Readers Write: Why Secure Messaging is Failing Hospitals

Why Secure Messaging is Failing Hospitals
By Ben Moore

Healthcare communications are growing up. Where we were once reliant on interruptive, one-way message pushes; device juggling; and kludgy workflows driven by pager use, modern clinicians have a wealth of tools at their disposal to facilitate effective care coordination.

Yet despite a relatively crowded marketplace (some estimates put the number of secure healthcare messaging providers at over 70) and a market that is ripe for disruption (just ask anyone who still uses a pager if they enjoy it), healthcare messaging solutions still face relatively low adoption, with an estimated 85 percent of hospitals still eschewing smartphones in favor of pagers.

Secure messaging and pagers share a common thread. Neither was specifically designed to address the nuances of healthcare communications. They were mass-market solutions that were adopted by healthcare owing to being in the right place place at the right time.

For pagers, adoption was spurred by the need to deliver around-the-clock care while also allowing providers to (occasionally) leave the hospital. For secure messaging solutions, it was a matter of encrypting PHI that clinicians were transmitting from unsecured personal smartphones, mitigating the risk that came with smartphone use in a clinical setting.

As smartphone use grew organically in healthcare workplaces, HIPAA pitfalls abounded:

• Data remained resident on personal (and often unprotected) devices.
• There was little control or policy enforcement.
• There was no guarantee of SMS message receipt.
• There was no visibility at an organizational level that any communication had occurred at all.
• Clinicians became accustomed to utilizing shorthand codes or acronyms to communicate, increasing the propensity for error.

The end result of this was an enormous financial risk of HIPAA violation and compromised care delivery and confusion in the healthcare setting. Secure messaging vendors sought to correct these problems by handling data through a single vendor, implementing message self-destruction from personal devices, guaranteeing message delivery, supporting rich media such as images and video, and performing integrated directory lookup.

If security is the only concern (and don’t get me wrong—it should be a very big concern), these solutions fit the bill. But if the 85 percent of hospitals still utilizing pagers are any indication, healthcare providers are looking for much more when it comes to enabling mobile communications.

In application beyond HIPAA compliance, secure messaging is falling short in a big way. According to a survey conducted this year, 56 percent of providers felt a lack of useful integrations with other software was the leading reason current providers fell short; 44 percent felt they lacked structure and policy; and 33 percent felt that low user adoption was the biggest hindrance.

Inclusion and integrations must be addressed by secure texting apps. Messages are data in its rawest form. If this information is siloed from other departments (for example, if nurses and physicians use different mediums) or different systems (such as scheduling, EMR, nurse call, and paging systems), it’s useless.

The Joint Commission ruling on secure texting states that mobile order entry is not permitted because basic secure messaging lacks the ability to verify the identity of the sender and record a copy of the original message against the EMR. Integrations with Active Directory and EMR software (in that order) ensure that mobile orders remain compliant. Ask any physician if they’re looking for another way be awakened at 4 a.m. when they’re not on call and you may begin to understand why they’re not falling over themselves to try something new (see “adoption issues.”) This can be easily mitigated by integrating with the on-call schedule to ensure that messages and notifications are automatically routed to the correct on-call party.

In the age of big data and informed decisions – and, we’re told, interoperability — there is no excuse for messaging applications to not pull and push relevant or necessary information from other systems to provide additional context, value, and insight.

Healthcare communications are, by and large, structure- and policy-based. Providers in a clinical setting are familiar with not only which information needs to be captured, but who that information needs to be relayed to and when. Basic messaging such as SMS or chat does absolutely nothing to address this (just look at a millennial’s messaging history to confirm.)

For a healthcare communications application to succeed, it must be able to ensure that the relevant information is being captured, and then navigate a complex web of individual providers, care teams, departments, and schedules to deliver that information to the appropriate individuals. Further, secure communication solutions must provide an automated escalation policy and user confirmation of receipt of critical labs to ensure those results are delivered in a timely manner, according to JCAHO’s National Patient Safety Goals.

To address this, next-generation healthcare messaging solutions are building fail-safes into the software itself, including continuous multi-channel delivery attempts (by text and phone), automated escalation rules and message routing in the event that a recipient is unavailable, and delivery visibility so that senders can conclusively confirm a message has been received.

Lastly, in the world of healthcare technology, particularly communication applications, a product is only as good as the number of people who use it. It’s no surprise that a number of secure messaging implementations have been scrapped or cancelled in the face of low adoption. Concerns about device number privacy, a lack of time to learn a new product, or even, yes, pager attachment (a digital version of Stockholm Syndrome) can prevent secure messaging solutions from being successfully rolled out enterprise-wide.

To overcome these obstacles, solution providers must support dedicated number provisioning (providing a unique phone number that exclusively works for communications within the app), pager network integration and pager functionality via a smartphone app (for the pager holdouts), and driving messaging through integration points (some hospitals use as many as 10 disparate systems, including call centers, scheduling solutions, and so on) and providing a user experience that is, at minimum, better than native SMS functionality on smartphones. Really, it’s not that difficult to do.

As a whole, secure healthcare messaging has a lot of room for improvement. However, with the willingness to listen to customers and the ambition to look beyond simply providing security as a service, the opportunity to transform how healthcare workers communicate, collaborate, and deliver care is there.

Ben Moore is founder and CEO of TelmedIQ of Seattle, WA.

How Providers Are Addressing Ransomware

Providers share their methods for staying one step ahead of healthcare’s latest foe.
By @JennHIStalk

While national headlines related to ransomware attacks on hospitals seem to have abated – for now – the healthcare industry’s interest in the latest cyberattack trend has only intensified. Research related to provider preparedness seems to come out weekly, highlighting what has by now become common knowledge: healthcare has a lot of work to do.

A HIMSS study released in early April found that 75 percent of surveyed hospitals were or could have been hit with a ransomware attack in the last year, with a significant number or respondents saying they aren’t sure or have no way to tell. Statistics like these make IBM’s data on industry-wide breaches in 2015 that much more believable, where the global company’s Cyber Security Intelligence Index found that healthcare was the most-attacked industry in 2015 with over 100 million patient records compromised.

The industry is working to handle what seems like a non-stop assault. HHS has created a Cyber Security Task Force to develop recommendations and best practices that could eventually impact legislation. Intermountain Healthcare (UT) has partnered with the University of Utah to establish a joint security center to help providers keep up with the latest cybersecurity threats, while providers in the trenches seem focused more than ever on assessing their cybersecurity vulnerabilities.

Taking a Proactive Approach

Northwell Health, a New York-based IDN with 21 hospitals and 450 ambulatory sites, has taken a proactive approach to cybersecurity, according to Mark Jarrett, MD, senior vice president, chief quality officer, and associate CMO. (Jarrett also serves on the new HHS task force.) “Recent events have only supported our enterprise-wide efforts to secure our network,” he explains. “We are performing hazard vulnerability assessments on a regular basis. As news becomes public of new events, we adapt our defenses. Maintaining all current security patches on our multiple systems is also key. To prevent ransomware attacks, we are employing all standard intrusion techniques from technical, such as firewalls, to staff education and testing so that they understand social phishing and the risks of non-certified thumb drives. We remain concerned as the sophistication of intruders to introduce malware has been increasing.”

Across the country, Texas Health Resources, a health system with 25 hospitals and 69 outpatient facilities serving the Dallas-Fort Worth area, has taken a similar approach. “In the last couple of years, we started to take aggressive action to defend against threats such as ransomware,” says Luis Saldana, MD, CMIO and medical director for clinical decision support. “This action included targeted reduction of direct user access to certain forms of unstructured data such as DICOM images and PDF files. We also have a robust anti-phishing program to reduce the possibilities of a user receiving or being lured into clicking on potentially malicious email links. We’ve also validated our backup and restoration strategies and have fine-tuned our incident response when we detect a ransomware attack.”

In terms of keeping up with emerging security threats, Saldana adds that Texas Health’s cybersecurity program is designed to continuously evolve and adapt. “We do this through a continuous risk-management philosophy that is linked to operations.”

Size Matters

Northwell and Texas Health are capable of taking such proactive approaches thanks to their internal resources – a luxury that smaller hospitals and physician practices are not typically afforded. “I believe small- to medium-sized health systems of stand-alone hospitals and practices that hadn’t had the opportunity to invest in a robust infrastructure to defend against this kind of threat, or that are unable to attract cybersecurity professional talent might be more vulnerable to the impact of such an attack,” says Saldana. “We are fortunate to have a fairly sophisticated cybersecurity program.”

Jarrett points out that with greater resources comes greater vulnerabilities. “Although our size allows us to have more resources than a small hospital or group of hospitals, it also means that there are many more potential sites for failure of our defenses,” he explains. “With 61,000 employees, the task of maintaining a high level of awareness around social phishing is monumental.”

Culture and Consultants Do, Too

Both Jarrett and Saldana are quick to point out that their organizations see cybersecurity threats like ransomware as more than just a problem for the IT department to solve. “Our organizational culture is really what makes this work,” says Saldana. “Our C-suite is very educated on the issues and very supportive, and the programs have been broad in scope – beyond just IT.”

“The C-suite recognizes this is not just an IT issue,” Jarrett adds. “They have supported IT in its efforts to ensure network security.”

For both organizations, support also comes in the form of outside expertise. Northwell engages third-party consultants to evaluate its cybersecurity and provide an outsider approach to vulnerabilities. Texas Health Resources has multiple partners that perform periodic testing of its internal and external defenses, as well as monitor its cyber defenses. “We have selected these vendors through proof-of-concept testing and self-defined cybersecurity capability needs,” Saldana explains.

Prevention Boils Down to Awareness

Saldana believes that cybersecurity prevention and preparation begins with awareness. “The first step is to acknowledge that you are constantly being targeted by threats,” he explains. “Then, backups, backups, backups. Know your recovery time requirements and build backup restoration capabilities to match those requirements. Ensure you have an effective and tested business continuity plan for scenarios when data might be unavailable.”

Saldana also suggested that providers keep their tools up to date and conduct frequent phishing training and testing to prepare employees. “Have an incident response plan in place and prepare your employees to have a heightened awareness,” he adds. “Carefully manage access and be prepared to respond and practice your plan. And don’t forget to keep up with industry intelligence. It’s important to see and learn from other organizations in many areas and to support other organizations who are targets for these types of threats.”

Learning from Hospital Peers

The Intermountain / University of Utah shared Security Operations Center will play a big part in helping providers share industry intelligence around cybersecurity threats in real time. “It will be an opportunity for partner organizations to share learnings and intellectual property around security,” says Intermountain CIO Marc Probst. “There is also the opportunity to share some technical solutions and security intelligence. For example, the ability to immediately understand threats that other organizations are experiencing and to take action to prevent these at your own organization. To the extent organizations are members of the shared SOC, they could inherit these benefits.”

Probst adds that organizers hope to see the center up and running before the end of this year. “There are many details to work out.” he explains, “It’s possible that the participants could change and/or increase. There’s still a lot of work to do, but we are convinced that this is a good idea and we are actively pursuing it.”

Probst’s words reflect the learning curve the healthcare industry is still experiencing when it comes to cybersecurity and more targeted ransomware attacks. There is still – and will likely always be – a lot of work to do. Culture, collaboration, and vigilance will be key to ensuring that ransomware-related headlines soon become a thing of the past.

Morning Headlines 4/27/16

Nokia Just Made Its First Big Move Into Digital Health

Nokia acquires Withings, a digital health company that markets Bluetooth connected scales, blood pressure cuffs, and other medical devices, for $192 million.

Proposed Sanctions – Conditions Not Met Immediate Jeopardy

CMS publishes the letter it sent to Theranos last month in response to the company’s plan to correct problems found at its California lab, noting that the company’s responses “show a lack of understanding of the CLIA requirements.”

Verisk Analytics, Inc., Signs Definitive Agreement to Sell Its Healthcare Services Business to Veritas Capital for $820 Million

Veritas Capital acquires the health service business of Verisk Analytics for $820 million.

News 4/27/16

Top News

Nokia will acquire France-based consumer digital health device vendor Withings for $192 million to create Nokia Digital Health.

Finland-based Nokia, which sold its mobile phone business to Microsoft in 2013, sells telecommunications infrastructure and licenses its brand name and patents.

Microsoft announced last year that it would write down $7.6 billion on its Nokia phone business (for which it paid only $7.2 billion) and would cut 7,800 related jobs as it refocused on the Windows Phone, sales of which were announced last week to be continuing their steady descent into market share rounding error territory.

Reader Comments

From Day1Date: “Re: NextGen. The ongoing restructuring continues with a layoff of around 5 percent focused on corporate, RCM, and ambulatory. This is to further the goal of focusing the company on being the best PM/EHR vendor in the market.” Several  readers report that NextGen has let 150 people go.

From Femdom: “Re: the HIMSS HIT rag. They’re creating a ‘room of one’s own’ with a separate section of their website and a newsletter for women only. I’m not sure that’s a good idea or even necessary.” That sounds like an awkward, paternalistic grab for feel-good advertising eyeballs to me. I doubt that whatever gender disparity exists in healthcare IT was caused by lack of vapid, gender-specific faux news; retweeted links to generic articles under the guise of “awareness” of which everyone is already amply aware; and running feel-good profiles of women whose accomplishments they devalue in spreading the recognition collectively over all women and not just the achiever. Creating what is in essence a special interest group for any demographic group seems like a step backwards to me no matter how well intentioned. Perhaps the publication could start by launching a hard-hitting investigative report as to why six of the seven executives of its parent organization HIMSS are white males.

Disregarding my own cynicism for a moment, I will defer to HIStalk readers – take my poll as to whether a separate HIMSS-published site and newsletter for women is a good idea. Click the poll’s Comments link after voting to make your case.

HIStalk Announcements and Requests

Mrs. Lee says her Arizona kindergarten students are using the math puzzles and magnetic wands we provided in funding her DonorsChoose grant to further their STEM knowledge.

Here’s a reminder to prevent the appearance of cluelessness: do not refer to times as “EST” since we’re on “EDT” until November 6. I’m surprised at how many seemingly otherwise competent people can’t keep this straight, and additionally surprised at how much it annoys me when they don’t. Under the premise that it’s better to mumble than shout when you aren’t sure, you can simply say “ET” and be correct all year.

Webinars

May 5 (Thursday) 2:00 ET. “Reducing CAUTI and Improving Early Sepsis Detection Through Clinical Process Measurement.” Sponsored by LogicStream. Presenters: Jen Biltoft, director of quality improvement, SCL Health; Marla Bare, EHR architect, SCL Health. This webinar will describe how SCL Health reduced catheter-associated urinary tract infections by 30 percent in just three months through clinical process measurement. The SCL Health presenters will also share their plans for applying a similar process to the early detection of sepsis.

Contact Lorre for webinar services. Past webinars are on our HIStalk webinars YouTube channel.

Acquisitions, Funding, Business, and Stock

Augmedix, which offers a Google Glass-powered remote scribe service, raises $17 million from five large health systems that include Sutter Health and Dignity Health, increasing its total to $40 million. Google’s development of an enterprise version of Glass – which never graduated from beta status and has largely disappeared even within Google’s hierarchy — has not been announced, leading Augmedix to suggest that it may explore other technologies. The company has a few hundred California doctors using its services.

CMS releases the 45-page warning letter it sent to lab testing vendor Theranos last month, in which it individually addresses the company’s responses to dozens of problems at the California lab of Theranos with, “The laboratory’s allegation of compliance is not credible and evidence of correction is not acceptable.” The letter adds that the company’s responses “show a lack of understanding of the CLIA requirements.” CMS notes that Theranos diluted finger-stick samples so they could be processed on a standard Siemens lab machine, a practice that CEO Elizabeth Holmes had previously denied.

Verisk Analytics will sell its Verisk Health services business to Veritas Capital for $820 million. I ran a rumor of the sale in early October 2015 and the company announced later that month that it was exploring strategic alternatives for the business. Veritas has no other healthcare holdings, but the private equity firm cashed in big in selling the Truven Health Analytics business it bought from Thomson Reuters for $1.25 billion in mid-2012 to IBM, which paid $2.6 billion to acquire the company in February 2016.

Medical communications transaction platform vendor MEA-NEA-TWSG renames itself Vyne. Its newly created Vyne Medical business unit includes the former Medical Electronic Attachment (claims attachments) and The White Stone Group (healthcare communications management), while its National Electronic Attachment business unit offers electronic attachment management for dental practices.

Blockchain technology vendor Gem launches Gem Health, which is partnering with Philips to build a healthcare blockchain ecosystem.

Roper Technologies – whose healthcare IT holdings include Sunquest and Strata Decision – reports Q1 results: revenue up 4 percent, EPS $1.48 vs. $1.54, missing expectations for revenue and non-adjusted earnings but beating on adjusted earnings. CEO Brian Jellison said in the earnings call that Strata’s growth is “really exceptional” and that Roper will make more acquisitions.

Patient payments and check-in software vendor Inbox Health acquires the consumer health expense management technology of CakeHealth, which seems to have accomplished little beyond spending its tiny 2011 funding ($150K) despite aspirations of becoming “the Mint for healthcare.”

Apple reports Q2 results: revenue down 13 percent, EPS $1.90 vs. $2.33, missing expectations for both and guiding down as the company records its first revenue decline since 2003. It was also the first quarter in which iPhone sales dropped as Apple produced little innovation beyond offering bigger iPhone screens. AAPL shares dropped sharply in after-hours trading following the announcement. They’re down 20 percent in the past year.

Also turning in crappy quarterly numbers is Twitter, shares of which are tanking in after-hours trading Tuesday as the company misses revenue and earnings expectations wildly and reports slowing user growth despite its desperation-smelling rollout of Periscope and Moments.

Sales

Baylor Scott & White Health (TX) will implement the Pieces surveillance and population health management system and will make an unspecified investment in the company. Pieces raised a $21.6 million Series A round last month.

People

Switzerland-based healthcare wireless and security technology vendor Ascom names Holger Cordes (Cerner) as CEO.

John Driscoll (Care Centrix) and John Glaser (Cerner) join the board of Press Ganey.

Announcements and Implementations

InterSystems will interface its TrakCare information system to the blood ordering and inventory management system of the Australian National Blood Authority to allow its users to automate blood ordering and distribution.

CareOne LTAC Hospitals (NJ) completes its implementation of NTT Data’s Optimum Clinicals.

Government and Politics

India passes a law requiring cell phone manufacturers to add a panic button and satellite-based locating technology to their smartphones, hoping to improve the country’s widely publicized rape problem. India doesn’t have a 911-type emergency number but hopes to introduce one soon. Companies sell several personal safety apps (such as My Safetipin, above) to India-based customers, most of which notify an emergency contact and share the user’s location.

In Australia, the state of Victoria will spend $23 million to develop a real-time database to help doctors and pharmacies identify patients who overuse prescription drugs. Victoria recorded 330 deaths from prescription drug overdoses last year, more than the number of people killed in car accidents or from overdoses of illegal drugs.

Parents of children with muscular dystrophy testify to the FDA about the benefits their children receive from taking a drug with questionable proven effectiveness. Afterward, the FDA declared that the drug company’s poorly designed, 12-patient study was not sufficient to prove the drug’s value, but three of the 10 panel members abstained from voting after being moved by the comments of the parents. Following the “no” vote, some of the audience members shouted at the advisory panel. The FDA says it will “take the views of the community into account.” I can’t decide if that’s an admirable move toward patient empowerment that shows the value of “little data” or an uncomfortable vaccine-like abandonment of science in allowing laypeople to argue with emotion rather than documented facts.

The FDA warns drug companies that it won’t accept clinical studies that use data prepared by India-based Semler Research Center after an FDA inspection turns up evidence of intentional data tampering.

New York Mayor Bill de Blasio will propose big changes and $2 billion in subsidies to bail out money-hemorrhaging NYC Health + Hospitals that include reducing ED visits, turning inpatient space into ambulatory facilities, and developing vacant property, all while closing no facilities or laying off any employees to avoid $6 billion in losses over the next five years. The consultant’s report is here.

Innovation and Research

A study of the 46,000 Maryland residents who had a least five ED visits in 2014 finds that 70 percent of them used more than one hospital, meaning that most hospitals won’t be able to identify those high ED users or coordinate their care using their own data alone.

Other

An op-ed article in a British newspaper says idealistic young Americans should work on domestic problems instead of trying to save the world in addressing overly simplified issues in exotic locations. It explains the “reductive seduction of other people’s problems” as being no different than if an idealistic, naive student in Uganda traveled to America for the first time, confidently expecting to win fame and maybe an award for fixing our gun violence problem. In a related item, a new book questions whether healthcare volunteers who trek off to developing countries for short stints help or hurt those communities, with the author concluding after analyzing the available data that the net effect is probably slightly positive if the volunteer has the right attitude. The problems with medical volunteers include that they may be tempted to perform tasks that exceed their skill level, they may try to impose unrealistic US standards,  and that they could hurt local doctors by undermining confidence or offering free services that put them out of business.

Western Australia’s health department, which hasn’t had a permanent CIO since 2010, gives up after finding no suitable candidates and instead creates a support services organization led by a procurement specialist who will oversee IT. WA Health’s troubled IT implementation delayed the opening of newly built 783-bed Fiona Stanley Hospital in 2013.

Sponsor Updates

• AirStrip announces that 4 million US births have been monitored using its system over the past 10 years.
• Interactive patient TV vendor PDi will provide patient education videos from Elsevier.
• Aprima will exhibit at the American College of Physicians Internal Medicine Meeting May 5-7 in Washington, DC.
• Audacious Inquiry’s Team Ai took first and second place at the Port to Fort 6k.
• Team EcoBase from First Databank and Zynx Health wins second place at the FHIR Connectathon in Indianapolis.
• Besler Consulting releases a new podcast, “Comprehensive Care for Joint Replacement (CJR) Target Pricing & Episode Spending Calculations.”
• CenterX will exhibit at the NCPDP May Work Group Meetings May 1-2 in Scottsdale, AZ.
• Obix posts a video covering the use of its perinatal data system at Norman Regional Hospital (OK).
• CitiusTech will exhibit at the LHC Executive Briefing with Milton Johnson, chairman and CEO, HCA, May 4 in Nashville.
• Crossings Healthcare Solutions releases its Spring 2016 e-letter.
• Direct Consulting Associates will exhibit at iHealth 2016 May 5-6 in Minneapolis.
• EClinicalWorks will exhibit at the American College of Physicians Internal Medicine Meeting May 5-7 in Washington, DC.
• Extension Healthcare will exhibit at the IONL Mid-Year Conference April 29 in Bloomington-Normal, IL.
• HCS will exhibit at the NALTH 2016 Spring Clinical Education & Annual Meeting April 28-29 in Memphis, TN.
• Healthwise will exhibit at the ZeOmega Client Conference May 2-4 in Plano, TX.

Blog posts

• Solving Notification Overload in Healthcare (TelmedIQ)
• Raise Your Patient Satisfaction Scores, 2 Planning Tips (Part 1 of 2) (AdvancedMD)
• Adapting to the New Wave of Nursing (AirStrip)
• Why Your Business’ Mobile App Strategy will Probably Fail (If It Hasn’t Already) (AirWatch)
• What in the Health IT is a Hierarchical Condition Category (HCC)? (Arcadia Healthcare Solutions)
• Filling Your Prescription for Desktop Security: 7 Levels of Access Management (Aventura)
• 4 Essentials to Establishing Clinical Integration (Catalyze)
• The Future of Enterprise Mobility is Here: What’s your strategy? (PatientSafe Solutions)
• Nine Notes from NAACOS16 (Caradigm)
• Things to Consider Before Starting a CCM Program: Requirements, Compliance, Buying vs. Building, and Integration (Caresync)
• Florida Joins Legislative Movement Toward Uniformity in Prior Authorization (CoverMyMeds)
• 50 Years and Counting (CTG)
• Placing a Premium on AMC Performance (ECG Management Consultants)
• Securing Your Practice (E-MDs)
• Maximizing Your Conversion Through Assessment (Galen Healthcare Solutions)
• Caring for the Clinician: The Key to Improving Patient Experience, Enhancing Health Outcomes, and Reducing Cost (Hayes Management Consulting)
• Epic Upgrade: Single vs. Double Upgrade (The HCI Group)

Contacts

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

Morning Headlines 4/26/16

What We Mean When We Talk About EvGen Part I: Laying the Foundation for a National System for Evidence Generation

In a blog post, FDA Commissioner Robert Califf, MD calls for greater interoperability and connectivity in healthcare IT in order to help researchers create a national system for evidence generation.

Customizing transitional care for N.C. Medicaid patients

Community Care of North Carolina, which coordinates care for 1.4 million Medicaid beneficiaries in the state, has developed an algorithm-based population health program that has significantly reduced hospitalizations and readmissions for patients with multiple chronic medical conditions.

Augmedix nabs $17M to ‘rehumanize’ doctor/patient relations using Google Glass

Google Glass startup Augmedix raises a $17 million investment round from Catholic Health Initiatives, Dignity Health, Sutter Health, TriHealth Inc., and a fifth anonymous investor. Augmedix is building an app that allows scribes to remotely monitor patient encounters, documenting the visit note and navigating the EHR on behalf of the provider.

Medicare’s New Physician Payment System

Health Affairs discusses the new physician payment system put in place with the passage of MACRA.

Curbside Consult with Dr. Jayne 4/25/16

I wrote last week about my experience with a client who had been swindled by a practice administrator who had promised far more than he could deliver. A reader commented: “I would have loved to hear a few more specifics on what a practice might do to avoid hiring such an administrator or office manager. It has also been my experience that too many independent practices don’t seem to know what to really look for and consequently suffer down the road.”

I’ve certainly done more than my share of hiring and firing over the last decade. On my own, I’ve employed medical assistants, office managers, and partners. I also had to terminate at least one of each. As part of the corporate world, I’ve had to deal with vetting a host of positions including clinical staff, IT staff, managers, and operations execs. As a consultant, I’ve been asked to deal with errant members of the C-suite and upper management and also to assist in finding their replacements.

The best tip I can offer anyone in a hiring position is an old adage: trust your gut. Nearly every time I’ve gone against my gut, there’s been a poor outcome. Sometimes you can’t avoid it, especially if you’re in an employed capacity or part of a larger corporate entity.

For example, I once had to hire an analyst to run some lab interface work. The health system’s HR department (which usually left something to be desired) was only able to find two candidates who were remotely qualified. Although their resumes were decent, both of them interviewed somewhat poorly. I felt the first one didn’t understand the job we were offering, despite our attempts to explain it and talk about the work she would be doing. She kept going back to what she had done in the past and how good she was at it, even though we were trying to assess whether she’d be a good fit going forward.

The second one was too folksy right off the bat. Don’t get me wrong, I’m a folksy girl myself, but there’s a time and place for familiarity and it’s not in a job interview. I don’t want to hear about your children and your weekend plans – not because I don’t care, but because it’s too easy to get close to discussion topics that are normally a bad idea during the interview process. She seemed to be much more eager than the other candidate, but I didn’t really feel that she would be able to get the job done.

I wanted to go back to HR and ask them to look for other candidates, but was under pressure to fill the open posting immediately to ensure we could get someone in the position before a series of budget cuts that might force us to pull the opening off the board.

Although her interface skills were decent, it turned out that her overly casual demeanor was reflective of casual regard which she paid to all her work. When asked for status reports, it always felt like she was on the cusp of getting to the tasks that needed to be done, rather than actually doing them. She also liked to spend a lot of time chatting with other team members, which impacted not only her productivity, but that of others. It felt like she spent a lot of time doing nothing and then sprinted towards the deadline, which was a poor fit for our company culture.

Although I was involved in the hiring, I wasn’t her direct manager. He didn’t seem to have the wherewithal to deal with her because she interpreted every element of constructive criticism as “being mean.” Needless to say, she didn’t last very long. My failure to fight for my gut feeling in that situation bothered me for a long time.

Besides following your instinct, it’s important to watch out for people that seem too good to be true. Maybe they have a seemingly stellar record of accomplishments, but are willing to work for a salary that is lower than they appear to be worth. Sometimes you can get a bargain, but usually there’s a good story to go along with it. For example, a highly-skilled administrator who moves to a small town to care for aging parents or someone who needs a more low-key role to provide greater work-life balance. Usually these candidates realize that they may seem oddly matched for a position and will take the lead on explaining their desire to move down the ladder.

Other times, though, they might not have a good explanation for why they left their last position, or the references they provide don’t seem to make sense. I admit that it’s getting harder and harder to get a decent reference, particularly from past employers. Often organizations will simple verify the dates that the individual was employed. If you’re lucky, they might tell you if the person is eligible for rehire. Getting a true reference that you feel you can trust is like gold.

Other things that I sometimes don’t see smaller practices do: the consumer background check. They may do a criminal check, but not a consumer one. In this day and age, it’s important to know whether the people you are hiring have had any financial difficulties, particularly if they are going to be a position to handle funds within the office. Of course, that won’t tell you if the employee will make bad decisions, like the front desk staffer that I fired after finding $1,200 in co-pays in the sample closet. Why, you might ask, was the money in the sample closet? Because she didn’t have time to go to the bank and do the deposit each night, so she wanted to keep it somewhere “safe.”

Organizations should also make sure that candidates have valid experience for the position they’re trying to fill. Candidates might not have held the exact same job or title, but should be able to clearly explain how their previous experience will translate to the new position. Especially for higher-level roles, most organizations don’t have time to deal with someone who cannot hit the ground running. I do occasionally see it though, with groups that feel like they can mold someone into something that they may not be able to become.

Administrators should be able to talk about their achievements in previous roles and cite metrics for practices they’ve led. How have their days in accounts receivable been? Even if they weren’t stellar, did they show a positive trend? What initiatives did the candidate lead to try to move things in the right direction?

Potential employers need to have a list of solid questions to ask that relate to the needs of the organization. If you’re planning to become a Patient-Centered Medical Home, ask about that experience. If the candidate doesn’t have experience, ask him/her what he/she would do to get up to speed should they be hired. Anyone worth their salt should be able to articulate a plan to learn about a new discipline or new initiative, especially since the healthcare system we may be operating in over the next few years doesn’t exist yet. If they can’t come up with a reasonable strategy, they might not be a good fit.

Once an administrator or practice manager is hired, the practice should keep close tabs on their performance, not only in the initial hiring period, but in a regular ongoing fashion. Practice leadership (owners, partners, managers, etc.) should be having monthly meetings to review financials and potential problem areas in the practice. If the administrator says everything is rosy all the time, something is wrong. Even in the strongest practices there is always opportunity for improvement or some sort of personnel issue to make management aware of.

Owners or top leadership should also watch out for staffers that continuously spread blame around to vendors, payers, or other staff without showing even the smallest level of introspection about whether they could have done something differently.

Another good question to help assess a potential hire is this: “Given what you know about our organization, if you are hired into this position, what do you see the first six months looking like?” In my experience, candidates who plan to do a good amount of listening and observing before making too many changes are often the best. They’re willing to take their time to figure out what they have to work with, assess the team’s strengths and weaknesses, and make a careful plan rather than coming in with guns blazing.

What’s your worst hiring or firing nightmare? Email me.

Email Dr. Jayne.

Best Practices Coming Soon to a Virtual Visit Near You

Top telemedicine vendors weigh in on a recently published study calling for them to share best practices.
By @JennHIStalk

A recent JAMA-published study comparing quality of care among six telemedicine vendors highlights the growing pains that this evolving method of healthcare delivery seems to be going through. The clinical variation found in the virtual visits – ranging from asking the proper questions and performing the correct examination steps to ordering medically indicated tests – prompted researchers to recommend that telemedicine vendors share best practices.

It’s a novel idea, one that suggests telemedicine is ready to move from its awkward “tween” phase to becoming a more mature and collaborative force. Would sharing best practices reduce clinical variation? Do telemedicine vendors or other stakeholders foresee improved patient care (or the chance to market themselves better) if they were to follow standards and share best practices? Would such collaboration even be feasible?

These are the questions that will drive telemedicine stakeholders — including payers and organizations like the American Telemedicine Association (ATA) — to the next phase of market maturity.

Aren’t We There Yet?

Some may argue that telemedicine already has standards in place. They would be half right. Most if not all vendors have their own internal set of guidelines and clinical best practices, in addition to those published by the Federation of State Medical Boards and the American Medical Association (AMA).

Doctor on Demand, for example, implemented protocols from Day One that include a double-blinded peer review, daily visit feedback, and an antibiotic stewardship program.

“We employ our doctors, which I think is a big differentiator,” says Doctor on Demand Chief Medical Officer Ian Tong, MD. “For instance, we couldn’t do our peer review program with a group of independent contractors who are just getting on our platform periodically to make some extra money and moonlight. That’s much more difficult to do.”

“The way that we leverage technology allows us to monitor a number of things,” he adds, “including duration of the visit, idle time for the doctor, and patient satisfaction scores. We can aggregate that information and give our physicians feedback, letting them see patient comments at the end of every day.”

“Am I ready to say that everything I just listed is the best practice?” Tong asks. “Not yet, but I doubt anyone’s doing more. I can tell you that brick-and-mortar practices don’t do half the things I just listed. Eventually those may lead to the development of best practices, but you have to go through a certain amount of market maturity.”

Getting Past the Growing Pains

Most telemedicine vendor executives agree that market maturity is a work in progress and that shared best practices won’t become the norm until the average consumer, employer, and even payer sees the benefit in virtual care.

“We wholeheartedly believe that absolute transparency in best practices and lessons learned from mistakes are key to allowing this industry to move forward responsibly,” says American Well President and CEO Roy Schoenberg, MD, MPH. “The biggest hurdle to telemedicine is the still prevailing misconception of what it can do and the operating know-how of how to make it a safe extension of traditional care delivery.”

Scaling telemedicine’s potential in terms of user acceptance and technical capability is top of mind for the entire market right now. “The industry is in its infancy based on the market potential,” explains Teladoc Chief Medical Officer Henry DePhillips, MD, who adds that the market potential for telemedicine visits is about 550 million interactions annually. “We’re predicting that we’ll do 900,000 visits this year,” he says, “and so we’re just barely scratching the surface of the market’s potential, which has a lot to do with why, up until now, best practices have not yet been established.

“A misstep by any of the vendors in the space will potentially have a negative impact on the entire industry, not just that particular vendor,” DePhillips adds. “I think it’s incumbent on all of us to have really high standards for clinical quality of care, patient safety, reporting, record keeping, and patient experience because the industry needs to keep moving forward.”

Third Parties Attempt to Take the Lead

It’s not for lack of trying that a nationally recognized set of telemedicine best practices has not been created and adopted among stakeholders. Organizations like the ATA, Health Information Trust Alliance (HITRUST), National Committee for Quality Assurance, and URAC (formerly known as the Utilization Review Accreditation Commission) have attempted to drive the best practices conversation via certification programs.

Tong sees immense value in attaining third-party accreditations, and points out that Doctor on Demand has certifications from ATA, NCQA, and HITRUST, “which is really important, but not as sexy. That involves the security of your health records and platform. I think that’s actually a pretty high bar, to be honest. A lot of hospitals don’t have all three of those certifications.”

Teladoc has pursued similar recognition and was the first telemedicine vendor to achieve NCQA recognition. “There are a number of players in the industry that want to be seen as the stamp of approval for the telemedicine industry,” DePhillips says. “I think they’re all heading in the right direction in raising the bar on patient safety and care quality, but I don’t think any of them have really figured out how to dominate that part of the industry yet.”

He does see potential in some kind of Energy Star-like stamp of approval for telemedicine. “I think the concept of having trusted third-party validation is correct,” he explains. “End users will eventually look for that. We actually display the NCQA logo on our website. I think that it will help business. It’s just a matter of which third party you want to hang your hat on at the moment. I think the players, from the stamp-of-approval standpoint, are probably going to shift over time.”

Schoenberg is in accord with his competitors, adding that telemedicine’s eventual stamp of approval will need to have two parts – “approval for the quality and safety of the platform used and a recognition of the quality of the clinical service, which will be implied by the already familiar brands offering it, e.g. Blue Cross Blue Shield, UnitedHealth, Cleveland Clinic, etc.”

Competitive Collaboration is Key for Now

While stakeholders wait for the gold standard of telemedicine certification to emerge, vendors like those reviewed in the JAMA article have focused on collaborating with each other to ensure best practices are shared in the interests of all.

“Although we compete for customers, we collaborate in many ways,” says DePhillips, noting that Teladoc is a member of the ATA and Alliance for Connected Care, a DC-based think tank that includes other broadly defined telemedicine companies. “When it comes to regulatory, care quality, and/or patient safety issues, there’s actually a lot of collaboration among at least the top-tier telemedicine companies,” he adds. “I actually have a professional relationship with my counterpart at our primary competitors. We’ll get together occasionally and talk about how we can work together to solve regulatory issues, most of which are in the past. In some cases, some of the companies will pool funds to help with a regulatory issue. We will not pool resources, but we’ll have a pretty good, detailed conversation around the best approach to patient safety, what standards are out there from the various specialty societies, and what we should be following as an industry. Like I said, a rising tide truly raises all ships. That’s the industry we’re in, especially at this level of maturity.”

Vetting Vendors in the Meantime

For now, potential users will have to use their best judgment in selecting telemedicine services for their members, employees, or themselves. In addition to the certifications mentioned, Schoenberg, Tong, and DePhillips have their own must-haves and red flags for vetting vendors.

“Video visits are a must,” says Tong. “It’s also important to look at the quality of the physicians. What are the hiring practices and training regimens? What are the quality assurance programs that practice has in place? They may not all want to give you their secret sauce, but I think it’s very reasonable to ask, ‘How do you do that?’”

DePhillips believes that, in addition to quality and patient safety assurances, potential customers should look at three key things. “When I look at the younger, smaller players in the industry, I find that they tend to cut corners in two areas. Number one is the way in which they put their provider network together. There’s no other company besides Teladoc that has licensed providers that are physically present in all 50 states. A lot of this cross-state licensing discussion is a non-issue for us. It’s heavy lifting and it’s expensive, but we chose to do that because we think it’s the best route to take. Vendors should also have the infrastructure to support future adoption and to scale.”

Schoenberg’s advice takes a more high-level approach: “First, map out all that you want to do with telemedicine — urgent care, follow-up care, provider-to-provider consults, etc. — and ask the vendor to show you how they can support it. Then, map out all of the systems you will need those services to integrate or exchange data with, and ask the vendor to show you how they can do that. Then, think of what it will take to roll out to all involved – patients, providers, payment stakeholders, marketing, actuaries – and ask the vendor to show their depth of understanding of what needs to be done to be successful in each. Finally, look for leadership you can trust to keep you ahead of the curve as the world of delivering healthcare via technology explodes forward.”

Morning Headlines 4/25/16

Lockheed Martin cuts 200 jobs in merger with Leidos

Lockheed Martin lays off 200 from its IT workforce in preparation for its $5 billion IT services merger with Leidos.

Testing electronic health records in the “production” environment: an essential step in the journey to a safe and effective health care system

A JAMIA article calls for testing EHR updates in both the test and production environment used by clinicians.

Vail Valley hospital says former therapist took patient records

Vail Valley Medical Center (CO) will inform 3,118 patients that their records were compromised after a former physical therapist copied their records prior to moving to a new job.

Monday Morning Update 4/25/16

Top News

Lockheed Martin lays off 200 IT employees in preparing for the $5 billion merger of its IT business with Leidos.

It’s called a merger rather than an acquisition because the companies are using a tricky Reverse Morris Trust so Lockheed can exit the IT business without paying taxes on its gain. A company creates a subsidiary, the subsidiary merges with another company to form a new company, and the new company then issues at least 50 percent of shares back to the original company’s shareholders.

Reader Comments

From Madison: “Re: Nordic. No more word of what happened with the Drew Madden sexual harassment and retaliation charges, but it looks like Nordic wanted a change. First they brought in a new CEO, moving Drew to president. Now he seems to be gone — he is no longer referenced on their page.” The LinkedIn profile of former Nordic President Drew Madden shows he left the company this month, with a tagline he added saying, “Honored and blessed to have worked for THE BEST company in the business!” A former marketing VP filed a complaint in 2014 against Nordic with Madison, Wisconsin’s Equal Opportunity Division, claiming she was fired for complaining about suggestive texts sent her by Madden, while Nordic says the VP willingly participated in such attention, their banter was lighthearted and not unusual for co-workers, and she was fired for poor performance. You can read what he said and she said.

From Finally: “Re: Epic. Heard they’re on a hiring freeze for roles they have been continually hiring for (implementation, development, etc.) for years. Seems like they overstaffed with optimistic thoughts of government deals.” Unverified. 

From Ben: “Re: Vail Valley Medical Center. Therapist steals medical records.” The Colorado hospital will inform 3,100 patients that a former physical therapist copied their medical records onto a thumb drive before leaving to join a new employer. The hospital says it has since added restrictions on how employees can copy patient files and adds that police are investigating.

HIStalk Announcements and Requests

It was nearly an even split between poll respondents who would be concerned about their privacy if they were being treated for depression by an EHR-using provider. Some respondents commented that the real problem is the perception of mental health issues as a personal weakness. Tami summarizes well in saying, “Depression and mental needs to be treated more along the lines of cancer. If you can get help before it progresses too far, treatment can be easier and perhaps quicker. If you wait too long, it can be a death sentence. There are risks with every piece of data that leaves you.”

New poll to your right or here: what is the best answer for reducing the time doctors spend entering data into EHRs?

We fulfilled the DonorsChoose grant request of Ms. Hamilton, whose Arizona special education middle school class asked for timers, books, and math games. She reports that the students are now competitively playing multiplication bingo and challenge themselves to beat the clock in completing their assignments.

Also checking in is Mrs. Bierhals, whose Pennsylvania second grade class received programmable robot kits and an iPad Mini. She says, “The children have been using the items from the minute we received them. We have managed to build all the robots and programmed them to run on different frequencies. Since the weather is starting to break, we are planning on having Robot Races outside for the end of the year. Now we have to work on their driving skills.”

I think we’re entering the summer health IT doldrums, at least as evidenced by the paucity of significant, interesting news items.

I wasn’t much of a Prince fan, but like a lot of people who are jarred into paying attention only after someone famous dies, I’m learning what I’ve missed in appreciating 2004 video of an ultra-cool Prince leading a supergroup with his scorching guitar solo on “While My Guitar Gently Weeps.”

Comcast, the “Most-Hated Company in America” that provides around half of the residential broadband connections in the US (under the Xfinity name) where many of its customers don’t have an alternative, finds a loophole around net neutrality to try to protect its cable and content businesses against cord-cutters who decide they only need a Roku box running Netflix or Hulu. The company is rolling out Internet usage caps that work like cell phone data plans in charging customers extra if they run over Comcast’s limit. Use of Comcast’s own Stream TV service doesn’t count since technically it uses Comcast’s wire but not the Internet, putting Netflix at a huge disadvantage. Comcast says the change is about fairness since customers who use less data pay less, but that’s not exactly true – nobody pays less and the best you can hope is to not get dinged extra for the same service. Complaints suggest that people are avoiding buying houses in areas where Comcast is the only source of Internet connectivity. Please, Google, put fiber everywhere.

Last Week’s Most Interesting News

• Maine becomes the second state to mandate electronic prescribing of narcotics.
• Patient privacy finally trumps the demand for medical reality TV as New York-Presbyterian pays $2.2 million to settle HIPAA charges that it provided patient information to TV crews.
• Parrish Medical Center (FL) says its IT payments spat with McKesson is endangering patients as the company stops providing drug database updates and threatens to pull its entire product line from the hospital.
• The federal government launches a criminal probe of Theranos.
• Court filings of MetroChicago HIE’s lawsuit against the defunct HIE vendor Sandlot Solutions show the HIE desperately trying to restore its Sandlot-housed data before the company closed its doors for good.
• Canada’s Alberta Health Services says it will RFP a new system, expecting to spend at least $316 million to replace 1,300 mostly non-interoperable systems whose purchase it subsidized.
• A Wisconsin jury awards Epic $940 million in its trade secrets lawsuit against India-based Tata Group.
• VA CIO LaVerne Council hints that the VA plans to built a VistA replacement instead of buying a commercial product, telling Congress that a working prototype of a product she likens to Facebook and Google will be ready within a few months. She also confirms that she has placed the VA’s $624 million patient scheduling system contract with Leidos and Epic on hold while they test a homegrown product that will cost only one-tenth as much.

Webinars

April 26 (Tuesday) 1:00 ET. “Provider-Led Care Management: Trends and Opportunities in a Growing Market. ”Sponsored by HIStalk. Presenter: Matthew Guldin, analyst, Chilmark Research. This webinar will provide a brief overview and direction of the provider-led care management market. It will identify the types of vendors in this market, their current and longer-term challenges, product capabilities, partnership activity, and market dynamics that influence adoption. It will conclude with an overview of key factors for vendors and solutions moving forward.

May 5 (Thursday) 2:00 ET. “Reducing CAUTI and Improving Early Sepsis Detection Through Clinical Process Measurement.” Sponsored by LogicStream. Presenters: Jen Biltoft, director of quality improvement, SCL Health; Marla Bare, EHR architect, SCL Health. This webinar will describe how SCL Health reduced catheter-associated urinary tract infections by 30 percent in just three months through clinical process measurement. The SCL Health presenters will also share their plans for applying a similar process to the early detection of sepsis.

Contact Lorre for webinar services. Past webinars are on our HIStalk webinars YouTube channel.

Technology

Several CNET editors who bought Apple Watches but then stopped wearing them say it doesn’t really do anything useful, its apps are lame, it’s easier to just pull out a phone, and it’s too complicated. Even Apple co-founder Steve Wozniak isn’t impressed:

I worry a little bit about — I mean I love my Apple Watch, but it’s taken us into a jewelry market where you’re going to buy a watch between $500 or $1,100 based on how important you think you are as a person. The only difference is the band in all those watches. Twenty watches from $500 to $1,100. The band’s the only difference? Well this isn’t the company that Apple was originally, or the company that really changed the world a lot.

Other

A JAMIA article says hospitals should not prohibit testing in their EHR’s production environment because test environments can’t perfectly mimic the live system’s interfaces and realistic patient data. I ran a poll in February at the suggestion of Dean Sittig, one of the authors, and 15 percent of respondents said they never allow creating test patients in production. The article offers these tips:

• Test software changes in the test environment first, then enable the change in production for a small group of testers if possible.
• Use distinctive names for test patients in the production environment, using a consistent prefix such as” ZZZtestingBWH345, OneTest” rather than cute names like “Santa Claus” or names like “Test” that actually exist as real patient names.
• Create specific user accounts for testers and lock them out of making changes to non-test patients if possible, auditing their transactions to make sure they are performing only approved work.
• Train downstream personnel on how to respond when they see the results of test patient transactions and notify them before testing starts.
• Filter test patients from reports and data extracts.

The death of Prince at 57 caused folks to look back on a year-old research paper that analyzed the deaths of US pop musicians, finding that they die nearly 20 years younger than the rest of us, with the most common age at death being 56. The author even looked at deaths by musical genre, finding that gospel singers had a better quality of life while rappers are nine times more likely to die by homicide than the average person. Metal and punk performers were much more likely die by accident or to commit suicide.

The Rochester, MN paper notes that Mayo Clinic has nicknamed its Epic project Plummer to honor internist and endocrinologist Henry Plummer, MD, who created Mayo’s practice model in 1910. He also developed the clinic’s “one patient, one record” paper records system and the pneumatic tube delivery system to deliver them (it was the interoperability API of its time). Apparently he was well compensated (or well inherited) since he built Plummer House, his 300-foot-long, five-story family Tudor estate on 65 acres that features 49 rooms, 10 bathrooms, and nine bedrooms. His mark as an innovator carried over into the design of Plummer House, which when completed in 1924 had a central vacuum system, underground sprinklers, a security system, garage door openers, a heated pool, and the city’s first gas furnace.

Here’s the first of three “2016 HIS Vendor Review” summaries from Vince Ciotti and Susan Pouzar of HIS Professionals.

Imprivata creates a pretty funny video urging hospitals to “ditch your page boy.” I noticed immediately that for both patients pictured, their vital signs monitors are working great despite not being attached to them (perhaps there’s a wireless innovation there as well) and that the guy’s IV drip is not actually dripping into him. I noticed a few other mistakes at re-creating a hospital room – do you?

Sponsor Updates

• T-System will exhibit at ILHIMA Annual Meeting April 28-30 in Tinley Park, IL.
• Verisk Health’s Sam Stearns and Molly Grimes contribute an article to Employee Benefit News on optimizing the value of maternity care.
• Huron Consulting Group will exhibit at the Association of Information and Image Management Conference April 26-28 in New Orleans.
• ZeOmega will host its Connections 16 client conference May 2-4 in Dallas.
• Xerox will host a Google+ Hangout on population heath management May 5 at 1pm ET.
• YourCareUniverse publishes a new white paper, “Addressing the Rise of Healthcare Consumerism & The New Marketing Reality.”
• ZirMed will exhibit at the Radiology Business Management Association Summit April 24-26 in Colorado Springs, CO.

Blog Posts

• NHS Tackles Patient Flow Challenges (TeleTracking)
• Value Based Healthcare: Valuable or Valueluess? (VitalHealth Software)
• VitalWare and Local Charity Come Together to Give Back (VitalWare)
• Riding the Third Wave of Automation (Voalte)
• Trouble with the Cost Curve (West Corp.)

Contacts

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

Morning Headlines 4/22/16

An Act To Prevent Opiate Abuse by Strengthening the Controlled Substances Prescription Monitoring Program

Maine will require all narcotics prescriptions to be transmitted electronically after June 1, 2018. Providers will also be required to check the state’s drug monitoring database prior to writing new prescriptions.

Rejecting employees’ pleas, EmblemHealth CEO sets major IT layoff

New York insurer EmblemHealth will lay off 250 IT and operations employees after contracting with Cognizant to modernize the company’s IT systems.

Hospital’s dispute with software provider puts patients at risk

A local TV station reports that patients at Parrish Medical Center (FL) are at risk after McKesson blocked the hospital from updating the drug formulary in its Horizon system. The hospital is in the process of suing McKesson over the implementation, which it says included unfinished software, missed deadlines, and monetary disputes.

Centra Selects Cerner’s Enterprise-Wide IT System

Five-hospital health system Centra (VA) contracts with Cerner to replace EHRs in use at each of its hospitals and 50 ambulatory and long-term care facilities.

News 4/22/16

Top News

Maine will require prescriptions for narcotic drugs be transmitted to pharmacies electronically beginning January 1, 2018. Prescribers of narcotics and benzodiazepines will also be required to check the state’s prescription monitoring database before issuing a new prescription and every 90 days as the prescription is renewed.

Reader Comments

From Meditech-Using CIO: “Re: Meditech. This comment from their 10-K is one of many reasons the company in its current state won’t be the company they seem to think it will be. Essentially all of its 2015 income was given back to shareholders as dividends rather than increasing R&D or hiring more talent. The whole corporate structure seems to be based on shareholder enrichment. Also, take a look at product revenue, which has dropped by nearly half in two years. Perhaps the problem is that everybody on the leadership team started with the company right out of school – not one executive knows anything other than Meditech, which I cannot imagine under any scenario being a good thing unless you’re all about dividend income.” Meditech’s executives average 36 years of employment with the company, starting their careers there at an average age of 25. The least-tenured of the executive team joined Meditech in 1990. I’m anxiously awaiting the company’s Q1 numbers, which rumors suggest will be highly interesting.

HIStalk Announcements and Requests

We funded the DonorsChoose grant request of Ms. W, who asked for three tablets for her California second graders. She has installed reading and math practice apps and says, “The tablets have been especially useful for my most struggling readers. They often have a hard time working independently during reading rotations. They all try really hard, but get stuck on some of the work. The tablets have given them an opportunity to work on fluency and sight words with a little more support even when a teacher is not available to help them out.”

Also checking in is Ms. Read from Texas, whose middle school class received a bunch of electrical components for working on “squishy circuits.”

This week on HIStalk Practice: AMA launches the Healthier Nation Innovation Challenge. Urgent Team goes with DocuTap’s EHR, PM, and billing software. Physician’s Computer Company works with ThinkMD to bring its MEDSINC technology to the US market. The Massachusetts League of Community Health Centers selects HIE connectivity consulting services from EMedApps. Everseat offers users rides to their doctor appointments via Lyft. SingleCare partners with AmericanWell to offer Pittsburgh members virtual consults. Robin Zon, MD of Michiana Hematology Oncology shares her experience with patient-friendly clinical trial technology.

We’re down another music legend on the year as Prince dies at 57.

Listening: new frantic, ragged dairy punk from Appleton, WI’s Tenement, a necessary antidote to over-produced, soulless musicians who never seem to sweat or express any emotion other than self-admiration.

Webinars

April 26 (Tuesday) 1:00 ET. “Provider-Led Care Management: Trends and Opportunities in a Growing Market. ”Sponsored by HIStalk. Presenter: Matthew Guldin, analyst, Chilmark Research. This webinar will provide a brief overview and direction of the provider-led care management market. It will identify the types of vendors in this market, their current and longer-term challenges, product capabilities, partnership activity, and market dynamics that influence adoption. It will conclude with an overview of key factors for vendors and solutions moving forward.

May 5 (Thursday) 1:00 ET. “Reducing CAUTI and Improving Early Sepsis Detection Through Clinical Process Measurement.” Sponsored by LogicStream. Presenters: Jen Biltoft, director of quality improvement, SCL Health; Marla Bare, EHR architect, SCL Health. This webinar will describe how SCL Health reduced catheter-associated urinary tract infections by 30 percent in just three months through clinical process measurement. The SCL Health presenters will also share their plans for applying a similar process to the early detection of sepsis.

Contact Lorre for webinar services. Past webinars are on our HIStalk webinars YouTube channel.

Acquisitions, Funding, Business, and Stock

Non-profit insurer EmblemHealth lays off 250 IT and operations employees and contracts their work out to Cognizant. EmblemHealth says using systems offered by Cognizant subsidiary TriZetto will save hundreds of millions of dollars in development costs and won’t require company maintenance resources. Displaced employees are complaining that they have been asked to train their offshore replacements. The attorney who was helping EmblemHealth’s IT employees unionize posts a video in which EmblemHealth CEO Karen Ignagni announces the layoffs. She has been CEO for just seven months following  long career as lobbyist-CEO of the American Association of Health Plans, but before that, she ironically worked for the AFL-CIO as director of employee benefits.

Microsoft reports Q3 results: revenue up 2 percent, EPS $0.62 vs. $0.61, missing earnings expectations.

Venture capitalist Bill Gurley says the the Silicon Valley “unicorn” bubble burst when the Wall Street Journal started its investigation of Theranos. He makes these points about those privately held companies with paper valuations of more than $1 billion:

• Theranos is an example of a company that raised money from a handful of investors with a high paper valuation, but that doesn’t mean the company is doing well or that shares are worth the valuation imputed by what those investors paid.
• Unicorns have rarely gone public, leaving insiders no way to cash out.
• High-profile startups are failing and laying off employees in attempt to slow their record-setting burn rates.
• Mutual funds are writing down some of their overly optimistic unicorn investments.
• Nervous investors are asking questions about profit, not just the previous goal of growth at any cost.
• CEOs desperately want to avoid new funding rounds at lower valuation, investors don’t want to write down investments that previously looked successful, and founders may cash in ahead of their investors in a rush to the exits.
• Opportunistic “shark” investors are offering funding with ugly terms buried in the details that underlie their seemingly high valuation, allowing entrepreneurs to prop up a high valuation with a ticking time bomb of unfavorable terms that can only be dodged with a successful IPO.
• Entrepreneurs accustomed to readily available capital will find it hard to accept new funding rounds at lower valuations, the pressure to quickly become profitable, or to reverse “stay private longer” thinking and prepare for an IPO.
• Gurley concludes, “Founders have come to believe that more money is better, and the fluidity of the recent funding environment has led many to believe that heroic fundraising is a competitive advantage. Ironically, the exact opposite is true. The very best entrepreneurs are relatively advantaged in times of scarce capital. They can raise money in any environment. Loose capital allows the less qualified to participate in each market. This less qualified player brings more reckless execution which drags even the best entrepreneur onto an especially sloppy playing field. This threatens returns for all involved.”

Sales

Centra (VA) chooses Cerner Millennium and HealtheIntent for its five hospitals and 50 non-hospital locations. 

People

HealthLoop names Bevey Minor (MarketPoint) as chief marketing and development officer and Harry Kirschner (The Advisory Board Company) as chief revenue officer.

Announcements and Implementations

Mount Sinai Health System (NY) joins the OpenNotes movement.

Northwell Health (the former North Shore-LIJ) announces that its 3D bioprinting body replacement parts project will receive $100,000 in additional funding after it received the most public votes among three of its innovation projects. Northwell will spin the project off as a separate company, which expects to have the technology ready for human use in five to 10 years.

Government and Politics

Politico reports that the Coast Guard has terminated its Leidos/Epic EHR project without any sites going live after spending $60 million, which is hardly news since I reported it here (and confirmed it with Epic) on October 7, 2015.

The State of Utah declares pornography to be a public health hazard that creates psychological and physiological addiction, although the non-binding resolution carries no funding to do anything about it.

England’s Health and Social Care Information Centre renames itself to NHS Digital, with Noel Gordon named chair.

Privacy and Security

New York-Presbyterian Hospital (NY) pays $2.2 million to settle HIPAA charges of disclosing PHI to the ABC crews filming the TV series “NY Med.”

Crouse Hospital (NY) fires one of its medical residents after he was caught hiding two spy pen cameras in one of the hospital’s ICU bathrooms. The doctor’s lawyer says his client – who also has three years’ experience as an investigative reporter — was trying to find the person who stole his Adderall prescription and GoPro camera, noting that the spy cameras weren’t pointed at the toilet and did not record anyone identifiable on the video.

The information of 3,200 patients of Wyoming Medical Center (WY) is exposed when two employees click links in phishing emails. The hospital says its email system contained PHI, such as medical record numbers, dates of service, and some medical information. One of the affected patients is the hospital’s CEO.

Other

Another healthcare payment quirk: a woman’s doctor-ordered genetic test isn’t covered by her insurance company because they say it’s experimental, but instead of being billed at the testing company’s $349 uninsured patient rate, they insist that she pay $1,494, the amount the company charges insurance companies. In other words, having insurance cost her an extra $1,145.

Arizona State University’s business school names McKesson Chairman, President, and CEO John Hammergren as its 2016 Executive of the Year, in which it recognizes “top executives who serve as exceptional models for future business leaders.”

An Orlando TV station says patients are being endangered at Parrish Medical Center (FL), which is suing McKesson for what it says is a botched software implementation. The hospital claims McKesson shut off its access to drug database updates and has threatened to remove all of its products the hospital uses if the hospital doesn’t pay the bills it is disputing. Parrish signed up for Horizon Clinicals, Horizon Enterprise Revenue Management, business intelligence, cardiovascular information system, ambulatory PM/EMR, and RelayHealth in February 2011.

I ran across a study concluding that only about half of psychiatrists (as surveyed in 2009) accept medical insurance, the lowest insurance acceptance rate of all specialties. That means those already-alarming studies showing that most behavioral information isn’t visible in EHRs actually understate the problem – they assumed that the denominator was the number of visits found in claims databases, but those visits insurance didn’t cover wouldn’t be recorded anywhere except in the private records of the mental health professionals.

A federal appeals court rules that Reading Hospital (PA) isn’t liable for the injuries sustained by an AMN Healthcare contractor who sued the hospital after falling down a flight of stairs while supporting the hospital’s Epic go-live. The court ruled that AMN’s contractor was actually a hospital employee because the hospital directed his work, leaving him unable to sue the hospital for personal injury because he was already covered as a “borrowed servant” by workers compensation.

Fox consumer affairs TV reporter John Stossel, writing from his New York-Presbyterian Hospital bed, says the hospital’s care is good but its customer service isn’t:

Doctors keep me waiting for hours, and no one bothers to call or email to say, "I’m running late." Few doctors give out their email address. Patients can’t communicate using modern technology … I fill out long medical history forms by hand and, in the next office, do it again. Same wording: name, address, insurance, etc. … In the intensive care unit, night after night, machines beep, but often no one responds … Patients will have a better experience only when more of us spend our own money for care. That’s what makes markets work.

Sponsor Updates

• Iatric Systems will exhibit at ANIA 2016 April 21-23 in San Francisco.
• Influence Health will host its annual Client Congress April 24-27 in Phoenix.
• Ingenious Med is recognized as a Pacesetter by the Atlanta Business Chronicle for the fourth year in a row.
• Cumberland Consulting Group will offer legacy system data management services in conjunction with Trinisys.
• Leidos donates $32,000 to the Special Operations Warrior Foundation through a Defend the Rim campaign with the Washington Wizards.
• Life Science Nexus features LogicStream Health in a new blog.
• Agency Spotter Founder Brian Regienczuk interviews Medecision CMO Ellen Donahue-Dalton about healthcare marketing trends.
• Netsmart will exhibit at the CIBHS National Behavioral Health Information Management Conference & Expo April 27 in Garden Grove, CA.

Blog Posts

• Changing Healthcare Staffing Could Affect Privacy Prognosis (ID Experts)
• Why Healthcare Should Embrace Digital Wallets, Tokenization and Apple Pay (InstaMed)
• Unrecognized Assumptions and Their Impact on Patient Care (InterSystems)
• Why EHR assessments make sense for every healthcare organization (Nordic)
• Working Smarter in Radiology (Spok)
• From Burritos to Billing: Best Practices for Your Patient Payment Process (Navicure)
• Why our Metro North Deal is a Win Win for Both Parties (Orion Health)

Contacts

Mr. H, Lorre, Jennifer, Dr. Jayne, Lt. Dan.
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EPtalk by Dr. Jayne 4/21/16

There has been a lot of buzz this week around the announcement of the Comprehensive Primary Care Plus (CPC+) model. CMS hopes to build on the previous Comprehensive Primary Care initiative, this time recruiting 5,000 practices into two tracks. The strongest candidates for participation will be practices that are already involved in care coordination and population management.

CPC+ differs from some of the other quality programs in that the incentive payments are prospective and the way in which practices manage their patients will determine how much of the incentive the practice gets to keep.

Practices will be selected after the identification of 20 participation regions which will be dependent on payer participation. The goal is for the majority of patients in the practice to be covered by one of the participating payers. Although physicians seem interested in the prospective payments, their enthusiasm was somewhat tempered by the need to wait until regions are determined. Payer proposals can be submitted through June 1, with submission of practice applications to follow. I attended one of the CPC+ webinars this week and actually enjoyed learning about some of the nuances of the program.

CMS also announced that those practices participating in the Bundled Payments for Care Improvement (BPCI) initiative can extend their involvement for an additional two years. CMS will use the extra time to evaluate outcomes and determine whether bundled payments are leading to better care while controlling costs. I wonder if their evaluation will also look at the stress levels of providers involved in the initiatives and the ratio of their patient-care hours to administrative time both before and after the initiative.

In other government news, our friends at ONC shared a comprehensive evaluation of the Regional Extension Center (REC) program. Highlights include data that 68 percent of eligible professionals receiving incentive programs under Stage 1 of Meaningful Use worked with a REC. If you don’t want to try to make it through the entire 124 pages, I’d recommend the Executive Summary, which is only six pages.

I’ve been waiting for the HIMSS16 presentations to be available online so I can grab a couple of slide decks. Although I understand they’re trying to be hip with their screen layout, you can only see eight sessions at a time, which leads to a lot of scrolling. I had quite a bit of difficulty finding the sessions I wanted, until I realized that sessions starting with “The” were filed under T.

After locating my sessions and downloading the slides, I decided to watch a couple of the sessions that I missed. The first one had audio which I couldn’t hear despite maximizing the settings of my tablet and the streaming content. I could tell the people were talking, but couldn’t make out any of the words. Good luck to the rest of you hoping to watch the sessions.

Being on the HIMSS website also reminded me that I needed to submit my sessions for continuing education. After my experience with the streaming presentations, I was hoping for a better experience, but left disappointed. Although I liked the fact that it prevented you from accidentally trying to claim credit for two sessions in the same time slot, it did it by refreshing the screen which required the user to re-select the day each time before searching for the next session.

I eventually was able to get all of my sessions selected. HIMSS has to submit them directly to the American Board of Preventive Medicine for credit, so I’ll be checking back in a week or so to ensure they get posted. Given the cost of attending the conference, I want to maximize my returns.

I’ve started to plan my next couple of trips and am excited to report that there will be no healthcare- or IT-related educational components. One trip involves camping in bear country, which is a new experience for me. The other involves wine country, so it should be a good balance.

What are your travel plans for the summer? Email me.

Email Dr. Jayne.

Morning Headlines 4/21/16

Report to Congress April 2016

In a MACRA-mandated report to Congress, ONC evaluates the feasibility of establishing an EHR comparison tool to support providers evaluating health IT products.

2016 Cyber Security Intelligence Index

IBM publishes its 2016 Cyber Security Intelligence report cites healthcare as the most targeted industry for cyber attacks in 2015.

US to Delay Release of New Hospital Ratings

CMS announces that it will hold off on publishing quality ratings for hospitals until July amid questions from health providers and Congress over the methodology behind the ratings, “We are concerned that the star rating system may be misleading to consumers due to flaws in the measures that underpin the ratings,” states an April 11 letter signed by 60 senators.

Here’s Why This Genetics Biotech’s Stock Plunged Today

Gene sequencer manufacturer Illumina’s shares dropped 23 percent Tuesday after reporting preliminary Q1 revenue of $572 million, missing its forecasted $596 million, and lowering its projected 2016 growth from 16 percent to 12 percent.

Readers Write: The Journey from Population Health Management to Precision Medicine

The Journey from Population Health Management to Precision Medicine
By David Bennett

Imagine a world where individuals receive custom-tailored healthcare. Patients are at the center of their own care, making key decisions themselves. They are supported by research and education, and their information is shared easily between caregivers and clinicians. Preventive care is more effective than ever, and medical interventions occur in record time.

With precision medicine, this world is not just within reach — it’s already happening.

Precision medicine (also known as personalized medicine) is the next step in population health management, transforming healthcare from being about many, to focusing on one.

Population health serves as the “who” to identify cohorts of patients that are at risk and require attention. Precision medicine is the “what,” providing caregivers with the specific information they need to create effective prevention and treatment plans that are customized for each individual.

Having the largest variety of data sets possible optimizes therapeutic tracking of each patient’s care plan to make and refine diagnoses. This sets the stage to pursue the most personalized therapy possible by detecting patterns in clinical assessments, behavior, and outcomes.

Data is essential, but it’s only useful if you have the ability to make big data small in order to personalize care. Today’s technology platforms can do just that, by capturing vast amounts of health data and applying real-time analytics that provide information and tools that help healthcare professionals and health insurers make more effective, individualized treatment decisions.

Using this information to engage patients and guide care management makes the journey from population health management to precision medicine that much easier, paving the way for an era of truly personalized medicine that prevents the deterioration of health.

The timing couldn’t be better for precision medicine’s heyday, and here’s why: one-size care does not fit all.

Many factors are converging to make the adoption of precision medicine a reality:

• A growing number of EMRs, EHRs, and HIEs are being connected and cover a significant number of individuals.
• Patients are more interested in participating in their care, especially when they get access to their own data. There are myriad devices on the market today that are relevant — from wearable devices that measure activity and sleep quality, to wireless scales that integrate with smartphone apps, to medical devices that send alerts (such as pacemakers and insulin level trackers). The data from these devices contribute to a robust longitudinal patient record. The interactive nature of the technology is also an excellent way to engage patients.
• MHealth advances allow us to easily capture consumer data using cellphone technology and monitoring patients remotely with telehealth and virtual consultations.
• Ability to see which inherited genetic variation within families contributes both directly and indirectly to disease development. We can now adjust care plans when genetic mutations occur as a reaction to the treatment in place.

If we look at healthcare outcomes in the United States, it’s clear that we need to anticipate patients’ needs with evidence and knowledge-based solutions. Only then will we will be able to identify a patient’s susceptibility to disease, predict how the patient will respond to a particular therapy, and identify the best treatment options for optimal outcomes. Precision medicine will get us there.

Precision medicine is about aggregating all forms of relevant data to enable different types of real-time data explorations. More concretely, specific areas of medicine are expected to make use of new sources of evidence, and the data types they leverage vary based on medical specialty. A good example would be the difference between the data sets used by oncologists versus immunologists.

There are two critical types of data explorations that both need a very large number of data sets to bring results:

• Medical research with scientific modeling. Precision medicine can be leveraged to advance the ways in which large data sets are collected and analyzed, which will lead to better ways and new approaches to managing disease.
• Clinical applications. Treatment plans and decisions can be greatly improved by identifying individuals at higher risk of disease, dependent on the prevalence and heritability of the disease. We call this cognitive support at the point of impact. To support this, more control is needed in real time over macro variables: genomics, proteomics, metabolism, medication, exercise, diet, stress, environmental exposure, social, etc. Precision medicine provides a platform that has an extensive number of data sets with the ability to easily create custom data sets to capture these types of variables.

Precision medicine not only means care tailored to the individual, it also brings to the healthcare industry the visibility on variability and the speed necessary to act expediently on findings to prevent the deterioration of health. Not only does this enhance patients’ lives, it saves healthcare dollars and prevents waste.

Tailoring deliverables to the needs of individuals is nothing new, at least in other fields such as banking and retail. Pioneers in these industries have leveraged open-source technology on a solid data foundation to meet their markets’ challenges.

Surely we can do the same in healthcare, where it’s literally a matter of life and death. That’s why so many of us are working on a daily basis to accelerate the science behind precision medicine and to encourage its adoption. Precision medicine is nothing short of revolutionary, and together, we can all make it a reality.

David Bennett is executive vice president of product and strategy at Orion Health of Auckland, New Zealand.

Readers Write: Three Tips for Supporting a Population Health Management Program

Three Tips for Supporting a Population Health Management Program
By Brian Drozdowicz

Provider organizations have a lot of options when selecting population health management expertise and system support, including analytics, data aggregation, clinical workflow / care management, and patient engagement solutions. With the market for these solutions expected to reach $4.2 billion by 2018, it is not surprising that new vendors pop up practically daily, or that existing vendors are beefing up their solution portfolios to capitalize on the opportunity.

As providers’ wish lists continue to grow, driven in part by government initiatives and commercial payer programs, system selection starts to take on the overwhelming feel of a second EMR implementation. This is causing providers to hesitate just when they need to act. How can providers find the right path to effective population health management?

No matter what shape a program might take, the right team is a foundational imperative. Assuming risk for populations often means that provider organizations are learning and mastering a new set of skills while simultaneously balancing the demands of “business as usual.”

One frequently deployed tactic is to hire staff from payer environments. They bring the requisite knowledge to the table and can help incorporate proven payer techniques and processes that both build on and complement a provider’s current infrastructure. Team members are needed who “speak data” and are also representative of groups across an organization (e.g., clinicians, program managers, business leads, finance team members, IT staff) to best determine what program goals are, what is possible for the specific organization, and what actions should be taken along what timeframe.

Once  the right team is in place, here are three tips to support the implementation of a population health management program:

1. Recognize that data quality is more important than data quantity. The foundation of any population health management program is data. However, providers don’t need or want it all because each type of data has to be managed and maintained, often by separate people and according to different rules (e.g., privacy constraints). Focus on obtaining and properly maintaining the right data to drive population analysis, program structure, program management, and ongoing assessment.
2. Learn to embrace claims data. Provider organizations need the longitudinal view that claims data provides to adequately assess utilization, total cost of care, and provider performance, and in turn to answer complex, multi-faceted questions about risk. Other benefits of claims data include that it is: (a) easier to manage and maintain; (b) more readily available and accepted than ever before; (c) controllable from a systems perspective; and (d) proven to yield accurate insights.
3. Show physicians the numbers and what drives those numbers. Physician change is required to embrace the concept of value-based care. Comparative performance data can be a huge eye-opener. Physician leadership can help physicians be the champions of program performance assessment by making sure they can dig deep into the data, develop confidence in its findings, and understand what precisely needs to change. Complement performance data with compensation plans that reward participation, improvement, and outcomes. Start by placing the emphasis on participation, and then weight improvement and outcomes more heavily over time.

Provider organizations must know what is essential versus nice to have before they go into the vendor evaluation process. In a new and volatile market, the number of vendors offering potential solutions is huge, and the allure of slick user interfaces that can perform every population health management function, while integrating all types of data, is understandable.

However, little is proven, and most organizations do not have the time to wait until it is. Solutions have a gestation period to build, test, and revise before they become accurate, produce valid results, and deliver actionable business value. Answers are needed now, so organizations should look for a track record of results in a similar setting.

What does an organization need to effectively manage risk and care for populations? Of course, the answer is, “it depends,” but if you build the right team and thoroughly research your options, these tips can help bring order to the chaos.

Brian Drozdowicz is executive vice president of product management at Verisk Health of Waltham, MA.

Readers Write: It’s Time to Get Doctors Out of EHR Data Entry

It’s Time to Get Doctors Out of EHR Data Entry 
By Marilyn Trapani

There was a day when medical transcription was neat and clean. A doctor dictated what happened during an exam and a transcriptionist accurately typed each detail into the patient’s record. Each future encounter built on that record, a detailed history meant to ensure quality care. It wasn’t a perfect system, but it worked.

Now doctors sit for hours each week in front of a computer screen entering patient encounter data into electronic health records (EHRs). These complex systems were meant to more efficiently and effectively track health data for hospitals, payers, and physicians alike. EHRs were promised to save physician practices, hospital systems, and other provider organizations millions of dollars in the long run. 

Reality shows something quite different. Placing documentation responsibilities on physicians is resulting in severe problems not only for doctors, but for patients and the hospitals and practices who serve them. Doctors are spending more time – in some cases, 43 percent of their day – entering data into EHRs, which means less time available for patients. This continual influx of data is bloating EHRs with unnecessary, repetitive, unintelligible information. 

Doctors play an integral part in developing and maintaining medical records. But we are asking them to do too much and the entire healthcare system is suffering because of it. Instead of dictating information into the medical record, many physicians are required to type notes into their EHR, which is time-consuming and distracting.

That’s just one challenge they face when required to directly document into an EHR. Upon accessing the system, the doctor enters a patient’s medical number and their record pops up. There are boxes for history, medications, procedures, etc. This “structured data” methodology allows physicians to click radio buttons or check boxes to denote what was done, but too often allows for little or no free text. Physicians are presented options from which to choose, even if those options aren’t applicable. The structured data choices can’t be changed, and the patient’s record is built off what the doctor ultimately chooses as the lesser of evils.  

Most EHRs allow doctors to copy and paste information from one area of the record to another. This creates “note bloat,” a serious issue that’s resulting in junk data and unwieldy, unmanageable records. It’s not uncommon for information copied from one patient’s record to end up in a different person’s file.

Not only does that create note bloat, it also causes mistakes. One hospital was recently sued by a patient who suffered permanent kidney damage from an antibiotic given for an infection. The patient also had a uric kidney stone, which precludes antibiotic use. The EHR file was so convoluted, none of the attending physicians noticed the kidney stone. Printed out, the patient’s record was 3,000 pages. The presiding judge ruled the record inadmissible, in part because a single intravenous drip was repeated on almost every page.

In late January, Jay Vance, president of the Association for Healthcare Documentation Integrity (AHDI), testified to the US Senate Health, Education, Labor and Pensions Committee that EHR documentation burdens on physicians can be reduced by expanding language to a draft bill aimed at improving the functionality and interoperability of EHR systems.

The move to pay providers based on the quality of the care they deliver instead of the volume of cases seen by physicians and specialists is driving much of the federal healthcare discussion. There’s a chance that work can help restore sanity to the interaction between doctor and document. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the bill that ended the onerous Sustainable Growth Rate, authorized the Centers for Medicare and Medicaid to pay physicians via value-based reimbursement. The law also called for a replacement for Meaningful Use.

One component of MACRA is the Merit-Based Incentive Payment System (MIPS) that, among other things, incentivizes providers for using EHR technology. The goal is to achieve better clinical outcomes, increase transparency and efficiency, empower consumers to engage in their care, and provide broader data on health systems. But there is more that can be done. 

This is progress, because at the end of the day, patient focus should always trump data entry by physicians. That’s not to say that physicians shouldn’t have a hand in documentation. According to AHDI, accurate, high-integrity documentation requires collaboration between physicians and the organization’s documentation team – highly skilled, analytical specialists who understand the importance of clinical clarity and care coordination. Certified documentation and transcription specialists can ensure accuracy, identify gaps, errors, and inconsistencies that may compromise patient health and compliance goals.

AHDI’s recommendation: include wording that expands the definition of “non-physician members of the care team” to include certified healthcare documentation specialists and certified medical transcriptionists.”

There’s not a single documentation and transcription scenario to meet every organization’s needs. But there is common ground to be found where all functions – EHR vendors, documentation specialists, transcription experts, physicians, hospital administrators – can create a structure that results in clean, effective, understandable patient medical records. 

Step 1 – reduce doctors’ administrative burdens. A physician’s role in documentation should be focused on dictation, not data entry. EHR voice recognition software allows doctors to directly narrate into the system. Like any other text, narrated notes need to be reviewed for accuracy and then approved. In some cases, doctors are approving their entries without reviewing them. This increases the risk of inaccurate data and mistakes. 

Step 2 – find the balance of structured and unstructured EHR data. There is a place for both structured and unstructured data in the EHR. Structured data can be queried and reported on with much greater ease than free flow text. However, doctors complain there aren’t enough options to share narratives about encounters and what patients had to say about their visit. The goal of an EHR is to provide a complete and accurate view of patients’ conditions, treatments, and outcomes. It makes sense to use structured data for entries such as those required by CMS. Using dictation and expert transcription assistance, unstructured free-text narratives and information also can be a part of the EHR while maintaining accuracy and completeness. 

Step 3 — eliminate interface barriers. EHRs require interfaces to “talk” with other systems. Fees charged for said interfaces prevent providers from using outside documentation and transcription services. Interfaces are necessary, but should be part of the standard development of EHR structured data forms and information collection.

Step 4 – put the responsibility of document editing and transcription in expert hands. I believe there will be resurgence of transcription services in 2016. Streamlining data entry into an EHR will never replace the need for documentation and transcription experts. Providers will continue to need outside assistance in ensuring patient data is accurately and cleanly logged in the EHR. 

EHRs are here to stay. So are documentation and transcription experts. Provider organizations need both of us. When experts on both sides to combine their strengths and expertise, we can put doctors, physicians, and other health care professionals back where they belong: taking care of patients.

Marilyn Trapani is president and CEO of Silent Type of Englewood, NJ. 

HIStalk Interviews Michelle Holmes, Principal, ECG Management Consultants

Michelle Holmes is a principal with ECG Management Consultants of Seattle, WA.

Tell me about yourself and the company.

I am a principal with ECG Management Consultants. I’ve been with the firm for about ten and a half years. I’ve worked in healthcare since 1993 and have been involved in healthcare IT specifically since 2003, which was when I was involved in my first EHR implementation.

ECG is a healthcare consulting company. We focus on providers and payers, specifically. We’ve been around since 1973 and have services in technology, operations, finance, and strategy.

How actively are health systems buying physician practices or affiliating with them in creative ways, and how are tighter linkages between health systems and practices affecting quality and cost?

I wouldn’t categorize it as an emerging trend. It’s a trend that we’ve been seeing for quite a while now, which is various forms of consolidation. Whether it’s acquisition or some other type of affiliation, the number of independent physician practices is reducing in size and the number of independent hospitals is reducing in size.

A lot of that has to do with efforts associated with improving quality and also containing costs. Reducing redundancy out of the system, whether it be from a personnel perspective, a technology perspective, whatever the cost basis might be in that regard. Also taking the things that the individual organizations do really well — in terms of service lines, specialty care, etc. — and proliferating that across a broader network of providers to try to increase the quality for that provider base up to a higher bar than what was previously variable from group to group to group.

Are you seeing any new urgency on the part of health systems to look harder at their costs since they are responsible for a lot of overall healthcare expense?

With the transition from volume to value, it’s essentially becoming a business imperative that they do that. Whether that includes acknowledgement that they they were part of the problem, or they see that now is the opportunity to focus on that and to act on that because it’s a requirement if they’re going to be sustainable and maintain any type of margins because of how the payer environment is shifting. Either way, the focus is there. You see cost control measures, but you also see a shift in care out to the ambulatory environment just to reduce the higher-cost acute care that tends to result in the larger bills.

Are hospitals prepared to be more responsive to their customers or patients than they’ve been in the past?

It’s highly variable in the market. You see some organizations that have led the charge on that and have made it a competitive advantage for themselves within their respective markets.

If you look at, for example, the portal adoption rate for Kaiser since they launched their portal in the early 2000s and had that focus, that’s become a mainstay of their business and has helped them to be competitive in many environments where the consumers have multiple options, in terms of insurers, but overall network providers. Then you see other pockets of the country that aren’t thinking that way at all yet. There is a ton of variability there.

For some payer and provider organizations in the country, you’re seeing entire consumer technology divisions being created and being supported with capital and operating dollars. To have the patient be more at the center of the decisions that are being made and do internal investment in consumer technologies, versus just waiting for the broader IT industry to necessarily catch up in some cases.

What is worrying academic medical centers right now?

The AMCs have a lot of the same pressures as other organizations, but then they have additional requirements that are put on them, whether it be research, their GME programs, or where they get their funding. They have their own concerns as everyone else, but they have a lot of additional challenges and requirements that they have to work through that make it much more difficult to figure out how they’re going to allocate funds and where they’re going to receive funds from.

You also see academic medical centers that have had a distributed group within them, separate sets of clinics that were operating fairly independently and they’re trying to create more of an integrated group within themselves to try to lower the cost basis, but also try to take out the variability from area of care, whether it’s department to department or specialty to specialty. To your point earlier, they can also look at the cost and the quality basis that they’re working from at the same time. 

They have to handle all that at the same time that they’re dealing with the challenges of operating a school of medicine, operating a school of nursing, looking at the research requirements, providing faculty oversight, running GME programs, et cetera. It’s a lot to handle.

It’s been said that we’ve laid the technology tracks and are now realizing what we can do with newly collected healthcare information. What ideas are out there?

In terms of Meaningful Use, it definitely got systems in environments of care where it didn’t exist before. Areas of the hospital, clinic, or whatever that were largely paper based. It did push a lot of organizations to at least get some digital storage. Did it get all of the benefits that were touted at the time? I personally don’t think so. I think a lot of people don’t think so either, in terms of it being the magic bullet that it was marketed as, to improve care and improve safety. As people have these systems, whether they be expensive systems or lower-cost systems, in their environments now, they’re seeing ways that they can optimize those systems so that they’re using the data to make better decisions.

A lot of the other benefits in terms of efficiency, I don’t think that we’ve seen those. The usability of most of the systems, especially on the clinician side, hasn’t been there to allow more efficient work flows. They’re looking at ways that they can use the information and system to make wholesale different decisions about how they’re going to run their organizations, versus just appending that, they plug the system in and it’s going to make cappuccino for them, for example, and do all these wonderful things. They’re going to have to make more transformational decisions about how the organization works on a day-to-day, week-to-week basis. If they can make some of those decisions based on what the data is telling them, at least they can be more directive in what they’re moving toward 100 percent reactive to whatever the latest firefight is.

What will the impact of the CPC+ program be? Do you see CMS wanting to become more involved with how EHRs are used?

Moving away from just the rules and regulations associated with Meaningful Use is allowing the vendors to put more of their R&D dollars in some of the stuff that matters more so in terms of how systems are used within environments of care and that usability factor that’s going to drive efficiency and adoption that actually results in these types of outcomes. I think CMS putting some focus on programs like this, as opposed to, “Which buttons are you clicking to produce which reports?” so that you can satisfy the requirements of a given stage and avoid the penalty for not complying with those stages — we’ve gotten a little bit of that behind us.

By having more quality-centered programs like this announced, it’s going to further help align the interests of the users of the systems and the makers of the systems so that those development dollars are going into things that can help the providers, help the hospitals and clinics, and ultimately and ideally, provide some efficiency and care outcome impact as well.

The nice thing about these programs is that they do emphasize the fact that there’s a lot in these technologies that people put in in the Meaningful Use era that they just haven’t really used yet. They were using the basics of it, whether it be decision support or outreach to patients for reminders, et cetera. They were using it to hit a numerator and a denominator without as much line of sight on what the impact of that could be or should be.

Programs like this one are a good reminder that you have a lot of tools at your disposal already. If you narrow your view and just try to move the needle a little bit in a couple of these areas, you can get some benefit out of them instead of trying to hit a numerator number just so that it looks right on the report, but not necessarily seeing what value that’s providing to your patients.

Do you have any final thoughts?

It’s an exciting time in the industry because organizations are  focusing on IT as a strategic enabler of other outcomes or directions that they want to move, as opposed to IT and IT investments as a standalone decision that they have to do or that may only be linked to the financial side of the company or the organization.When I first started implementing EHRs, it was really common that the IT director, or even CIO, reported up through the CFO, for example, and didn’t necessarily have an equal seat at the table with those making decisions. We’ve changed a lot of that in the last 10 years.

Organizations, especially now as they’re looking at how to optimize their systems and, more and more, if they need to replace their systems and how they need to replace their systems –  that’s a much more coordinated and collaborative conversation with strategic drivers, financial drivers, and clinical quality drivers. You have your IT leaders saying, "We’ll help enable whatever the best thing is to support those other goals and initiatives," as opposed to having more of an IT decision or an IT implementation in a silo, where we hope that we get those other benefits and we definitely hope that we don’t introduce harm or a step back in those other areas of the organization. “We’re going to do this with the intent of improving those areas and measure our success as to whether or not we did that,” versus measure our success on, “Did we get everything turned on at the time that we said we were going to flip the switch and within the capital budget that was given to us as part of our implementation?”

For me as a consultant, it’s a lot of fun right now. We’re doing this and we’re actually seeing some of the outcomes from what we’re doing, as opposed to, we’re doing this and we’re trying to get really excited about a go-live event, not knowing whether or not that go-live event is actually going to lead to anything meaningful in terms of real outcomes on the care and safety side, or on the cost control side.

For a while there, it was a bit of a sludge getting through healthcare IT consulting on a day-to-day basis, where it was so focused on go-lives and numerators and denominators. We took a step too far away from why it is that we got in this business in the first place. Now we’re getting closer to some of those original projects, at least in philosophy and emphasis, where nobody was making us do it, but we did it because it was the right thing to do. For me, my job is a lot more fun, over the last 18 to 24 months even, than it was for the few years before then.