about it as copied and pasted from White House talking points) are blocking their vocal constituents on social media after deleting their comments. An example is Congressman Peter King (R-NY), who not only appears to be censoring critical comments, but is also declining to conduct in-person town hall meetings because attendees scream at him.

Privacy and Security

In Australia, Queensland Health experiences a major EHR failure after applying WannaCry security patches from Microsoft, Cerner, and Citrix that slowed down systems and affected the ability of users to log on.  

A survey finds that only 9 percent of medical device manufacturers test the security of their products at least once a year, with nearly half saying they don’t perform security testing at all. One-third of both manufacturers and health systems say no single person is in charge of device security and half say they don’t follow the FDA’s guidance to reduce security-related risk.

A security researcher finds that medical claims processed by insurer Molina Healthcare were freely accessible over the Internet simply by changing the number at the end of any claim’s URL to bring up a different claim, with no authentication required. The company fixed the problem after being notified and has shut down its portal pending a security review.

Other

NantHealth CEO Patrick Soon-Shiong announces plans to open a cancer center, saying that the city has a great basketball team and newspaper (he owns a chunk of both), but not a great cancer center.

Slides from Cerner’s investor conference presentation show that Cerner and Epic (which Cerner references by name, which doesn’t happen often) each hold 24 percent of the acute EHR market. Cerner won decisions involving 109 hospitals in 2016 vs. Epic’s 91, although it was 69 vs. 66 when excluding existing customer add-ons. It also notes that 2,400 hospitals are using legacy systems that offer a replacement opportunity, with more than one-fourth of them running Meditech Magic or C/S.

A group from Kaiser Permanente writes a Harvard Business Review article about KP’s efforts to get surgery patients out of the hospital quicker by using standardized processes and team coordination. The authors honor Jess Jacobs, who at the time of her death in 2014 at 29 had measured that in her 20 ED visits, 54 inpatient days, and 56 outpatient visits, only 0.08 percent of her time was spent actually treating her medical problems.

The State of New Jersey temporarily suspends the medical license of a psychiatrist who had prescribed thousands of doses of oxycodone for a single patient, with the attorney general announcing, “Our message to these doctors is clear: if you are not checking the Prescription Monitoring Program database as required by the new law, we will take swift and punitive action against you.”

The Wall Street Journal profiles CVS Health EVP/CIO Stephen J. Gold, who says that 30 percent of the company’s pharmacy customers use its text messaging system for prescription refills. He mentions CVS’s Fast Mobile Prescription Pickup, which allows customers to pick up their refills at the counter or drive-through by scanning the barcode sent to their phones. The company is also using a proprietary health engagement engine to look for intervention opportunities, such as sending a message to patients who aren’t taking medications as prescribed or reminding diabetics to test their blood glucose. Another CVS digital tool allows patients to synchronize the refills of all of their prescriptions to save a trip and to improve adherence.

The State of Minnesota, admitting that it can’t keep up with complaints about nursing homes that mistreat their residents, warns nursing homes that they cannot harass families who install “granny cams” in the rooms of residents to document the care their loved one receives. The ruling came after a woman who had placed a $199 video camera in her mother’s room complained that nursing home employees frequently covered it with a towel, unplugged it, pressured her mother to remove it by refusing to speak to her when entering her room, and eventually seized it.

The US finishes in its customary back-of-the-pack spot in a new global health measure that looks at: (a) how well countries prevent deaths by applying known medical interventions; and (b) how health measures improve with increasing national wealth. The author says it’s “an embarrassment” that the US spends $9,000 per citizen annually on healthcare while failing to improve its lagging world health position.

Sponsor Updates

• The Chartis Group publishes a white paper titled “Performance Transformation: An Undeniable Requirement in Uncertain Times.”
• GE Healthcare previews its upcoming film, “Heroines of Health.”
• Meditech announces that it sold systems to five customers representing 16 hospitals in Q1.
• EClinicalWorks will exhibit at the 2017 MPHCA Annual Conference May 30-June 2 in Biloxi, MS.
• FormFast, HealthCast, Iatric Systems, Imprivata, and Intelligent Medical Objects will exhibit at the 2017 International MUSE Conference May 30-June 2 in Dallas.
• As of May 18, people have counted on Healthwise information 2 billion times.
• DrFirst is sponsoring next week’s MUSE conference, where its executives will present seven medication management sessions.
• InterSystems will exhibit at the DoD/VA and Gov Health IT Summit May 31-June 1 in Alexandria, VA.

Blog Posts

• Prevention is Better Than a Cure: An In-Depth Look at Proactive Health (Evariant)
• From working with the pediatric population to diving into technology (Infor)
• 3 reasons why the CBO score should be a wake-up call for hospitals (Advisory Board)
• Four Considerations for CJR Payment Reconciliation: Is Your Organization Prepared? (ECG Management Consultants)
• Recap of expanded Community Giveback Week (Nordic)
• Why Healthcare Technology Innovation Must Consider the Patient Story (Hayes Management Consulting)
• Responding to the WannaCry Cyber Attack (The HCI Group)
• 4 Questions with Joan McFaul, Former CIO of Southcoast Health System (Optimum Healthcare IT)
• Houston. Healthcare. Fossils. Profits. (Healthcare Growth Partners)
• Smart Pumps at MUSE 2017 & how this topic relates to all of us (Iatric Systems)
• Patches aren’t the silver bullet; hospitals can keep systems running when hit by ransomware attacks (Imprivata)
• Why Horizontal Martech Won’t Work for Healthcare (Influence Health)
• 3 Key Security Threat Trends Healthcare Organizations Can’t Ignore (InstaMed)
• Overcoming Entropy: Cultivating Care Coordination at eHealth Week (InterSystems)
• Five Must-Track Digital Marketing Metrics for Health Systems (Kyruus)

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne, Lt. Dan.
More news: HIStalk Practice, HIStalk Connect.
Get HIStalk updates. Send news or rumors.
Contact us.

EPtalk by Dr. Jayne 5/25/17

I’d wager that 99 percent of people who have worked with me wouldn’t classify me as a delicate flower, a special snowflake, or someone who is easily offended. I’ve spent the majority of my academic and professional careers in male-dominated fields and have been on the receiving end of sexual and other harassment.

I take issue, however, with organizations that pay lip service to diversity and inclusiveness when their actions say otherwise. Not everyone has a thick hide, however, so when one of my consultants reported that a client was behaving badly, I wanted to gather some evidence.

I spent a good chunk of today listening to recordings of conference calls, which unfortunately demonstrated everything my consultant said was going on and more. Boorish and unprofessional are the mildest adjectives I could come up with as I prepare my letter terminating our professional relationship.

We had been hired to assist a small practice with their workplace dynamics and to help try to correct some issues they’ve had with staff turnover. Our first onsite assessment revealed countless sports and gambling analogies (in nearly every conversation) that had a tendency to alienate members of the staff who might not find stories about betting at the dog track to be amusing or in harmony with their religious beliefs. Based on our findings, we agreed that you can coach your way through a lot of that, and we persisted because they seemed willing to participate in making things better.

Many of their issues were process related, with staff being frustrated by lack of policy and procedure documents that would explain why they were constantly being told by one partner or another that what they were doing was wrong. My consultant worked on getting an employee handbook together and at standardizing their office workflows knowing that reduced variation would make things less stressful and perhaps increase retention. She did some stakeholder assessments that identified many of the issues being attributed to a couple of the physicians, with the rest of the providers being highly respected.

The two physicians who needed the most work have been abrasive to my team, but within the realm of what the team felt they could handle. Plus, they were treating both male and female consultants badly, so we chalked it up to boorishness rather than discrimination.

Over the past few weeks, though, the behavior has escalated. One consultant (who happens to be a man) never complains about anything, so I knew that there was more to the story when he described some of the behavior as “unseemly.” We discussed strategies for discussing it with the managing partners and office manager and that we’d monitor how things were progressing.

At this week’s management meeting, however, some comments were made about certain office responsibilities being “women’s work” and one of the managing physicians told a young female physician to stop bringing her complaints to office meetings and maybe bring some cookies or cupcakes instead. It may have been meant in jest, but I doubt he would have said the same to a junior male physician. In fact, after reviewing the recording of the meeting, he didn’t say anything of the sort to a male peer who was also complaining. He listened to the same types of concerns from one while chastising the other for hers.

It wasn’t just that. The meeting ranged all over the place, with outright mocking of the regional dialect of one staff member and some snarky commentary about various ethnic groups and international political conflicts. There was also some talk that could be graciously referred to as “locker room talk” that was pretty rough.

Listening to some of the banter, all I could picture in my mind was an episode of “The Three Stooges.” Some of the comments were so bad and so highly inappropriate that I felt like the physician in question was trying to sabotage himself. I don’t care who you are, or where you are, or what your beliefs are, some things are just not OK and there are lines that should not be crossed.

I transcribed some of the dialogue and scheduled a call with the head physician to address it. Although he was apologetic, he wasn’t willing to address his partner and essentially told me that since Dr. Lawsuit-Waiting-to-Happen was the top biller and we needed to stop making waves.

At that point, I let him know that I was unwilling to put my team in a hostile environment and that we were done since the entire point of the consulting engagement was to help them get to the root of (and hopefully fix) their office turnover issues. If he wasn’t able to assist with the process, there was little more for us to do. He seemed to take it in stride, said he understood why I was canceling our agreement, and asked me to send a formal written termination notice so he could release us from the rest of the engagement.

It was at that point that I realized the extent of his partner’s bullying. He knows he has a problem and he knows he’s not ready to take on his partner, so he is going to go along with it. I hope he comes to his senses before they get slapped with some kind of lawsuit, but I’m not holding my breath.

For practices struggling with the transition from fee-for-service to value-based care, or dealing with shifting payments and increasing patient responsibility, or all the other pressures, having a physician behave like this is the last thing they need. You need your office running as a finely-tuned machine. But until they’re willing to address it, or let someone else address it, they’re going to get what they get.

Like I said, I’m not easily shocked, but this guy took the cake (regardless of whether a man or a woman baked it). I didn’t have the opportunity to shadow him with patients, but I wonder how he is on the other side of the exam room door and why patients continue to flock to him. He has to have some redeeming value, but after this week I am challenged to figure out what it might be. It makes me more grateful to be in my current practice situation, where this sort of nonsense would never be tolerated.

Since most of us can’t fire our colleagues or co-workers when they act like this, how does your organization handle boorish behavior? Email me.

Email Dr. Jayne.

Morning Headlines 5/25/17

Congressional Budget Office: HR 1628 American Health Care Act of 2017

CBO reports that by 2026, AHCA will reduce the federal deficit by $119 billion but increase the number of uninsured Americans by 23 million.

Putting America’s Health First: FY2018 President’s Budget for HHS

President Trump’s budget proposal includes a $22 million reduction in ONC’s budget.

U of C receives $100 million donation for new wellness institute

The University of Chicago Medicine receives a $100 million donation, the largest in its organization’s history, from Chicago investor Craig Duchossois and his family. The donation will be used to establish a wellness research center.

Patient Safety and Information Technology

Former National Coordinator Karen DeSalvo, MD speaks at the release of Bipartisan Policy Center’s report on health IT safety.

CIO Unplugged 5/24/17

The views and opinions expressed are mine personally and are not necessarily representative of current or former employers.

Leading with Fear – Not!

Researches say we are born with two fears — fear of falling and fear of loud noises. Every other fear is learned. Fear is developed and reinforced because of the consequences and punishments we experience.

Ironically, 85 percent of our fears are never realized. In fact, many are irrational, often based on emotion, not data. Real or imagined, the consequences of fear, especially in the workplace, are devastating.

Insecure leaders rule with fear. Even when effective, the use of fear to motivate employees is morally corrupt. Fear has no place at work. Confident leaders can achieve better results creating an engaged culture without fear. Who wants to work for a leader whose primary tactic is fear to motivate? Nobody.

Clearly, people still work for fear mongers. Leaders throughout history have leveraged fear. Despite the contemporary focus on management theory and professional development, leadership by fear continues.

Employees feel they may not have a choice but to capitulate to the fear mongers. Others have a victim mentality, feel incapable of escape, and assign the experience to fate. At the edge are those who believe they may deserve the punishment.

Naïve workers who know no difference may believe all leaders rule by fear. A smaller percentage know it is wrong, actively resist, and look for the first opportunity to escape. This reinforces the trend where the best employees tend to leave unhealthy environments while peers begrudgingly accept abuse and stay.

Leadership by fear is a management form of bullying. We spend too much time at work to be miserable and treated disrespectfully. There is a better way, and if you find yourself working for an abusive leader, you must stand up for yourself or leave. Pacifism only reinforces the behavior and nothing changes for you, nor for those who follow. Stay and fight if you have the skills, but move on if you have no support. Nobody deserves to be bullied.

I once observed an iron-fisted peer who ruled by fear. Insecure and simply unpleasant, he would routinely yell, curse, belittle, and threaten his team. I watched otherwise aspiring leaders shake to their core. His team trembled working for him. The more they passively accepted his leadership by fear, the deeper it became ingrained.

His power over them grew. His bullying became the new norm and eventually worked its way down to the depths of his division. Weak subordinates accepted and adopted this style and soon the stain and stench of fear permeated. Engagement plummeted as the culture shifted into the abyss. Next, performance fell. Fear, left unchecked, grows and takes no prisoners.

I felt sad. Heartbroken for the people who came to serve each day wanting to do good work, but were bullied. Torn to see aspiring leaders snuffed too early in their careers. Disappointed for customers who suffered deteriorating service. It became a slow death spiral. Lead with fear, and when performance suffers, add more fear.

By the time our parent organization took action, the damage was profound. The division was rebuilt over time, but the scars and pain from fear never disappear. Healing takes time and love.

Love is the antidote to fear. How can you change a fear-emboldened leader or a fear-based culture? Love does not imply that you overlook poor performers and sing Kumbaya all day holding hands sitting in a circle. No, love is a verb and is action-oriented. Love is discipline. Love is tough. While love is kind and respectful, it is never a crutch or excuse. Love does not accept mediocrity. Love propels performance. Love inspires.

I try to incorporate love into who I am as a person and as a leader. I remain a work in process, but it is easier to love then to hate. Love helps me develop compassion for those dealing with adversity. It increases my empathy towards others, which is why I’ve learned to listen to the heart as much as to words.

I am less judgmental and more tolerant. I am increasingly open to new ideas, diversity of styles and beliefs. I have embraced others very different from me and am better for it. Embracing love as a leader quickened my healing of wounds from past hurts. My heart aches for those who have not yet found love. Life is short; there is not time for fear to rule us.

It was awkward the first time I introduced love in the workplace. I was a young officer commanding my first platoon. My platoon sergeant was everything you would think of in a professional warrior. Battle-hardened, he chewed up Second Lieutenants like me for breakfast. But our platoon had challenges and we were not getting better by simply amping the fear in our squad leaders and soldiers.

First I and then SSG Hammer stopped yelling and otherwise intimidating our soldiers. While expectations and discipline never waivered, we demonstrated care and compassion to each of them. Word spread that upon an unexpected deployment, I mowed his young family’s lawn each week in his absence. It was small, but embodied the change in culture we sought. We changed, the platoon was transformed, and arguably it became one of the best engineering units in our battalion. Awkward at first, but love worked.

Love transformed me, my teams, my divisions, and my organizations. Love reached our customers and improved service. It created better opportunities for individuals to become whom they were created to be. It helped foster a culture of civility, setting a firm foundation for individual, team, and organizational success that exceeded expectations.

I learned of love from many sources and I continue to dig deep to find more. My mom loved me and believed in me before I believed in myself. My dad, who bared his soul in a TED Talk about his concentration camp escape while his family was left behind…and how he chose love over fear and till this day he has not once showed anger towards those responsible. Those family and friends who love me despite my failures. My life mentor led with love in a fear-based society and changed the world. Love wins.

Love chases away fear. The two can’t coexist. Where there is love, there is freedom. Where there is freedom, we are inspired to do our best. Lead with love and you’ll witness a transformation that may seem small on some level, but will be giant for those you serve.

Ed encourages your interaction by clicking the comments link below. He can be followed on LinkedIn, Facebook, Twitter, or on his web page.

Readers Write: Technology Can Lift the Veil of Secrecy on Drug Prices

Technology Can Lift the Veil of Secrecy on Drug Prices
By Thomas Borzilleri

Thomas Borzilleri is CEO of InteliScript.

The recent story about the rift over prescription drug prices between insurer Anthem and its pharmacy benefits manager Express Scripts should anger — and frankly, befuddle — any physician or electronic health record (EHR) vendor. Providers and IT vendors should be fed up with payers and patients getting ripped off by inflated drug prices, taking a disproportionate share of the healthcare dollar. They also ought to be puzzled about why, with all of our advances, we are still living in a marketplace where no one knows what drugs really cost.

It’s particularly absurd because technology exists that can put an end to the opacity, overpayment, and oligarchy that characterize prescription drug purchasing today. Providers deserve and EHR vendors can offer tools that deliver the prices for any drug at the five cheapest pharmacies nearby. Doctors can have this data at their fingertips, within a few seconds, at the point of care, integrated into their existing workflow. These technology solutions can also track prescriptions to make sure they are picked up and refilled on a regular basis to gain new insight into which patients are at risk for adverse events due to medication non-adherence.

For years, insurers and patients have just accepted that the price they are getting is the best price, or the only price. However, allegations like Anthem’s — that Express Scripts overcharged the insurer by $3 billion — should make everyone in the healthcare ecosystem skeptical about the fairness of drug prices. But truly lifting the veil on drug prices will take a concerted effort by many stakeholders in the provider and IT vendor communities to take on the PBM juggernaut.

Strangely enough, when PBMs gained widespread popularity in the 1980s, there was an understanding that they worked on behalf of payers to lower prices, both by securing discounts and by steering patients towards lower-cost drugs. The truth, however, is that PBM “discounts” have always included heavy padding in the form of ingredient spreads and per-prescription fees. In fact, while PBMs are typically paying manufacturers 96 percent off the Average Wholesale Price (AWP) —the “sticker price” for drugs —the prices they charge insurers and employers are between 70 percent and 85 percent off the AWP. PBMs are skimming 10-25 percent off each prescription.

Insurers and employers have had little recourse, both because they did not know the true price of prescription drugs and because they did not have a way to easily shop around between competing pharmacies to get the best price on every medication. Instead, complex, opaque package deals with PBMs mean the payer might be getting good deals on some drugs and getting raked over the coals on others.

Drug price transparency and shopping tools are essential for payers to rein in costs and keep both premiums and co-pays from spiking. The urgent need for this data has also intensified recently because an increasing share of prescription drug costs are borne by consumers themselves. Patients simply won’t take their drugs properly, or at all, if they are out of reach financially. Affordability is now the number one reason for non-adherence to medications, which leads to poor outcomes, including avoidable hospital readmissions. A lack of medication adherence is estimated to cause approximately 125,000 deaths, at least 10 percent of hospitalizations, and cost between $100 billion and $289 billion a year.

In the past, some patients have looked to Canadian or other foreign mail-order pharmacies to try to lower drug costs. But these transactions are usually outside the doctor-patient relationship and may cause more harm than good to the patient, either by exposing him or her to dangerous drug formulations or by causing rifts in care continuity.

Doctors and patients, together, must come to the best decision about the right drug for their condition and price must be a part of that equation. We need technology solutions that enable doctors to find the best price on any drug, at local pharmacies that are convenient to the patient. Tools exist to address these concerns. The key is to embed these tools into existing EHR systems. By doing so, we can avoid disrupting doctors’ workflow and can ensure that all e-prescribing information is captured in the patient record.

These solutions must achieve savings for both the payer and the consumer. First, the solution must provide the lowest possible retail price while consumers are still paying off their deductibles, and then provide the lowest negotiated payer price to the insurer or employer once they start picking up the tab. These solutions can also be used to circumvent common PBM strategies, such as excluding low-cost brand and generic drugs from formularies to artificially increase co-pays on these cheaper drugs, which costs insurers and self-insured consumers billions of dollars each year.

Typically, consumers don’t realize that the cash price is in many instances lower than their adjusted co-pay, with the excess going right into the pocket of the PBM. Drug price transparency and shopping solutions should crunch the numbers for the doctor and patient, letting them know when it’s better to pay the cash price and when it’s more cost-effective to pay the co-pay.

Health IT solutions are typically geared towards one healthcare user: hospitals, doctors, patients, insurers, or employers. But drug price transparency technology is one of those rare innovations that will benefit each of those audiences. Doctors and patients, together, will be able to make the best decisions about medication management, at the point of care, during the prescribing process. Hospitals will enjoy better population health management through better medication adherence. Insurers and employers will be able to wring more value from each healthcare dollar.

What we need now is a commitment from EHR vendors to adopt this type of technology. The bottom line is that we can’t succeed in bending the cost curve in healthcare if we don’t know what the costs are in the first place. That includes prescription drugs. We in the health IT industry have the insight and ingenuity to draw the curtain back on drug price secrecy and we have a real obligation to do so.

Morning Headlines 5/24/17

Patient Safety and Information Technology: Improving Information Technology’s Role in Providing Safer Care

The Bipartisan Policy Committee publishes a report on health IT and patient safety, calling for “a coordinated effort—supported by public and private sector funding—to set health IT safety priorities, drawing upon existing reporting and analysis efforts,” in addition to disseminating best practices and continued development of safety standards.

Evaluation of Suicide Prevention Programs in Veterans Health Administration Facilities

An OIG investigation of suicide prevention programs in VHA facilities finds that while veterans account for 18 percent of all deaths from suicide within the US, many VHA facilities still fail to conduct mandatory community outreach activities designed to bolster suicide hotline call volumes.

What Hospital CIOs Think About Data Security and Clinical Mobility 

A survey of 100 hospital CIOs finds that 30 percent of respondents believe PHI is being shared via unsecure methods within their facility.

NantHealth Names Ronald A. Louks as Chief Operating Officer

NantHealth names former BlackBerry President  Ronald Louks as its new COO.

News 5/24/17

Top News

The Bipartisan Policy Center calls for creating a public-private effort to set health IT safety priorities and to disseminate best practices.

The report recommends:

• General patient safety efforts should incorporate the safety of health IT throughout its life cycle.
• Health IT safety should be addressed via a non-punitive learning system similar to medical error reporting.
• Voluntary and mandatory reporting systems should collect de-identified data about health IT safety issues that can drive creation of evidence-based practices and tools.

The report does not specifically address ONC’s proposed EHR safety center.  

Reader Comments

From Vaporware?: “Re: Cerner. How long do they get a free pass on selling interoperability without delivering? Beth Israel Deaconess Care Organization lists just six EHRS of the 40 its providers use – Cerner not among the six – that are willing and able to contribute information to its population health analytics system. Do the live MHS Genesis pilot sites have connectivity to outside EHRs?” I’ll invite readers with the firsthand experience with either project that I don’t have to comment anonymously.

From Chaste Kiss: “Re: this HIMSS-owned publication’s story. I’m embarrassed that I actually clicked the tweet to read more.” No wonder – you were cheated when a publication runs a story titled “Is a takeover of Athenahealth inevitable?” that doesn’t actually answer the question it poses (nor could it). It simply rewords a lazy Bloomberg opinion column in which those original authors speculated  –without using any sources or providing evidence of analytical thought — that maybe Cerner, IBM, UnitedHealthGroup, Aetna, or Epic might be interested in buying Athenahealth (the fact that Epic was named means the authors are clueless). The embarrassingly lazy source article wasn’t improved one iota by having the HIT publication improperly legitimize it by rephrasing its undisciplined conclusions. In both cases, the writers seemed desperate to fill their allotted space with whatever fizzy “news” they could make up with a minimum of expended effort.

From Greg: “Re: sepsis monitoring. The new Meditech 6.1 Surveillance product has a rules-based approach that looks at real-time EMR clinical data in the EMR. There the clinician can be notified and take appropriate action in an efficient and sometimes life-saving manner. These actions can include orders, medications, labs, documentation, problems, interventions, etc. I have personally not seen another EMR that is as far advanced with regards to surveillance.”

From SgtPerkins: “Re: John Brownstein’s tweet about Epic’s App Orchard developer terms. It is no longer available. $50 says he got a C&D from Epic to remove it. Even their awful legalese is intellectual property to them.” Unverified. My screenshot of his tweet from the Boston Children’s chief innovation officer is here. My experience is that such takedown requests often come from an individual’s employer rather than the subject of their comments, especially when the employer is a partner of the company mentioned (as I well know, having been threatened in my early, less-anonymous HIStalk days with being fired by my hospital employer for writing about one of our vendors even though it wasn’t inside information). Also, Epic’s App Orchard legal wording wasn’t really a secret anyway since it’s publicly available and, as other readers have noted, is similar to that of the Apple Store.

HIStalk Announcements and Requests

Readers funded the DonorsChoose grant request of Mrs. D in Arkansas, who asked for writing journals and math activity kits and games for her elementary school class. She reports, “These materials have allowed students to learn using a hands on approach. We love all of our games and our writing journals! Students are so proud to have their own journal to write in each day. You have made all the difference! Thanks again.”

Webinars

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

Acquisitions, Funding, Business, and Stock

Post-acute care software vendor Optima Healthcare Solutions acquires Hospicesoft, which offers hospice software.

Sales

Five Ontario hospitals add PatientKeeper CPOE and medication reconciliation to their existing system and will expand their use of the company’s physician documentation solution, providing an overlay to Meditech Magic and other systems. 

St. Joseph Health (CA) will expand its use of Clearsense analytics in implementing Inception for archiving, access, and visualization of its legacy Meditech data.

Harbin Clinic (GA) chooses analytics from PrecisionBI, a division of Meridian Medical Management.

People

A Philadelphia innovation organization recognizes Children’s Hospital of Philadelphia AVP/Chief Health Informatics Officer Bimal Desai, MD, MBI as its healthcare innovator of the year. He co-founded CHOP spinoff Haystack Informatics, which offers security technology that detects EHR snooping by learning normal staff behavior and calling out exceptions.

NantHealth hires Ron Louks (BlackBerry) as COO.

Announcements and Implementations

Rush Health (IL) launches Rush Health Connect, which aggregates information from its Epic and Allscripts EHRS using InterSystems HealthShare to give clinicians patient information and real-time alerts and notifications.

Change Healthcare joins the Hyperledger open source blockchain project.

The Fresno paper covers the use by Community Medical Centers of RightPatient iris recognition at patient registration, which the article explains isn’t an infrared scan, but rather just a photo of the patient’s eye. It also notes that palm vein ID systems are an alternative. RightPatient can also analyze a patient’s general headshot to identify them going forward.

DrFirst will integrate prescription pricing information from GoodRx into its e-prescribing platform.

Government and Politics

A VA OIG suicide prevention report finds that around 20 percent of inspected VA facilities don’t perform the mandated five outreach events per month, haven’t developed suicide prevention safety plans that are documented in the EHR, and don’t flag high-risk patients in the EHR. More alarmingly, OIG found that while 84 percent of non-clinical hospital hires completed their mandatory suicide prevention training within 90 days, nearly half of newly hired clinicians did not do so.

The director of Denmark’s version of the FDA expresses concern that US tech companies like Google and Apple are rolling out medically-related fitness tools and devices that “have no requirements to demonstrate efficacy and safety, but we are forced into the direction of taking them seriously.” The finance minister warns that while patients are notified by email any time their Denmark-based interoperable electronic medical records are viewed, private services and apps offer no such protection, explaining, “We need to make our citizens aware that there is no free lunch with these big companies. People should make some more demands when they give their data away. These companies want to know what you want before you know it yourselves. We need to look into regulation. These private companies will have this patient data for eternity. Can we be sure they’ll always do good things with it?”

A report by HHS’s Office of the Assistant Secretary for Planning and Evaluation blames the Affordable Care Act for the 105 percent jump in premiums from 2013 to 2017 in the 39 states participating in Healthcare.gov, as the average monthly premium increased from $224 to $476. The report, however, didn’t look at the increase in non-exchange sold individual plans and admits in its “Limitations” section that much of the premium increase is probably due to older, sicker people signing up in 2017 vs. 2013. The analysis also fails to note that pre-ACA policies (Healthcare.gov went live in 2013) were often full of coverage loopholes, exclusions, lack of coverage for pre-existing conditions, and lack of insurer experience with an uncertain risk pool.

HIMSS complains about President Trump’s proposed federal budget that calls for major funding cuts for ONC, CDC, CMS, and NIH along with zero money for AHRQ, which would likely be rolled into NIH. The proposal also calls for cutting Medicaid by $800 billion over 10 years.

Other

A Spok survey of 100 hospital CIOs finds that 40 percent of hospitals don’t discipline staff members who violate mobile policies, 30 percent say a significant portion of hospital data is shared insecurely, and more than half of doctors and nurses are unhappy with the communications methods available outside their EHR. Forty-one percent of hospitals don’t offer secure texting and those that do are equally split between providing it via the personal devices of employees vs. hospital-issued technology. Nearly one-third of clinical staff can’t receive clinical alerts or mobile messages from colleagues. CIOs say their hospitals are still using pagers because they are appropriate for some groups, are reliable, and are cheap and easily supported. More than half of the respondents say their biggest challenge in protecting hospital data is a lack of money and people.

A ProPublica investigative piece observes that the still-increasing US maternal death rate is the highest in the developed world and 60 percent of those fatalities are preventable, profiling NICU nurse Lauren Bloomstein, who died of preeclampsia shortly after giving birth in which hospital medical errors apparently contributed. Factors include women giving birth later in life when their medical histories are complex, the nearly half of US pregnancies that are unplanned, the complications of C-sections, and the fragmented health/insurance system that makes it hard to get prenatal care (likely to get worse with any cutbacks to Medicaid, which pays for nearly half of US births). The article notes that perhaps the healthcare system is focused so much on saving the lives of babies – which it has done well – that it isn’t paying enough attention to the health of the mother. A standardized approach to quickly reacting to possible preeclampsia reduced UK maternal deaths to just two in three years, while up to 70 US mothers die of it annually even as US hospitals push back on implementing evidence-based processes.

All you need to know about US health insurance is contained in this one story. An Army veteran whose wife requires pregnancy-related injections not covered by their medical insurance finds that they make $70 too much per month to quality for Medicaid, so they move from North Carolina to Alabama for a job that offers better insurance. He pays COBRA to cover the one-month lapse before their new insurance kicks in. The baby came in early, the NC insurance wouldn’t pay since Alabama is out of network, and the couple gets a bill for a two-week NICU stay for $178,000, of which neither insurance would pay a penny. They can’t get loans and he will lose his defense-related job if they file bankruptcy. They raised a few thousand dollars in a GoFundMe campaign and are hoping to work out a hospital payment plan for the balance that will probably last the rest of their lives.

Instead of the help desk tech term PEBCAK (problem exists between chair and keyboard), this was PEBCASW (steering wheel). In China, a car show model who is demonstrating Nissans’s emergency braking system by standing in front of the moving car is run over (with only minor injuries despite being thrown 10 feet) after the demo driver – who was not familiar with the system – pushes its button twice, turning it on and then off again.  

Sponsor Updates

• Docent Health assembles bags and lunches for Boston-based charity Bridge Over Troubled Waters.
• The American Association of Critical Care Nurses chooses Kathy Douglas, RN, MHA, chief clinical officer of Abililty Network’s ShiftHound, for its Pioneering Spirit award.
• CSI Healthcare IT provides at-the-elbow support for MaineHealth’s Epic go-live.
• Besler Consulting releases a new podcast, “Lessons learned from the introduction of a physician incentive compensation plan.”
• CapsuleTech and Dimensional Insight will exhibit at the International MUSE Conference May 30-June 2 in Dallas.
• Spok executives will speak at several industry events.
• Direct Consulting Associates will exhibit at the SIIM Annual Meeting June 1-3 in Pittsburgh.
• The American College of Radiology – a National Decision Support Co. partner – wins the ABIM Foundation Creating Value Challenge for its Radiology-Teaches initiative.

Blog Posts

• Hiring the best executives and professionals, monetarily guaranteed to be retained for 1 to 2 years (Direct Consulting Associates)
• EHealth Partnership Unites Ontario Hospitals on MEDITECH (Video Series) (Meditech)
• Specialists Training Specialists (Optimum Healthcare IT)
• Interactive Patient Care Platforms (Sphere3)
• State of the Union Address (AdvancedMD)
• Impressions of a very busy Health IT Expo 2017 in Paris (Agfa Healthcare)
• A Day in the Life of “Death by a Thousand Clicks” (Arcadia Healthcare Solutions)
• Hybrid Cloud is Now the Preferred Option Within Healthcare (Datica)
• Have You Adopted Electronic Prescriptions for Controlled Substances? (Caradigm)
• Prescription Nonadherence: An Infographic (CareSync)
• Growing Pains: A Practical Approach to Managing Your Application Portfolio During Organizational EvolutionGrowing Pains: A Practical Approach to Managing Your Application Portfolio During Organizational Evolution (CTG)
• Healthcare On-Demand: An Experience with Epic MyChart (Culbert Healthcare Solutions)
• 3 Takeaways from the New England HIMSS Spring Conference (Dimensional Insight)

Sponsors named to Modern Healthcare’s “Best Places to Work in Healthcare” 2017 list:

• Cumberland Consulting Group
• Divurgent
• Encore, a Quintiles Company
• Hayes Management Consulting
• Healthfinch
• Impact Advisors
• Imprivata
• Nordic
• PMD
• Santa Rosa Consulting
• The Chartis Group

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne, Lt. Dan.
More news: HIStalk Practice, HIStalk Connect.
Get HIStalk updates. Send news or rumors.
Contact us.

Curbside Consult with Dr. Jayne 5/22/17

I ran across an article about the impact on multi-tasking and memory. We’ve known for a while that the idea of multi-tasking is a myth. What really happens when we try to do multiple things at once is rapid switching of attention, which sometimes doesn’t work very well.

In my experience, trying to tackle two tasks simultaneously only works when one of them is significantly less critical and the majority of attention is paid to the more critical task. This is how we can get away with browsing Facebook while on conference calls, or reading the newspaper while eating breakfast.

When people try to do equally critical tasks at the same time, that’s when things start falling apart. I’ve had a couple of instances where people tell me they’re on two conference calls at the same time, and based on their participation on my side, it’s clear that they’re probably not paying adequate attention to either.

The article specifically looks at the impact of multi-tasking on memory. Research has showed that when people don’t fully attend to an event, they’re less likely to be able to create a strong memory of the event. One of the people interviewed in the article, Anthony Wagner, is a neuroscience researcher. He intentionally avoids having a smart phone, and has found that without it, he’s not lured into surfing the Internet or being constantly connected. As a result, he’s more focused on the activities around him. According to research coming out of the Stanford University Memory Lab, this means he’s more likely to remember the activities he’s watching.

There’s something to be said about just saying no to technology, although most people would be reluctant to give up their smart phones. Unfortunately, it then becomes a matter of discipline, where you have to consciously leave your phone in your pocket or bag rather than give in to the need for constant connection. That seems to be getting harder and harder for many people. I’ve had several uncomfortable conversations recently with employees who cannot pull their noses out of their phones long enough to pay attention to even a brief conversation. Fortunately, these people are not my personal employees because they wouldn’t last long.

Still, I’ve been increasingly asked to help teach people how to work in the new world of technology. People sometimes assume that because younger employees have grown up with technology, that somehow they know the best practices. I’ve found this challenging as workers struggle with prioritization of work, distraction, and follow through. Some of them are not aware of seemingly straightforward work habits, such as how to assess and prioritize an overflowing inbox when time is limited, or how to carve time out of the day to look at that inbox when you’re assigned to train end users or support a go-live.

The research shows that abilities such as attention and recall can be trained. It’s human nature for our minds to wander, but some of us definitely go walkabout more than others. One study mentioned in the article looked at brain function in heavy multi-taskers vs. that in light multi-taskers. The heavier multi-tasking group did worse on certain tests, and brain activity showed they were having to work harder to focus on the task at hand. It’s not clear whether this is a chicken or egg phenomenon – whether this was caused by multi-tasking or whether people with more fluid attention were more likely to multi-task.

Other research has looked at whether using technology causes our cognitive skills to atrophy. One study mentioned looked at those who used Google Maps for navigation vs. using landmarks. Those who used landmarks built better mental maps than those relying on digital assistance. Another looked at people taking pictures of museum pieces vs. those who simply looked at them. Those with cameras had worse recalls of the details. Anyone who has ever been to a school program, assembly, concert, or recital in the last decade has to wonder about the people who are experiencing the entirety of their children’s lives through the screen of an iPhone. Are they really seeing what is going on or are they more focused on getting the perfect video? Regardless, I long to attend events without people holding phones and tablets in the air, blocking everyone’s view.

The article also mentions a 2011 paper titled “Google Effects on Memory: Cognitive Consequences of Having Information at Our Fingertips.” It showed that people are more prone to think of how to find information than to be able to remember it. As someone who deals with tremendous volumes of complex information, the ability to look things up instantaneously is a great asset. On the other hand, if it’s making us somehow less able to retain and recall information, it might not be so great.

One researcher talks about being selective regarding the use of technology. For tasks that are going to be done multiple times, it’s better to learn the information. For one-and-done type work, it might be OK to leverage technology. A non-tech example would be for those of us from the days of the dinosaurs, where we had to memorize our multiplication tables and regurgitate them on 60-second “timed tests” rather than calculating out the numbers each time. No one wants to have to use a calculator to figure out 7×6.

You can easily identify people who haven’t figured out how to successfully leverage technology. They’re the ones who repeatedly ask you questions that fall into the “let me Google that for you” category. They’ve been habituated to need external resources to figure out even small things. Frankly, I’d be glad for some of these folks to use technology as their primary resource rather than waste their employers’ consulting dollars asking me for basic information because it’s easier to ask someone else than to leverage your company’s Intranet, personnel manuals, and policies and procedures.

These are the kinds of basics I’m having to work on at some of my client sites. I recently taught a class on the successful integration of instant messenger into the clinical office to improve patient care rather than detract from it. People don’t inherently know when they should use IM, when they should use email, or when they should simply talk to one another. They need to understand the right use of each modality and then solidify it with documented processes for patient care. Unless you address it head-on, it will continue to cause chaos. I never thought I’d be teaching these kinds of skills, let alone teaching them to physician peers. It’s part of the evolution of technology and healthcare, though, and if a practice is savvy enough to ask for help, I’m certainly glad to provide it.

What’s the most egregious example of multitasking you’ve ever seen? Email me.

Email Dr. Jayne.

Telemedicine Benchmark Survey Points to Increasing ROI and Improved Outcomes

Digital health updates are written by LoneArranger, an anonymous industry insider.

A recent survey conducted by Reach Health on the status of telemedicine initiatives at healthcare organizations identified that these programs are evolving from specialty offerings to mainstream services.

Survey participants represented a broad mix of healthcare organizations. More than half of the 436 respondents were from teaching hospitals or systems, with just over a quarter from non-teaching hospitals or systems and slightly over 10 percent from physician practices. Around a third (31 percent) of the organizations have revenues of $1 billion or greater, 21 percent have revenues between $50 million and $1 billion, with just under half (48 percent) at the low end of the scale with under $50M in revenues.

Patient-oriented objectives including improving patient outcomes, improving patient convenience, and increasing patient engagement and satisfaction were the most common objectives for telemedicine programs. Reducing the cost of care also ranked consistently high across objectives.

The overall priority of the telemedicine program at an organization, as ranked among other provider priorities, had a strong correlation with success. Telemedicine programs with a dedicated program coordinator or manager are also 20 percent more likely to be highly successful.

Reimbursement, both government and private, continues to create the most significant obstacles to success, accounting for the top four unaddressed challenges to telemedicine. Challenges related to EMR systems also create significant obstacles to success, accounting for three of the next four unaddressed challenges. Interoperability and integration issues continue to pose significant challenges.

Telemedicine platform features were rated by respondents based on their value to an organization. Three of the top six platform features were related to telemedicine data, including clinical documentation, ability to send documentation to/from the EMR, and ability to analyze consult data. All of these features were rated as critical or valuable by nearly 80 percent of respondents.

Over half of participants indicated their telemedicine platform was primarily purchased or licensed from a vendor. In general, larger organizations are more likely than smaller organizations to build systems internally. However, the survey results indicated that the mix of build vs.buy is highly consistent across the spectrum of organizational sizes.

Two-thirds of the survey participants indicated their telemedicine solution is a standalone system, and not integrated with their EMR system. Only 10 percent indicated their EMR system serves as their telemedicine system. This is beginning to change as vendors improve integration capabilities, but not rapidly.

Over the past three years that the survey has been conducted, there is a clear transition toward enterprise level programs instead of departmental initiatives. A key driver is improving ROI with several primary motivators, including improving patient satisfaction, keeping patients within the health system, securing reimbursement, enhancing the reputation of the organization, and increasing provider and staff productivity.

Activity has increased across the board and for all settings. However, active E-visit programs grew by 40 percent in 2017 and general practice initiatives also showed strong growth. Maturity levels of programs vary. Service lines requiring access to specialists, especially those in increasingly short supply, are maturing more rapidly than the more generalized service lines. Over 70 percent of the survey participants operate telemedicine programs within the boundaries of a single state.

Morning Headlines 5/22/17

How ECMC got hacked by cyber extortionists

A local paper covers the Erie County Medical Center’s (NY) recent ransomware attack, in which hackers likely executed a brute force attack to identify the password needed to access the hospital’s system, after which they manually encrypted system files and then demanded a $44,000 ransom.

Teladoc Expands Virtual Care Capabilities in Texas

After fighting a six-year legal battle regarding the use of telemedicine in Texas, Teladoc wins the right to expand statewide.

MUSC plans to change the way doctors are paid and the doctors are ‘livid’

Medical University Hospital (SC) will stop paying its providers based on the profitability of their department and start using an RVU-based system, a change that has is unpopular within the local physician community.

Monday Morning Update 5/22/17

Top News

A Buffalo News report describes the ransomware infection of Erie County Medical Center (NY), from which the hospital has still not fully recovered six weeks later. The hospital declined to pay the $44,000 demanded because it had backups, users could look up patient information from the HealthLink HIE, and administrators worried that the hackers might not restore its files even if the hospital paid up.

The hospital thinks hackers used a brute force password attack to gain control of a hospital Web server a week before the attack, then manually logged on looking for files to encrypt. Clinical systems weren’t restored until a month later.

A hospital-provided screenshot of the ransomware message suggests that the malware is Samas, in which hackers use a variety of tools (including login-stealing malware) to gain credentials and install programs that use Active Directory to propagate the malware to all attached devices.

MedStar Health fell victim to Samas in March 2016 days after both Microsoft and the FBI issued public warnings of its threat. The malware requires online access to just one vulnerable server, often one that’s running unpatched Red Hat JBOSS middleware.

Reader Comments

From Identity Thief: “Re: CHIME’s patient ID challenge. Is anyone questioning its usefulness? The $1 million winner has to provide their solution to the market free of royalties, which means they can’t use any underlying technology that isn’t free. Also, the challenge is based on authentication rather than identity assurance. From NIST, ‘authentication’ implies confirmation of the patient’s presence using authentication factors, while ‘assurance’ means verifying that the person presenting those factors is in fact who they say they are. The solutions of the finalist appear to focus on using tokens (most likely biometric) to authenticate themselves. But before a token can be used, there is a need to identify the patient via inspection of their documents, verifying via a third party , or conducting KBA activities. The FY17 Omnibus legislation requires a strategy that is more than just the pervasive use of an authenticator. It requires a way to roll out a program nationally for all patients and to link a known patient to all of their records from any location in which they have received services. We should question whether a winning authentication solution truly solves the patient identity problem. In my opinion, it does not.” I agree that someone would need to physically verify a person’s identity in issuing their authentication token, but then there’s the question of how a different provider would connect to that information collected elsewhere (perhaps it would be self-contained, like a fingerprint profile stored on a smart card.) As you said, positive identification doesn’t necessarily imply data sharing, but that doesn’t seem to be part of the conversation despite the NIST definition. I would be happy with a solution that would (a) prevent identity fraud; and (b) give hospitals a single ID that would eliminate patient merges and that would link all of a patient’s information even just within that one organization’s systems.

From Arm Twister: “Re: Athenahealth. They say they have 35 MU attestations using their complete inpatient solution, but CMS shows only 17 inpatient attestations. Also, is it really Athena that’s being used to attest? HIMSS Analytics shows that most of Athena’s 25 sites are still running RazorInsights for registration, scheduling, and patient billing, so wouldn’t they also be running at least parts of the Razor clinical package, too?”

From Bushie: “Re: Athenahealth. Is it undervalued as the activist investor says?” Value is whatever the buyer thinks it is, but certainly the company has struggled to meet longstanding high-flying expectations as investors begin to question its slowed growth, management changes, forays into marginally related business lines that are defended by deeply entrenched competitors (inpatient), slowing post-HITECH EHR sales, and erratic investor guidance and resulting performance. I would also question, as I have from the day the company announced its IPO, if there’s too much of a Jonathan Bush cult of personality among fanboy equities analysts and whether Athenahealth is really a tech high-flyer vs. a boring business process outsourcer that just sends scanned paper to teams in India for manual entry. The stock price jumped after last week’s announcement that Elliott Management had acquired a 9.2 percent stake (and Wall Street firms predictably applied their impressive 20-20 hindsight to immediately upgrade their share price targets), but that’s probably more of a kneejerk reaction to the assumption that change is inevitable. Carving up the business into parts that are more valuable than the whole doesn’t seem likely and I don’t see opportunities to gain unmet synergy. I suspect the biggest fear out there is that JB will be pushed out and Athenahealth will be left as just another mature, sometimes struggling, not all that interesting industry player whose arc flattened out short of expectations. Quite a few EHR companies looked smart when the government was paying for EHRs in its $40 billion cash for clunkers program, but nearly all of them are scrambling frantically to pivot into population health, analytics, or revenue cycle to prop up their businesses that weren’t prepared for the inevitable scale-back required once the HITECH fired had been extinguished and doctors realized that the EHRs they hated pre-HITECH weren’t any more likable just because someone else (you and I) paid for them. I’ll turn to readers – is ATHN undervalued, what changes should it make, and what companies might like to buy some or all of it?

From Carry On: “Re: HIMSS. What are they paying Steve Lieber these days?” The newest IRS Form 990 I can find is for the fiscal year ending 6/30/15, when he made $1.1 million, a number that’s sure to swell dramatically this year as his retirement benefits are paid out. HIMSS paid more than $400K that year to Carla Smith, Norris Orms, John Hoyt, Jeremy Bonfini, and Alisa Ray. I would enjoy dissecting the HIMSS 2015 990 form if anyone has it – it’s apparently not online anywhere like the older ones.

From Lengua Taco: “Re: VIPs. I was surprised to read that hospitals treat VIPs differently.” You must never have worked in one. My first eye-opening experience was when, as a recent graduate turned hospital department head (unimpressively – it was a crappy, for-profit rural hospital) the awful second banana executive nearly lost his mind upon hearing that the mother of our big-money ophthalmologist was being admitted. He cleared all the rooms around hers, mobilized the dietary people to make special meals well beyond their culinary capabilities, and bossed around the nurses and techs to make sure they tiptoed about deferentially and didn’t screw up clinically (which as any hospital person knows actually makes mistakes more likely in replacing well-honed routines with new exceptions). In hospitals, everyone is treated the same in the ED, but once they are admitted and are found to have connections, money, or power, they are elevated from economy class to first (which, like the best table at McDonald’s, still isn’t that great). Wealthy, demanding local businesspeople and politicians don’t share semi-private rooms with the unwashed rest of us, nor do celebrities or Middle Eastern oil sheiks who might get their own entire floor. I doubt their clinical outcomes are any better, though, just their accommodations, a free pass to break hospital rules, and the endless middle management fawning over their magnificence.

HIStalk Announcements and Requests

Nearly 40 percent of poll respondents say the most important factor in reducing US healthcare costs is to move to a single-payer system that eliminates middlemen, with the next top choices being to control prices and increase emphasis on prevention. Frank provided a thoughtful response in saying that consumerism has worked well with cosmetic surgical procedures, won’t work as well with routine outpatient care and non-emergent elective procedures, and won’t work at all with care in emergencies, with the aged, and involving terminal illness, at least without societal upheaval. He adds that, unfortunately, most of the cost is involved in those areas where consumerism isn’t effective. He also warns that medical technology is advancing in providing expensive treatments for more Baby Boomer conditions. Cosmos says the best use of federal money is for public goods that have not not been addressed by the free market, such as disease prevention, promoting access to care and insurance, and rewarding physicians who do the right thing. Cash payer says treatment costs should be standardized to allow consumers to shop effectively.

New poll to your right or here: does your business card or email signature list a certification or fellowship credential? That issue comes up sometimes in HIStalk, where people complain that I don’t list their FHIMSS, FACHE, CHCIO, etc. My policy is that I list only academic degrees above the US bachelor’s level, with one exception — the non-US MBBS, which technically is a bachelor’s degree but is equivalent to the US MD. I also don’t list licensure, but it gets fuzzy where someone’s practice requires only a bachelor’s degree, such as a nurse, where I wouldn’t ordinarily list either the BS or the RN but there’s otherwise no good way to indicate that the person is a nurse. Sometimes I omit even graduate “degrees” that LinkedIn shows came from unaccredited (and sometimes hilariously phony) schools or that were honorary rather than earned, thus upsetting the folks who are anxious to flaunt a pointless credential in hopes nobody will notice the source.

Readers funded the DonorsChoose grant request of Mrs. A in California, who asked for a projector, document camera, USB camera, and laser printer for her middle school’s library, where she teaches math to 150 students. She reports, “The document camera and projector have improved the quality of my instruction. We will often show different strategies with different colors so that students understand that there is more than one way to solve a math problem. Lately, students have been going up and presenting their work under the doc cam, while other students ask them questions about their work. I also use the document camera and projector heavily for instruction. One particular student who has warmed to the doc cam and projector is Ramses. He loves presenting his work, and he was the first student to do so under the document camera in my 6th grade class. After he presented, students gave him ‘glows’ and ‘grows feedback about his presentation. Now other students present based on his model presentation and students are able to practice presenting their work proudly in front of their peers.”

This Week in Health IT History

One year ago:

• Kansas Heart Hospital (KS) pays a hacker after a ransomware attack, but still doesn’t regain access to its systems.
• Fired Practice Fusion founder and CEO Ryan Howard launches iBeat, which will offer a heart monitor and emergency notification watch.
• Apple CEO Tim Cook says the company is focused on health and its entry point will be Apple Watch, which will have new sensors added.
• HP announces plans to spin off its enterprise services business in a merger with CSC.
• Paul Tang, MD joins IBM Watson Health as VP/chief health transformation officer.

Five years ago:

• Cerner CEO Neal Patterson predicts that the company will hit $10 billion in annual revenue by 2020 and says he will probably retire before then.
• Victoria, Australia ends its HealthSMART hospital software project that involves Cerner, CSC, and InterSystems after running over budget to $557 million.
• HealthCor launches a proxy fight against Allscripts following the resignation of three Eclipsys-connected directors the previous month.
• The VA announces plans to spend up to $5 billion to enhance VistA via the private sector and open source community.
• US CTO Todd Park announces the Presidential Innovation Fellows Program.
• The UK NHS announces plans to shut down its HealthSpace personal health record.

Weekly Anonymous Reader Question

I made last week’s question too specific, I think, given the small number of responses to the question of the most customer-unfriendly contract term or condition seen. I’ll just list those few responses here:

• Charging maintenance fees for applications that just kicked off an implementation, as well as charging implementation and hosting fees! The ultimate double-dip rip-off.
• Arrogant PeopleSoft VP refused to include any language protecting the customer should they be acquired, after all, “they are PeopleSoft”. Two years later, Oracle had them.
• Non-compete clauses that inhibit people from their employment choices.
• Having one vendor try to set the terms for who else I can engage with to optimize pieces of my organization. I have software I like to buy. And I have professionals I prefer to do business with for process improvements. When the software company tries to restrict my ability to engage with the professionals I trust, I view that as very unfriendly toward me.

This week’s reader-requested question: what factors have helped you attain job promotions?

Last Week’s Most Interesting News

• Activist investor Elliott Management takes a 9.2 percent stake in Athenahealth.
• Two highly-touted, well-funded, for-profit primary care clinic chains fail.
• GQ exposes the efforts of fired Trump campaign manage Corey Lewandowski to sell access to the President, with Flow Health hiring the company hoping to reverse the VA’s termination of its data analysis contract.
• Global impact of the WannaCry ransomware is muted when a security researcher finds and activates its kill switch.

Webinars

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

Decisions

• Johnson Memorial Hospital (IN) will switch from Meditech  to Cerner in August 2017.
• Marshall Medical Center (CA) will replace McKesson with Epic in November 2017.
• St Michaels Medical Center (NJ) went live with Epic this year.

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

People

Melissa Bell (MedAssets) joins Inovalon as SVP of client success.

Jim Feen is promoted to SVP/CIO at Southcoast Health (MA).

Announcements and Implementations

Messaging and patient engagement technology vendor Talksoft integrates its appointment reminder app with Uber, allowing patients to click an app button to call a car to take them to their appointment.

Teladoc will expand telemedicine services in Texas following the end of its six-year legal battle with the state over the now-eliminated requirement that patient-physician relationships begin with a face-to-face visit.

Other

Doctors at MUSC’s Medical University Hospital (SC) are reportedly “livid” that the hospital will start paying them based on the number of patients they see (RVUs) instead of based on the profits of their department. The CEO says that doctors who aren’t clinically productive “are going to have a tough time. Everyone has to be accountable to this clinical productivity.,” He adds that the current system is unfair to trauma surgeons who treat uninsured patients but benefits gastrointestinal surgeons who treat mostly Medicare patients. A patient safety advocate whose son died from a MUSC medical error says, “Paying doctors by RVUs is a terrible system and absolutely antithetical to patient safety, never mind workplace satisfaction. The doctors are right to be worried. I think this is a real comment on the priorities of the current MUSC leadership.”

Sponsor Updates

• Encore publishes a white paper, “Enabling Value Based Care through IT.”
• QuadraMed, a Harris Healthcare company, will exhibit at the Texas Regional HIMSS Conference May 25-26 in San Antonio.
• Sphere3 CEO Kourtney Govro co-authors an article on business relationship management in health IT.
• Sunquest Information Systems will exhibit at the API – Pathology Informatics Summit May 22-25 in Pittsburgh.
• Frost & Sullivan features Agfa Healthcare in a new whitepaper, “Vision 2027: Enterprise Imaging.”
• Visage Imaging will exhibit at ACR 2017 May 22-23 in Washington, DC.
• Huron employees volunteer time on day of service to give back to 51 communities worldwide.

Blog Posts

• Art of the Pitch: How to Tell and Sell Your Startup Story (Salesforce)
• How Hospital Billing and Claims Management Processes Affect Revenue (The SSI Group)
• 4 Reasons Text-Enabling Your Landline is Essential (Solutionreach)
• Healthcare is No Longer Local: Explore the Cost of Disparate Health Data (Surescripts)
• Value in Healthcare, Part 2: Linking Reimbursement to Quality and Value (ClinicalArchitecture)
• Improving healthcare quality: four proven health plan strategies that providers should adopt (Verscend Technologies)
• Mobile communication generates excitement at WONE. (Voalte)

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne, Lt. Dan.
More news: HIStalk Practice, HIStalk Connect.
Get HIStalk updates. Send news or rumors.
Contact us.

Morning Headlines 5/19/17

Athenahealth shares soar after Elliott discloses 9.2 percent stake

Athenahealth shares jump 22 percent after hedge fund Elliott Management disclosed a 9.2 percent stake in the company.

ECMC exec on ransomware attack: ‘This is a form of terrorism’

Erie County Medical Center (NY) confirms rumors that the cyberattack that brought its entire network, including email, EHR, and billing systems, was indeed a ransomware attack. Hospital executives declined to pay the ransom and have instead been working to restore services from backups.

“Shoot the messenger:” NYC hospital and vendor threaten DataBreaches.net for reporting on their security failure

DataBreaches.net is served a threatening cease-and-desist letter from Bronx-Lebanon Hospital Center lawyers after reporting that the hospital was exposing patient information due to an improperly configured server.

CHIME National Patient ID Challenge

CHIME announces finalists from its National Patient ID Challenge.

News 5/19/17

Top News

Activist hedge fund operator Elliott Management takes a 9.2 percent position in Athenahealth, sending ATHN shares soaring 22 percent Thursday.

The fund issued its standard language that refers to “operational and strategic opportunities” (often involving selling the company) and expresses its interest in engaging with Athenahealth’s board.

Elliott has pressured other healthcare-related companies to increase shareholder value, most recently The Advisory Board Company and Cognizant.

Reader Comments

From Justin Box: “Re: Mary Washington’s video ‘Right Hand Man.’ We’ve reposted it on YouTube.” Justin, who is SVP/CIO of Mary Washington Healthcare (VA), said the hospital initially pulled the unlisted video from YouTube after I mentioned it Tuesday since it was intended to be for an internal audience only, but has since decided to repost the original, unedited version, which is spectacular. The hospital’s marketing people did an amazing job putting it together and the hospital employees who appear in it were fantastic. This would win my HISsies Best Picture award if I had one. Here’s an even more impressive factoid from Justin – President and CEO Mike McDermott, MD, MBA came up with the Hamilton theme idea, wrote the lyrics, and took on the starring role. I’ve watched it at least 10 times so far today. In one of those IMDB-type “goofs,” listen for the Epic product name that is mispronounced.

From Aftab: “Re: Aspen Valley Health (CO). A failed Epic implementation caused a loss of millions of dollars and the RIF of dozens of long-term employees. The 20-something IT director brought in an inexperienced team with no healthcare background and farmed out the technical IT jobs to an Indian outsourcing company. There was open revolt from the hospital staff, coupled with the CEO and CIO leaving.” Unverified. The 25-bed hospital signed up for Epic at a cost of $5.4 million in October 2015, affiliating with UCHealth. I reviewed the online video minutes of the hospital’s recent board meetings to look for updates — in the March 2017 session, the board talked about choosing a new EHR from among Cerner, EClinicalWorks, and current vendor Meditech, focusing on a system that is “affordable and accessible to any practice.” The board also wants its own MPI that isn’t shared with another hospital and its own EHR build. The board also noted that Cerner and EClinicalWorks are cloud-based, while Meditech would require 50 hospital servers, but they want to make sure cloud-based systems are ready for prime time. They’ve issued an RFI and hope to be live by 2020.

From Publius: “Re: Health Gorilla. Have you heard of them? They’re seemingly a Web-based EMR that supports electronic lab ordering. Is it used by smaller private practices?” I’ve mentioned the company a few times, labeling them as a “medical record aggregator” and secure network that allows sharing records and placing electronic lab orders. Practice price ranges from free to $60 per month. The Silicon Valley-based company – formerly known as Informedika — has raised $4.4 million, none of it recently, and hasn’t issued a press release since October 2015.

From SugerHound: “Re: Apple Watch and glucose monitoring. The rumors are more substantial than are being reported. Chrissy Farr has a great report on CNBC that cites multiple sources.” The article says Apple’s team of biomedical engineers has been developing non-invasive blood glucose sensors for several years in a project originally envisioned by Steve Jobs. They are reportedly conducting feasibility trials and figuring out how to earn FDA approval, which probably won’t come easily or quickly.

HIStalk Announcements and Requests

Readers funded the DonorsChoose grant request of Ms. S in California, who asked for non-fiction books for her third graders, with an emphasis on the environment. She reports, “My students and I have become passionate about plants! Not just any plants, but native plants in particular. The chaparral biome which surrounds our school and community is thriving with plant and animal life. Using the books that you so generously donated, my students learned about the environment, and they started a close study of their backyard ecosystem: the chaparral. Caring for the plants and becoming experts of many of the living things in our ecosystem, my students are now serving as stewards for the environment. Without your generous donation, our project would not have been able to take off.”

My “Listening” selection from three weeks ago was the new solo release of Soundgarden and Audioslave front man Chris Cornell. He died by suicide Wednesday night after a Detroit performance of the reunited Soundgarden. His last song on stage was a cover of Led Zeppelin’s “In My Time of Dying.”

This week on HIStalk Practice: One Medical opens first practice in Seattle. Vivid Vision raises $2.2 million for VR-enabled vision disorder treatment technology. US HealthWorks develops telemedicine app. MD EMR Systems, Bridge Patient Portal work on Centricity integration. CMS allocates $30 million for medical societies interested in helping to develop MACRA measures, adds four regions to CPC+ program. Premise Health will roll out Epic over the next two years.

Webinars

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

Acquisitions, Funding, Business, and Stock

A Singapore-based private equity firm buys a majority position in supply chain technology vendor Global Healthcare Exchange from PE firm Thoma Bravo, which bought the business in February 2014 and will remain a minority owner.

Seattle-based primary care clinic Qliance Medical Management, which had raised $33 million from investors that included Amazon’s Jeff Bezos, shuts down. The two principal officers bought the company in March 2016 from its investors.

Clinical process improvement technology vendor LogicStream Health closes a $6 million Series B funding round.

Credentialing and compliance software vendor Symplr acquires Vistar Technologies, which offers a provider data management system.

Conversa, which offers doctor-patient conversation programs, raises $8 million in a Series A funding round led by the venture arm of Northwell Health (NY), which will also use the company’s systems.

UnitedHealthcare subsidiary Harken Health, launched in 2015 to offer health insurance combined with low co-pay visits in its Atlanta and Chicago health clinics, will shut down after extensive losses.

Amazon is considering entering the pharmacy market, according to reports, which could involve either selling drugs online (which it already does in Japan) or extending its in-house pharmacy benefits management program.

McKesson is basically out of the health IT business (or will be soon), but if anyone still cares, the company announces Q4 results: revenue up 5 percent, EPS $16.76 vs. $1.88, although that includes a pre-tax net gain of $3.9 billion related to the creation of Change Healthcare. MCK shares rose 6 percent in early after-hours trading Thursday, having beaten earnings expectations but falling short on revenue.

Sales

National non-profit behavioral health provider Compass Health Network chooses Netsmart’s EHR in a 10-year agreement.

The VA awards Document Storage Systems (DSS) a $19.6 million contract to implement its ForSite2020 patient self-scheduling system that integrates with VistA. DSS acquired the product in December 2016 with its $2 million purchase of Streamline Health’s Looking Glass patient scheduling and surgery management software, which Streamline had previously bought in its February 2014 acquisition of Unibased Systems Architecture.

Prime Healthcare will implement real-time sepsis surveillance systems from Hiteks Solutions, integrated with Meditech and Epic.

People

Robert Califf, MD — who served less than a year as FDA commissioner before the administration change — returns to Duke Health as vice chancellor for health data science and will also split time in a leadership role at Alphabet’s Verily Life Sciences, where he will work with turning health-related data into practical applications. Verily, formerly known as Google Life Sciences, has worked on continuous glucose monitors, smart contact lens, retinal imaging, and surgical robotics.

Announcements and Implementations

Visage Imaging releases its Visage 7 Open Archive solution of its enterprise imaging platform to customers in North America.

Athenahealth announces a Meaningful Use Stage 3 guarantee for its hospital customers. The company also opens San Francisco-based MDP Labs, an innovation program that offers workspace, mentorship, and exposure to potential investors, partners, and customers.

Healthgrades enhances its online scheduling system to allow health systems to display their nearby alternative providers when a given one is booked up.

Siemens Healthineers will integrate test results from its HbA1C and urinalysis diagnostic equipment with practice-based EHRs via technology from Scotland-based Relaymed, owned by Goodmark Medical of Longwood, FL.

CHIME announces the finalists in its patient ID technology challenge that will move to the prototype testing round:

• Michael Braithwaite (multiple biometrics)
• Bon Sy (behavior information, biometrics)
• HarmonIQ Health Systems (blockchain, FHIR, encryption)
• RightPatient (photos, biometrics, other data)

Government and Politics

The Justice Department files a civil fraud lawsuit against UnitedHealth Group, claiming that the insurer was overpaid at least $1 billion in Medicare Advantage payments after intentionally submitting inaccurate risk adjustment data. UHG says it tried to comply with CMS’s “unclear policies” and adds that the Justice Department either misunderstands or ignores how Medicare Advantage works.

Insurance company executives and state insurance regulators say the ACA insurance marketplaces aren’t collapsing under their own weight, but rather because of the Trump administration’s erratic management, vocal lack of support, and ongoing threats to stop payments, according to an LA Times article. In a remarkably partisan response for a federal department employee, 28-year-old Alleigh Marre — quoted as an HHS spokesperson but self-identified on her LinkedIn profile as a “Republican Communicator,” —  said, “Obamacare has failed. For this reason, Republicans are reforming healthcare so it delivers access to quality, affordable coverage to the American people.” The article also notes that CMS Administrator Seema Verma told insurance company executives that the White House would continue allowing the payment of cost-sharing reductions (premium subsidies, required by law to be paid unless a court rules otherwise) if insurance companies would in turn support the Republican ACA repeal bill, a puzzling offer (even for a near-shakedown political demand) since repeal would do away with the subsidies.

Privacy and Security

Bronx-Lebanon Hospital Center (NY) and its contractor iHealth send threatening cease-and-desist letters to the author of DataBreaches.net after she let the hospital know that their patient information was exposed due to an improperly configured server, for which the hospital originally thanked her. They claim that the discovery of their apparent screw-up constitutes “hacking,” which happens often when companies are embarrassed and attempt to shoot the messenger.

Erie County Medical Center (NY) finally confirms that the April 9 cyberattack from which it is still recovering six weeks later was indeed ransomware, which had been widely speculated. The hospital declined to pay and was forced to move back to paper as its systems were slowly brought back online from backups. They don’t believe it was the WannaCry malware.

Technology

Google is applying machine learning to millions of de-identified patient records from major teaching hospitals to see if it can predict an individual’s medical events.

Google’s major announcements from its developer conference:

• Google Lens, an app that can identify objects from a smartphone’s camera.
• New Daydream virtual reality headsets.
• Photo facial recognition that will suggest sharing images with people pictured in them and AI-powered removal of unwanted objects in photos.
• A visual positioning system that will identify a precise location based on nearby objects, such as finding items on a store shelf.
• The addition of calling and proactive information presentation to Google Home and the porting of Assistant to the iPhone.

In India, Aetna rolls out the first phase of its global launch of it subscription-based vHealth by Aetna, which offers unlimited PCP visits by video or telephone, diagnostic tests at home, home prescription delivery, and referrals. Patients can rate their doctor experience afterward.

FiercePharma profiles Israel-based MedAware, which uses aggregated prescription data and a patient’s own medical records to predict what drugs are likely to be ordered, improving patient safety in providing what it calls a “spell checker” for prescriptions. The CEO has astutely noted that all of that information is also attractive to drug companies that are interested in targeting their physician prospects, giving it an unexpected yet lucrative market.

Other

Boston Children’s Chief Innovation Officer John Brownstein weighs in on the language in Epic’s App Orchard agreement, which basically says that Epic can use any of the submitter’s information to develop a competing product and that Epic permanently owns any documentation that the applicant submits. In other words, it’s exactly opposite of the highly restrictive language contained in Epic’s customer contracts.

In an interesting twist on medical tourism, a nearly completed medical center in Jamaica plans to lure not only medical tourists to fly there for procedures at discounts of up to 40 percent, but also to recruit American doctors to perform the work while taking a Caribbean vacation. Critics point out that it’s been tried before, failing because doctors are too busy to interrupt their vacations and are not likely covered by their malpractice insurance when doing work outside the country.

Bizarre: Michigan suspends a DO’s license after a patient complained that her liposuction surgery was performed in an unfinished pole barn, during which the doctor poured her removed fat down a sink drain.

Sponsor Updates

• Medicity and Clinical Computer Systems, developer of the Obix Perinatal Data System, will exhibit at the Texas Regional HIMSS Conference May 25 in San Antonio.
• Wavelink is named as the first Spok distributor in Australia.
• Medecision presents its annual innovation awards at its Liberation 2017 conference in Austin, TX.
• Definitive Healthcare is recognized by Boston Business Journal for its growth and work environment.
• FormFast and Imprivata will exhibit at the 2017 Spring Hospital & Healthcare IT Conference May 22-24 in Atlanta.
• Healthwise will exhibit at the Cognizant Healthcare Conference May 21-24 in San Antonio.
• InstaMed will exhibit at the 2017 HFMA Florida Chapter Annual Spring Conference May 21-23 in St. Petersburg, FL.
• InterSystems releases a statement on the WannaCry cyberattack.
• Intelligent Medical Objects will exhibit at the Advanced Healthcare Analytics Summit May 24-25 in Boston.
• Liaison Technologies will exhibit at the Bio-IT World Conference & Expo May 23-25 in Boston.
• NEA Powered by Vyne announces the recipients of its 2016 NEA Dental Awards.
• Meditech customer Beaufort Memorial Hospital receives an ‘A’ for safety from The Leapfrog Group.
• Health Professional Radio features Medicomp Systems CEO Dave Lareau.
• National Decision Support Co. will exhibit at ACR 2017 May 21-25 in Washington, DC.
• Consulting Magazine names NTT Data’s Mandy Selmer a Top 25 Consultant.
• Experian Health will exhibit at the HFMA Florida Spring Conference May 21-24 in St. Petersburg, FL.
• Forbes Councils interviews PokitDok Chief People Officer Maria Goldsholl.

Blog Posts

• Be First: How Clearsense Leverages Big Data Anlaytics in Healthcare (Clearsense)
• Disaster Recovery – Minimizing Data Loss (Optimum Healthcare IT)
• Spending a Few Days in a Blog Cabin (Access)
• Can a Medicaid Admission be Profitable? (Definitive Healthcare)
• Business Intelligence Initiatives Require More Than Just Technology to Succeed: Metric Design Development (ECG Management Consultants)
• Arming the Marketer: Creating the Dashboards for the C-Suite (Evariant)
• Non-Medicare Payer Contracts and High Deductible Health Plans: 5 Things to Consider (Hayes Management Consulting)
• The Wazzups and Fist Bumps of Communicating with Patients (Healthgrades)
• Lessons Learned: General Ledger Revenue Mapping (Impact Advisors)
• Government funding bill includes huge step forward for patient identification (Imprivata)
• Healthcare consumer experience takeaways from HMPS17 (Influence Health)
• Nursing 2.0: From Bedside to Techside (InterSystems)
• Agile Healthcare: Leveraging Technology for Real-Time Care Coordination (LiveProcess)
• AWS Hackathon: Blendr, Amazon Alexa, Service Config (LogicWorks)
• Ransomware Attack is Serious Business (NEA Powered by Vyne)
• Why healthcare needs to get ready for big data (Meditech)
• Mother’s Wisdom can Prevent Turnover in Your Front-office and Billing Teams (Navicure)
• Netsmart Associates Become Mental Health First Aid Instructors (Netsmart)
• PIMSY + SayIt (Nvoq)
• Meditech 6.1x Implementation Phase 6: Training (Parallon Technology Solutions)
• Nurses balance it all. (PerfectServe)

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne, Lt. Dan.
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EPtalk by Dr. Jayne 5/18/17

The National Patient Safety Foundation is holding its annual Patient Safety Congress this week in Orlando. This is the first meeting since NPSF merged with the Institute for Healthcare Improvement at the beginning of this month. I’m a big fan of both organizations, not only because patient safety is such a big deal, but because they both offer accessible and cost-effective training for practices and organizations trying to improve their safety culture.

Awards programs recognized NYC Health + Hospitals/Bellevue for their primary care diabetes program and recognized Christiana Care Health System for a care coordination program aimed at reducing readmissions. For all of us who complain about EHRs, we need to remember how hard it was to pursue these types of initiatives with paper charts. If you missed it, next year’s Congress will be held in Boston from May 23-25.

Although telehealth continues to be promoted as a way to increase access to patient care and reduce costs, it isn’t being widely adopted in the primary care trenches. Researchers from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care queried family physicians to understand their use of telehealth and what barriers exist that prevent expansion. The results were published in the Journal of the American Board of Family Medicine and indicate that although many of us are interested in providing these services, few of us are actually doing it. The survey is somewhat limited by its 2014 data; it would be interesting to see whether adoption has been driven forward given changes in technology and payment policies. At the time, however, only 15percent of respondents had used telehealth services during the year, with many using it only a handful of times throughout the year.

The most common uses of telehealth services included diagnosis/treatment (55 percent), chronic disease management (26 percent), follow up (21 percent), second opinions (20 percent), and emergency care (16 percent). I always shudder when I hear about virtual care of emergency problems, but many of the “emergency care” situations aren’t truly emergent in reality, so perhaps this number isn’t as shocking as I originally found it. Those using telehealth were more likely to be rural, have an EHR, and be in a smaller practice that was less likely to be privately owned. Respondents cited lack of reimbursement and lack of training as obstacles to use – both among those who used and did not use services. The authors recommend that residency training be expanded to include telehealth services and that payers should expand coverage.

Personally, I don’t see the latter happening. As we shift towards value-based care, it’s more likely that physicians will explore telehealth as a relatively low-cost care option, at least compared to office visits. As physicians receive bundled payments and operate under payment systems that are tantamount to capitation, they’re going to look for alternatives to bringing people in.

What remains to be seen is how well telehealth vendors will be able to integrate their solutions into mainstream EHRs and how clunky the arrangements are. I’m working with a third-party care management vendor with one of my clients and the technology itself is a major barrier to use. They actually partner with the primary care office to provide telehealth chronic care management services, which the primary care practice bills for under the Medicare Chronic Care Management codes. The vendor has nurses and care managers who review patient-generated data such as daily weights, blood pressures, blood glucometer logs, and more.

The vendor’s employees meet with patients and document care plans and progress, then send the information back to the EHR. In principle it sounds great, but in practice it’s a tangled mess.

First, the vendor offers a standalone patient portal and wants the patient to submit all their data and conversations that way. This directly competes with the practice’s patient portal and creates confusion for the patient on what kinds of questions should be sent to the office and what should be sent to the care management portal. Although the practice sends data to the vendor discretely, what is pushed back to the office to document the virtual visits and care plans comes back as an image. That means it lives in a separate place in the patient chart from all the other data that physicians are reviewing when they see the patient.

Apparently the root cause of this disconnect is the fact that the third party wanted to quickly partner with multiple EHR vendors to sell its chronic care management services, but the EHR vendors were too busy building certification requirements into their products to be able to build the kind of integration that needs to happen. Unfortunately, my client (the practice) didn’t pick up on this during the slick sales demo, and now is stuck with this hybrid approach, at least until their contractual obligations end.

They’ve stopped enrolling new patients in the service in the meantime and are struggling to stand up their own care management team, which is how I came into the picture. Their EHR has great care management content but just couldn’t handle the billing piece, so we’re working through that gap. They will fully separate from the third party in a few months and I’m confident they’ll be able to ramp up their own program. The practice may not have the same slick videoconferencing capabilities that the third party had, but they can practice telehealth the old fashioned way — via phone. This approach can still help with access issues and cost issues as well as reduction of readmissions. We’ll see how it goes.

As a side note, I’m waiting for the EHR vendors I work with to get through all their regulatory certifications and mandatory releases so they can get back to the business of enhancing usability and coding features that their users actually want. Of course, I’m not delusional enough to think that there won’t be some other burdensome pack of regulations coming right after, but there might be a window of opportunity to do some good work before it hits.

Email Dr. Jayne.