Curbside Consult with Dr. Jayne 4/11/16

Although the majority of my consulting work revolves around healthcare IT, I’ve done a fair number of practice management and operations engagements along the way. Many of the opportunities have bubbled up as a result of a practice or medical group trying to implement EHR.

Going through the process tends to highlight overall inefficiencies, role confusion, lack of management, financial issues, and more. Over the last six months, I’ve seen the requests for those types of services increase, which is part of why I joined forces with another consultant. We’ve written a number of engagements that don’t really have any information technology components.

As we’ve been exploring the different kinds of services we can offer and the needs of our potential customers, we’re seeing more organizations that are at a crossroads. It seems that quite a few primary care organizations are having what amounts to an identity crisis. Should they press ahead towards value-based care? Should they transform their systems and prepare to accept full-risk contracts? Or should they retreat towards their roots with personalized (and sometimes concierge) care? Two emails this week from the American Academy of Family Physicians highlighted this looming crisis.

On one hand, the AAFP has launched what is describes as a “full-court press” to ensure that family physicians are ready for payment reform. Calling it a “ground-breaking, knock-your-socks off change that opens to the door to a whole new era of Medicare physician payment,” the AAFP is positioning itself to help physicians “reap the benefits of a new payment system that, unlike fee-for-service, values the training, skill level… and time that goes into taking care of patients in a family medicine setting.”

In order to prepare for the transition, they’re encouraging physicians to participate in the Physician Quality Reporting System (PQRS). They also recommend that practices review their Quality Resource and Use Reports (QRURs) which will show physicians where they stand as far as future payments for the MIPS track. Most of the primary care physicians I know have never heard of a QRUR and would be put off by the process one needs to go through to obtain theirs.

AAFP also recommends that practices embark on clinical practice improvement activities around access to services, patient engagement, care coordination, and more. Smaller practices (and some larger organizations) are often ill-equipped to try to make these changes on their own. Their articles are pushing physicians towards the new models with comments that the process won’t go away or be delayed, and that “this train has left the station.” There’s going to be a huge market for services around helping physicians make the transition and I’m sure the AAFP teams will be gearing up with offerings of their own.

On the other hand, AAFP is hedging its bets by also marketing services towards physicians who are choosing to opt out of payment reform entirely. They’ll be hosting a Direct Primary Care Summit in July. The meeting is targeted towards not only physicians who have already converted to direct primary care, but for those who are thinking about it or trying to figure out how to manage the transition. They’ll be educating physicians on the legal aspects of operating a direct care practice as well as how to address business development around the new model. The conference promotion materials cite the “momentum” and “growing excitement” saying Direct Primary Care is “no longer a trend” and is being supported by positive legislation across the country.

I certainly don’t fault AAFP for playing both angles. Primary care is at a crossroads. The National Residency Matching Program “Match Day” was last month. This year’s match saw only 1,481 graduates from United States medical schools choosing family medicine. There were some other interesting statistics coming out of the Match:

• Family medicine offered 11.7 percent of all positions in the Match.
• The fill rate in family medicine for US seniors has decreased from 1996 (72.6 percent) to 2005 (40.7 percent) with a slight increase this year (45.4 percent).
• The fill rate in family medicine for US seniors has been below 50 percent since 2001.
• Aggregate primary care positions (family med, general internal med, general pediatrics, and internal med/peds) filled with US seniors at a rate of 50.7 percent.
• Only 12 percent of US seniors participating in the Match selected primary care residencies.

Looking at non-US seniors who matched into family medicine, the numbers are climbing overall. Although I’m happy to see qualified international graduates matching into primary care specialties, I think the fact that US grads continue to choose other pursuits is very telling. Primary care salaries are among the lowest in the physician ranks and primary care physicians report some of the highest burnout levels compared to their peers.

The loss of autonomy brought by shifting healthcare policy over the last decade has hit primary care physicians disproportionately compared to specialists in many markets. Although payment reform may extend that loss of autonomy more fairly across the board, if feels like we’re moving towards the lowest common denominator rather than trying to elevate everyone.

Lots of people are looking at the decline of primary care. A recent JAMA article looks as the expanded use of the term “primary care provider” as having negative consequences for the future of primary care. It asserts that although increased use of the term provider “reflects the importance of a multidisciplinary approach to modern primary care delivery, extending beyond the traditional dyad of patient and physician,” it has also had negative impacts. Patients may not be reaching the appropriate member of the primary care team if they can’t distinguish between different types of primary care providers. A mismatch in care delivery can lead to both over- and under-performance as well as challenges to patient safety and the delivery of cost-effective care.

The article specifically cites the rise of Direct Primary Care as being from “the resultant uncertainty and insecurity about who is going to handle their medical problem.” It also mentions that not differentiating between providers may put some individuals into “situations beyond their level of training and competence.”

I’ve seen this with one of our practice’s competitors, whose push for their nurse practitioners and physician assistants to practice independently is causing them to seek employment elsewhere. Healthcare IT is cited as a potential bridge for providers in those situations, who may be able to use protocols and clinical decision support mechanisms to “help mitigate some of the front-line diagnostic and management challenges for team members facing situations beyond their level of expertise.” I leverage technology often in practice, but it’s not a substitute for experience.

The authors also mention that the provider designation ”risks de-professionalizing” physicians, NPs, PAs, and nurses “who value their specific professional identities.” My favorite part of the article says it all:

Using the “provider” designation in primary care also suggests that primary care is simple care that can be commoditized and delivered piecemeal in a variety of settings by less well-trained personnel operating interchangeably at low cost. As such, use of the term may promote low levels of compensation and diminishes respect for the field, compromising its fundamental mission. Although low-cost approaches to some very basic elements of primary care, such as immunizations and treatment of upper respiratory infections, make enormous sense, they do not apply to the resources, skill, and training needed to deliver the full spectrum of comprehensive primary care in personalized, coordinated fashion, especially to an aging population with multiple comorbidities. “Provider” belies the complexity and amount of effort required. Note that the designation of “provider” has not been applied to such fields as surgery or cardiology, even though these too entail multidisciplinary, team-based care structures.

It goes on to recommend that we “cease referring to and treating primary care clinicians (as well as all other physicians and health care practitioners) as “providers” and address and relate to them as the highly trained professionals they are. If only things were that simple, that we could change some terminology and things would improve. Healthcare seems to just keep riding tide after tide and grabbing after the next shiny object that they think will solve the problems. We hoped for the last decade that technology would solve all our problems, that if we just added automation to the practice of medicine that we’d solve problems. Unfortunately, automation was often poorly applied and shifted the work to physicians.

Now we think that if we make the data more accessible, we can fix the problem. It feels like we’re pinning our hopes on interoperability, but we’re not doing what we need to make better use of the data, whether by physicians and other care providers or by patients themselves. Professional and educational organizations are weighing in, but are somewhat hampered by the lack of details on how new care models will unfold.

“Providers” are tired of waiting and continue to leave practice or pursue alternatives such as Direct Primary Care or to opt out of Meaningful Use or Medicare/Medicaid. The giants of our industry are increasingly reactive rather than being proactive or innovative. Eventually, something will have to give, and I fear it will be the people on the front lines.

Do you think emerging payment models will fix the healthcare crisis? Email me.

Email Dr. Jayne.

HIStalk Interviews Jim Litterer, CEO, Vital Images

Jim Litterer is president and CEO of Vital Images, A Toshiba Medical Systems Group Company, of Minnetonka, MN.

Tell me about yourself and the company.

Vital Images is a company that’s been around for about 25 years. It was founded by Vincent Argiro. For the first 20 years of existence, it focused on advanced visualization and clinical applications. We’ve been broadening the focus of the organization over the past several years because we realized that advanced visualization and 3D imaging capabilities are a great way to communicate to downstream care teams.

We’ve been broadening our solution offerings and have created three divisions within Vital. One is focused on enterprise imaging, our Personalized Viewing Solutions.

In the second, Enterprise Informatics, we deliver a unique interoperability solution where information can be connected across disparate structured content systems to provide the right information to the right person at the right time within the care cycle.

Our third division focuses on image practice management software and an analytics platform. We are able help IDNs visualize the imaging operations across all locations in real time, in conjunction with the ability to drill down to patient-level quality benchmarking. That data is then used to make informed decisions on operations management and capital investments in lockstep with accountable care imperatives within the organization.

Describe what visualization tools do and how they are used.

Visualization tools can range from diagnostic decision-making tools to enterprise viewers to assist the care team. Even patient communication, which is crucial as organizations strive to attain patient engagement.

The personalized viewing platform delivers the ability to adapt to simple examples of clinical review, or drill down to diagnostic view, then further advanced visualization. In essence, the platform adapts to the role of the clinician and disease state of the patient.

Our advanced visualization solution creates quantitative data that can then be stored as discrete data that can be leveraged in broader sets of applications.

From the diagnostic imaging side, we provide patient-centric viewers to imaging specialists — such as radiologists and cardiologists – who use that to make the diagnosis.

Finally, we have viewers beyond diagnosis that help care teams treat patients ongoing. Clinicians use our zero-footprint viewer, VitreaView, to understand the diagnosis and make treatment planning decisions.

What will the next generation of VNAs and enterprise viewers look like?

It’s heading to a place where hospitals are looking for enterprise systems that connect not just imaging information, but discrete data as well. We’ve all heard of PACS 3.0. These solutions are migrating to where you’re accessing locations of information, and then you use viewers and interfaces to create care dashboards for the clinical specialists to more effectively treat patients by being presented with the right information at the right time.

We reviewed the VNA and enterprise viewer market, Based on direct feedback of our customers, we launched second-generation products. For instance, VNA On Demand allows the CIO to incrementally build a VNA based on their architecture.

What is the expectation that images will be shareable in an interoperable world?

Images, multimedia, and other structured content are critical to decision-making and treatment planning. As a support line within a hospital, imaging practices are going through a large amount of change due to the effects of the Affordable Care Act. Hospitals need solutions that help align imaging activities with bundled payment models. Imaging is a key technology to driving cost-effective diagnosis, but in order to get the full value from imaging practices, the information needs to be completely integrated in with the health record.

In the past, it was assumed that you’d have to aggregate information to a central location to use it. We’re creating solutions that can access imaging data and imaging content in their native sources, which allows physicians to access that data through the health record in a patient-centric context.

What are the most pressing issues in medical imaging?

Imaging data is exploding and accounts for the majority of the storage claimed within a health system. This large set of data is also one of the most underutilized in terms of population management and risk stratification.

The largest task at hand is to take that image content that is being successfully used within a radiology department and then extend it across the healthcare enterprise. Imaging investments are large and there is much more we can do to leverage the information for improved patient care outcomes and improved efficiencies to align with the Affordable Care Act payment models.

Who consumes the actual images rather than the interpreted description of what the images are believed to show?

Text-based reports have been the primary focus of delivering imaging results to the treating physicians. We have found that if you provide treating physicians with a zero-footprint, three-dimensional viewer and quantitative results displayed on image itself, this information is used just as much as the text-based report. The old adage, “A picture is worth a thousand words” couldn’t be truer in medical imaging.

As an example, once you’re able to provide simple volumetric viewing tools along with the text information, it’s a much easier way for a surgeon to plan a complex procedure or learn the best way to operate on a specific disease to save OR time, not to mention educating the patient on the procedure.

We’re seeing applications for this imaging data as health systems investigate 3D printing applications. 3D printing is a hot topic and is starting to build momentum in the market today, primarily for treatment planning and for patient education. We are just starting to scratch the surface with this technology. It will be something to pay attention to.

What has been the impact of having the surgeon be able to walk through a representation of the procedure as a practice run before doing it for real?

We’re on the edge of 3D printing becoming a much more broadly used application. We have about 5,000 installations of our advanced digitalization tools around the world. We’re seeing a lot of interest from radiology practices that are looking to offer 3D printing as a value-add to their practice for downstream physicians. We’re certainly seeing it in big hospitals and large academic sites. Many of them have invested in 3D printers to handle this type of workflow.

You released an imaging analytics solution specifically for ACOs. How are their needs different?

We are using Vitality IQ to enable IDNs to visualize the all activities that are happening within their imaging department. Operationally, this solution provides real-time access to frontline management to understand where bottlenecks and idle time are occurring. Strategically, the solution provides aggregated information from EMR, PACS, HIS/RIS, and financial systems to make larger informed decisions on future equipment investments or how to better market to referring physicians based on trending information.

Where do you see the company in five years?

We will be a healthcare informatics company that provides an enterprise service bus for structured data that help HIEs and IDNs integrate in the imaging information through our viewers. We’ll continue to be focused on viewing or imaging-based applications, but we know that these solutions must tie in much beyond a specific department. We’re going to continue to evolve our solutions to help our customers solve the challenges they have within imaging and in the utilization of that information.

Morning Headlines 4/11/16

Dell: The going rate for a hacker to break into a Gmail account is $130

Dell Security Works publishes its annual Underground Hackers Markets report, which lists the typical cost of various black hat services, including hacking email and social media accounts, running DDoS attacks, and stealing bank account information.

Lessons From More Than A Decade In Patient Portals

In a Health Affairs article, Kaiser Permanente researchers outline lessons learned in the ten years since implementing its patient portal.

Pfizer Taps IBM for Research Collaboration to Transform Parkinson’s Disease Care

Pfizer partners with IBM to co-develop remote patient monitoring solutions for patients with Parkinson’s disease.

Sentient Technologies is using AI to tackle deadly diseases

Artificial Intelligence company Sentient Technologies sets its sights on healthcare with AI nurse, a system that forecasts changes in a patient’s condition, predicting sepsis and other critical conditions.

Monday Morning Update 4/11/16

Top News

Dell’s security business finds that the going rate for hiring a hacker to penetrate Gmail, Hotmail, or Yahoo email accounts is $129, while breaching a corporate email account runs $500. They will hack into a Facebook or Twitter account for $129, provide a complete US identity (driver’s license, Social Security Card, and utility bill) for $90, or provide a Visa or MasterCard for $7. They’ll even turn over a US bank account with a $1,000 balance for just $40.

The enterprise price list is even more sobering – hackers will launch a denial-of-service attack for as little as $5 or will install a remote access Trojan for $5 to $10. Security sites have noted that hackers are selling Ransomware as a Service for $50 plus a 10 percent commission on the ransom money paid, allowing non-technical criminals to easily and immediately launch their own extortion business.

Reader Comments

From Twidiots: “Re: [publication name omitted]. Stole your story about the DoD’s EHR project name without giving credit. I’m going to email them.” It’s common for sites to miss subtle but significant news items until they read about them on HIStalk, but it’s obvious this time because I ran the Tuesday evening announcement in my Thursday night news and suddenly everybody’s running it first thing Friday, pretending they found the days-old announcement themselves. That’s OK, but it’s still lazy to reword the DoD’s announcement without linking to it and to cite the published quotes as “US Department of Defense officials said” like some general called them up with a scoop. I guess they get lots of readers, just like those clueless “9 things you need to know” sites that rarely contain anything you might actually need to know. I think HIStalk readers are smarter than that, so there’s no need to email the publication.

From Vince Ciotti: “Re: Leapfrog’s tests that showed CPOE systems missed 39 percent of harmful drug orders and 13 percent of potentially fatal ones. That means they flag 61 percent and 87 percent, respectively – great progress since paper charts caught none of them!” Leapfrog took a measured approach in describing its findings as it does every year during Medication Safety Awareness Week, noting that CPOE warnings are doing a pretty good job. It’s nice that we’ve moved from questioning whether such warnings work at all to urging that it work 100 percent of the time.

From boyfrommer: “Re: Decision Resources Group. CEO Jim Lang quit and will be replaced with Jon Sandler of IndUS Group, the private equity arm of the group that purchased (and overpaid for) DRG in 2012. Jon has no operating experience and neither does his COO, who also comes from IndUS.” I’ve never heard of the company, which appears to provide medically related research reports.

From The PACS Designer: “Re: ICD-10-PCS. It’s an exciting time for healthcare as the ICD-10-PCS Procedure Codes will be updated with 3,651 additions by CMS to further enhance it starting October 1. Here’s a sample: 0273356 Dilate 4+ Cor Art, Bifurc, w 2 Drug-elut, Perc (abbreviated version) or Dilation of Coronary Artery, Four or More Arteries, Bifurcation, with Two Drug-eluting Intraluminal Devices, Percutaneous Approach.”

HIStalk Announcements and Requests

Poll respondents would fell safest having their medical information in the hands of Apple and an EHR vendor, placing the least trust with Microsoft and an HIE. My suspicion is that the spate of health system breaches of many kinds has cause people in general (and healthcare IT people in particular) to lose faith that their information will remain confidential. New poll to your right or here: have you had a virtual visit in the past 12 months?

Ms. Chestnut from Indiana says her fourth graders are becoming better world citizens by studying the library of nearly 100 books we provided in funding her DonorsChoose grant request.

Also checking in is Mrs. P from Virginia, who says she has “been laminating like a mad woman and our new printer is SO FAST” in describing some of the supplies that we provided, from which her elementary school students are creating their own math and reading games that they play independently.

Listening: The Raconteurs, the possibly defunct Detroit-Nashville supergroup foursome that includes Jack White, formerly of The White Stripes. It’s catchy, has big horns, and pushes into acid rock/Led Zeppelin in its experimentation. That sent me back (as happens frequently) to one the greatest (and most intelligent) live rock and roll bands in the world, Sweden’s Howlin’ Pelle Almqvist and The Hives.

Last Week’s Most Interesting News

• The Department of Defense gives its Cerner project the name MHS Genesis.
• MedStar Health (MD) disputes reports that its ransomware attack was made possible by unpatched server software.
• HHS asks for suggestions for interoperability measures that it should incorporate into MACRA objectives.
• Massachusetts General Hospital (MA) and two hospitals of NYC Health + Hospitals go live on Epic.
• At least two more hospitals are taken offline by ransomware attacks, this time in California and Indiana.

Webinars

One of the best (and most timely) webinars we’ve done was last week’s “Ransomware in Healthcare: Tactics, Techniques, and Response” by Sensato CEO John Gomez. We had a big, engaged crowd that asked John so many questions that we didn’t have time to address them all in our scheduled one hour. It’s worth watching — we asked John to put this together purely as a public service, so there’s zero pitch or commercial influence involved.

None scheduled soon. Contact Lorre for webinar services. Past webinars are on our HIStalk webinars YouTube channel.

Acquisitions, Funding, Business, and Stock

Medical equipment and workflow vendor Midmark Corporation will acquire RTLS vendor Versus Technology to enhance its clinical workflow offerings.

Asset, facilities, and real estate management software vendor Accruent acquires Mainspring Healthcare Solutions, which offers equipment maintenance and asset management systems.

Oncology EHR vendor Flatiron Health announces strategic partnerships with its drug company customers Celgene and Amgen, both of which participated in the company’s $175 million funding round in January 2016.

People

St. Peter’s Health Partners (NY) promotes interim VP/CIO Chuck Fennell to the permanent position.

Announcements and Implementations

IBM and drug company Pfizer will collaborate to remotely monitoring sensor data from people with Parkinson’s disease to look for new diagnostic and treatment insights.

Privacy and Security

Einstein Healthcare Network (PA) notifies 3,000 people who filled out a web form requesting information that their entries were exposed when the form’s underlying database was inadvertently opened up to the Internet.

Target says in a securities filing that it has spent $300 million cleaning up the mess from its 2013 data breach, of which it expects only $90 million to be covered by cyberinsurance.

Adobe urges computer users to upgrade to the latest level of Flash released last week after finding flaws that allow delivery of ransomware. Steve Jobs was right when he said in 2010, “Symantec recently highlighted Flash for having one of the worst security records in 2009. We also know first hand that Flash is the number one reason Macs crash. We have been working with Adobe to fix these problems, but they have persisted for several years now. We don’t want to reduce the reliability and security of our iPhones, iPods, and iPads by adding Flash.”

Other

Want to make it obvious you don’t really know healthcare IT? Refer to inpatient drug “orders” as “prescriptions.”

Wired profiles artificial intelligence technology vendor Sentient Technologies, which has raised $143 million in funding since 2008 to create financial applications. The company is developing an “AI nurse” that can predict patient condition changes. The co-founder describes how such a system can teach humans:

One of the good things about evolutionary AI is that — if you know how to read it — you can actually see the rule sets. In the case of traders or of AI nurses (on which we are working, too), they are fairly complex beings. A trader may have up to 128 rules, each with up to 64 conditions. Same thing for an AI nurse. So, they are pretty complex systems and the interplay among these rules is not always linear. But if you spend some time on it, you can still understand what this thing is doing, because it’s declaratory — it says what it is doing, in other words. So we can certainly take this and learn from this what works and what doesn’t work when it comes to solving a certain problem. AI can teach people to make better decisions.

Authors from Kaiser Permanente describe what the organization has learned from having many of its patients use its patient portal over several years.

• Seventy percent of KP’s eligible adult patients, 5.2 million people, have registered to use its Epic MyChart-powered portal called My Health Manager.
• KP providers and patients exchanged 23 million secure emails in 2015, representing one-third of all PCP encounters in the first half of 2015.
• Use of secure email was associated with a 2 to 6.5 percent improvement in HEDIS measures and a 90 percent approval rate by users with chronic conditions.
• My Health Manager users are 2.6 times more likely to remain KP members.
• KP is studying the disparities introduced by e-health technologies after its studies found that a disproportionate number of users are white, older, and better educated.

Weird News Andy says he’s a sucker for stories like this. Wichita, KS police arrest a 36-year-old man for child abuse after the two-year-old son of his 21-year-old girlfriend is brought to the ED not breathing due to a two-inch dead octopus blocking his throat. The boyfriend claims the child swallowed the octopus while the mother was at work. Police say it wasn’t a pet – it was intended for sushi. The child is OK.

Sponsor Updates

• DrFirstwill exhibitat the 2016 International MUSE Conference May 31 – June 3 in Orlando, FL.
• T-System will exhibit at the UCAOA National Urgent Care Convention April 17-20 in Orlando.
• TierPoint will host a seminar on Emerging Threats & Strategies for Defense April 13 in Liberty Lake, WA.
• TransUnion CMO Julie Springer is inducted into Direct Marketing’s 2016 Marketing Hall of Femme.
• Valence Health will exhibit at the First Illinois HFMA Spring Symposium April 11-12 in Chicago.
• Visage Imaging will exhibit at the 2016 Spring Radiology & Imaging Conference April 13-15 in Atlanta.
• VitalWare will exhibit at the 2016 Vizient Supplier Summit April 11-13 in Las Vegas.
• Huron Consulting Group will exhibit at the 2016 AAPL Annual Meeting and Spring Institute April 11-17 in Washington, DC. 
• West Corp. will exhibit at the World Health Care Congress April 10-13 in Washington, DC.

Blog Posts

• Key benefits of e-prescribing controlled substances (DrFirst)
• People are Talking Patient Flow at AONE & AORN (TeleTracking)
• Decompressing Post-HIMSS16 (Verisk Health)
• Key benefits of e-prescribing controlled substances (DrFirst)
• Bouncing Back at AONE 2016 (Voalte)
• “Master” Your Claims Submission Process (ZirMed)
• People, Not Patients – It’s More Than Semantics (Zynx Health)

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 4/8/16

MHS Genesis rolls out as name for new electronic health record

The DoD brands its Cerner implementation project MHS Genesis.

Hospitals’ Computerized Systems Proven to Prevent Medication Errors, but More is Needed to Protect Patients from Harm or Death

A new report finds that CPOE systems fail to flag 39 percent of potentially harmful drug orders and 13 percent of potentially fatal drug orders.

MedStar disputes report it ignored warnings that led to attack

MedStar disputes recent allegations that the ransomware attack it suffered exploited known security flaws from 2007 and could have been prevented with a simple software update.

As hospitals go digital, human stories get left behind

A physician at Massachusetts General Hospital (MA) argues that EHRs fail to capture a meaningful patient story, arguing that EHRs mask “how one symptom relates to another, the emotional context in which the symptoms or events occurred, or the thought process of the physician trying to pull together individual strands of data into a coherent narrative.”

News 4/8/16

Top News

The Department of Defense christens its Cerner-centered EHR project as MHS Genesis. The functional project champion explains, “We want people to know MHS Genesis is a safe, secure, accessible record for patients and healthcare professionals that is easily transferred to external providers, including major medical systems and Department of Veterans Affairs hospitals and clinics. When our beneficiaries see this logo or hear the name, they’ll know their records will be seamlessly and efficiently shared with their chosen care provider.”

I might quibble that the DoD’s new logo incorrectly contains all capital letters in spelling GENESIS and looks like something a Photoshop newbie might design, but at least it uses the correct Greek mythology symbol of the wingless Staff of Asclepius – which denotes healing and medicine –rather than the oft-mistaken winged Staff of Caduceus, which is symbol of commerce. Still, I  can understand how the latter is more appropriate than the former in our convoluted healthcare system, where the lines at the financial trough are often serpentine.

Reader Comments

From ZenMaster: “Re: Sandlot Solutions. Website down. Phone not working. Clients frantic. A cautionary tale for all the start up Population Health Analytics companies out there. HIE / Healthcare Data Aggregation / Population Analytics is hard. Proceed with caution.”

From A Vendor That Also Finds Email Tracking Slimy: “Re: vendors being informed when you open their spam email and then contacting you directly. Most of these programs function by embedding a one-pixel image into emails and tracking when that image is loaded. Disable the automatic download of images in your mailbox settings or contact your organization’s IT team about blocking or filtering items that are created using similar methods like Tout, Sidekick, Yesware, Streak, etc.” Promos for the Yesware tracker shows why aggressive companies keep using it for “prescriptive analytics” to pester prospects – unfortunately, it works, just like other sales techniques that range from cold calling to outright lying.

HIStalk Announcements and Requests

We funded the DonorsChoose grant request of Ms. S in Texas, who asked for five animation studio kits for her elementary school class to produce STEM-related movies.

Also checking in is Mrs. S from Connecticut, whose middle schoolers are using the Chromebooks we provided to publish and discuss their writing, with some of the most active participants being those students who don’t otherwise engage.

Speaking of Chromebooks, I decided to round out my little technology arsenal of everything I use to research and write HIStalk (a $300 Toshiba laptop and a $200 iPad Mini) with a Chromebook. The Asus C201 has an 11.6-inch monitor (perfect for traveling), 4 GB of memory, a 16 GB solid state drive, a very nice Chiclet keyboard (I’m not a fan of on-screen and tiny Bluetooth keyboards), and a battery life of around 10-12 hours. It weighs about 2 pounds and is 0.7 inches thick. It powers on and off almost instantly and took almost no time to set up, automatically updating itself as needed in the background with no third-party antivirus needed. The learning curve is pretty much zero – the only workaround I had to look up was how to regain Delete-key function since that key is omitted from most Chromebooks for space reasons. Best of all, it was only $200 complete with a nice padded sleeve and a wireless mouse with nano receiver. Chromebooks use the Chrome OS operating system instead of Windows or Linux, so they won’t run most desktop apps, but the Chrome browser is very fast (as are Google Docs and Gmail), Dropbox works fine, and thankfully my most valuable program LastPass works great on it for automatically logging me in password-protected sites I’ve saved, like Amazon. I even installed the Chrome OS version of Teamviewer in case I need to remote back into the laptop to do something. It’s not for everyone – for example, folks who rely on desktop versions of Office – but you might be surprised at how much of your work is online once you think about it and this is an inexpensive, lightweight, headache-free alternative to Windows or Apple laptops. 

This week on HIStalk Practice: KAI Innovations acquires Trimara Corp. Family physician Kim Howerton, MD stumps for direct primary care in Tennessee. DuPage Medical Group expands relationship with PinpointCare. Cable and home security business Connect Your Home gets into the telemedicine business. Culbert Healthcare Solutions VP Johanna Epstein offers advice on improving patient access (and ROI to boot). Kaiser Permanente Northwest puts medical record access at patient fingertips. Tribeca Pediatrics founder details the drastic steps he took to revitalize his failing practice. Biotricity CEO Waqaas Al-Siddiq offers his take on what’s holding physicians back from making the wearables leap.

Webinars

April 8 (Friday) 1:00 ET. “Ransomware in Healthcare: Tactics, Techniques, and Response.” Sponsored by HIStalk. Presenter: John Gomez, CEO, Sensato. Ransomware continues to be an effective attack against healthcare infrastructure, with the clear ability to disrupt operations and impact patient care. This webinar will provide an inside look at how attackers use ransomware; why it so effective; and recommendations for mitigation.

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

Acquisitions, Funding, Business, and Stock

Andover, MA-based National Decision Support Company opens a research and development headquarters in Madison, WI.

Population health management systems vendor Lightbeam Health Solutions acquires Browsersoft, which offers an HIE solution built with open source tools.

Digital check-in vendor CrossChx raises its second $15 million round in two years, increasing its total to $35 million.

Sales

Tampa General Hospital (FL) will implement the Voalte Platform for caregiver communication.

Universal Health Services will replace the former Siemens Invision revenue cycle solution with Cerner’s revenue cycle solution, integrating with UHS’s existing Millennium products. For-profit hospital management company UHS operates 25 hospitals.

The Department of Defense awards a five-year, $139 million contract to McKesson’s RelayHealth for patient engagement and messaging solutions. I assume that’s an extension or expansion since the military was already using RelayHealth.

Ernest Health (NM) will expand its use of NTT Data’s Optimum Clinicals suite in four facilities. The organization uses Optimum RCM in its 25 locations.

Queensland, Australia’s Metro North chooses the referrals management system of Orion Health.

People

Influence Health names Michael Nolte (MedAssets) as CEO. He replaces Peter Kuhn, who remains as president, chief customer officer, and board member.

Announcements and Implementations

Franciscan Alliance (IN) uses InterSystems HealthShare to create a vital signs viewer for legacy data that can be accessed from inside Epic by its 140-physician group.

India-based doctor finding and appointment scheduling app vendor Practo begins answering medical questions from India, the Philippines, and Singapore at no charge via Twitter using the @AskPracto account.

Government and Politics

National Coordinator Karen DeSalvo, MD, MPH says of information blocking in a Wall Street Journal interview, “We don’t have all the authority we need to really be able to dig into the blocking effort. We have put forward a proposal to Congress asking for more opportunities to address the issue.” She says that it’s a big step that the major inpatient EHR vendors have pledged to not participate in information blocking vs. a year ago when “people said blocking is a unicorn and not happening.” She adds consumers are interested in third-party apps that can extract data from elsewhere to create their own longitudinal health record and says that person-centric medical records will shift “very deliberately away from the electronic health record as being the source or center of the health IT universe.”

HHS asks for ideas about how to measure interoperability within MACRA objectives, with responses due June 3. The most interesting part of the information published in the Federal Register is that ONC is considering analyzing the audit logs of EHR users to determine how often they exchange information.

AMIA says proposed HHS changes that would give drug and alcohol abuse patients more control over their medical records aren’t adequate and fail to address electronic information exchange. AMIA wants HHS to revisit the idea of giving patients granular sharing control over their entire medical record, saying that managing substance abuse data differently is “a dated concept and flawed approach.” Doug Fridsma, MD, PhD, AMIA president and CEO, said in a statement, “Clearly, the trend in healthcare is to make patients first-order participants in their care. This means giving them complete access to their own medical records, and it should mean giving them complete control over who sees their medical information.”

Privacy and Security

MedStar Health (MD) disputes earlier Associate Press reports indicating that an unpatched JBoss server allowed hackers to take its systems down with ransomware. MedStar says Symantec, which it hired to investigate the attack, has ruled out unapplied 2007 and 2010 JBoss patches as the problem. The AP stands by its earlier report and adds that experts say that the Samsam ransomware that infected MedStar can be prevented by keeping updates current.

Google’s Verily Life Sciences biotechnology company comes under fire for awarding a research contract to a company its own CEO owns and for failing to tell its Baseline health study volunteers that it is planning to sell their data to drug companies for a profit.

Metropolitan Jewish Health System (NY) announces that an employee of one of its participating agencies responded to a phishing email in January 2016, with the unidentified hacker gaining access to the email account that contained PHI.

Other

Leapfrog Group  finds that CPOE systems still miss a significant number of drug ordering errors, failing to warn the prescriber of potentially harmful orders 39 percent of the time and also missing 13 percent of potentially fatal orders. Leapfrog collects voluntary CPOE test results from hospitals that use its testing tool.

The AMA publicly supports AllTrials, a global campaign that calls for every past and present clinical trial to be registered with their methods and summary results reported. The campaign says it’s not fair to study participants to hide study results that are inconclusive or unfavorable to the sponsoring organization, such as a drug company buying a study that finds one of its products ineffective. Commendably, the AMA’s involvement came from a proposal from its Medical Student Section. 

The COO of BCBS of North Carolina, promoted from CIO four years ago, resigns abruptly after the botched rollout of a billing and enrollment system last November during Healthcare.gov’s open enrollment period. The company is scrambling to rewrite the system in time the next open enrollment that starts November 1. It found an unspecified “fatal problem” in its software before last year’s open enrollment began, but continued anyway thinking it could fix problems as they arose, causing 147,000 customer calls on November 1 alone and 500,000 in the first week. The company imposed emergency measures in January 2016 after projecting that it will lose $400 million in North Carolina Healthcare.gov business, turning off the ability for consumers to apply online since they had no way to determine whether the applicant was actually eligible to purchase insurance.

The always-hustling Newt Gingrich pens an editorial criticizing his home state of Georgia for proposing to outlaw people doing their own eyeglass exams at home via a company’s app. USA Today got the assurance of Newt’s people that he had no financial interest in any related firms before running his op-ed piece, only to find out afterward that he’s running a $100 million tech fund with a private equity firm.

I missed a great April Fool’s prank by MedData, who announced the April 1 hiring of Hayden Siddhartha "Sidd" Finch as chief experience officer, slyly referencing a 1985 George Plimpton April’s Fool fake story in Sports Illustrated involving a Tibetan pitcher with a 168 mph fastball. The brilliant Plimpton even led off the 1985 story with a clever clue in spelling out “Happy April Fool’s Day” with the first letters of each word in the opening sentence, but still duped a significant number of people who should have known better (including a Senator, reporters, and Mets fans looking for hope).

An article questions whether it’s OK for sexting-comfortable teens to send genitalia photos to their doctors for diagnosis, wondering whether those images should be sent securely or whether the doctor receiving them might even be charged with possessing child pornography.

A woman who recorded her hernia operation with a hidden recorder captures OR staff making fun of her belly button and calling her “Precious” from the movie about an overweight teen. Harris Health System (TX) declined to comment citing HIPAA, but told the woman they had reminded OR staff to watch their comments and that was enough. She says she was racially profiled and is considering suing.

A primary care physician at Massachusetts General Hospital (MA) says the lack of patient narrative in EHRs dehumanizes patients and hampers the diagnostic abilities of physicians, noting that the story of Cinderella, if entered into the hospital’s newly implemented Epic system, would be a problem list consisting of “Poverty, Soot Inhalation, Overwork, and Lost Slipper.” She describes Epic (and thus EHRs in general) as:

Epic features lists of diagnoses and template-generated descriptions of symptoms and physical examination findings. But it provides little sense of how one event led to the next, how one symptom relates to another, the emotional context in which the symptoms or events occurred, or the thought process of the physician trying to pull together individual strands of data into a coherent narrative. Epic is not well-suited to communicating a patient’s complex experience or a physician’s interpretation of that experience as it evolves over time, which is to say: Epic is not built to tell a story.

A Boston Globe article ponders why the medical schools of Harvard and nine of its prestigious peers like Yale, Johns Hopkins, and Columbia don’t have a department of family medicine. Harvard blames lack of costly participation by its affiliate hospitals to support a residency. However, a Harvard medical student says doctors specializing in internal medicine and pediatrics often bolt for more lucrative subspecialties while most family medicine practitioners remain in primary care, adding that Harvard Med thinks, “You’re less competitive or you’re less rigorous if you’re interested in primary care.” Ironically, Harvard launched one of the first family practice residencies in 1965, but the federal government ended its funding 10 years later due to poor quality. The chair of the recently created family medicine program at Icahn School of Medicine says bluntly, “It’s bizarre to me that you have these institutions that don’t really feel that there’s a requirement to introduce their students to the second-largest specialty in the United States.”

The department of physical and occupational therapy at Massachusetts General Hospital (MA) create a video just before its April 2 go-live with Epic.

Sponsor Updates

• CloudWave joins the Microsoft Cloud Solution Provider program.
• Experian Health will exhibit at the SE Managed Care Conference April 7-8 in Charleston, SC.
• PeriGen publishes its annual review of labor and delivery malpractice awards.
• Red Hat announces the winners of its 2015 North American Partner Award Winners.
• The SSI Group will exhibit at the Texas Ambulatory Surgery Center Society 2016 Annual Conference April 7-8 in San Antonio.
• Streamline Health will exhibit at the 2016 HASC Annual Meeting April 13-15 in Dana Point, CA.
• Surescripts announces its 2015 White Coat of Quality Award winners for excellence in e-prescribing quality.
• Iatric Systems will exhibit at the Hospital & Healthcare IT Reverse Expo April 13-15 in Atlanta.
• RTLS technology from Versus earns Cisco Compatible Extensions certification.
• A record number of attendees gather at InstaMed’s annual user conference.
• InterSystems will host its annual Global Summit April 10-12 in Phoenix.
• Intelligent Medical Objects will exhibit at HealthCon2016 April 10-13 in Lake Buena Vista, FL.
• Netsmart will exhibit at the Texas Public Health Association Conference April 11 in Galveston.
• Obix Perinatal Data System will exhibit at the SSMHealth Annual Perinatal Nursing Conference April 14 in Fenton, MO.

Blog Posts

• Medicity Highlighted in KLAS HIE 2016 Specialty Report (Medicity)
• Healthcare Security, Part 1: More than a Firewall (CloudWave)
• 6 Reasons to Choose Secure Text Messaging for BYOD (Spok)
• Platform Openness and the Art of Integration (PatientSafe Solutions)
• Change the Paradigm (PatientKeeper)
• Reimagine traditional business models to fix healthcare (Lexmark)
• How will I-STOP Affect Specialty Prescribing? (Point-of-Care Partners)
• 5 Tips for Designing Efficient Epic Workqueues (Sagacious Consultants)
• Moneyball Meets Cost Modeling (Impact Advisors)
• How are Companies Managing Risks in the New Data-Centric World? (Liaison Technologies)
• Banishing CDs: A Two-Pronged Approach to Streamlining Outside Image Management (LifeImage)

Contacts

Mr. H, Lorre, Jennifer, Dr. Jayne, Lt. Dan.
More news: HIStalk Practice, HIStalk Connect.
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Contact us.

EPtalk by Dr. Jayne 4/7/16

In a previous post, I mentioned Epic vital signs alerts with values that were way out of range. Several readers commented, with one saying this couldn’t possibly be a client value and another wondering what other customer-built “garbage” might be in their system. The original reader who shared the alert sent me a screenshot of the Epic foundation build, showing the Epic-released values that are delivered read-only. Although you can modify it on age-based overrides, the the maximum pulse of 500 is out of the box.

Even worse, I noted that the pulse values all have trailing zeroes. I’ve spent more than a decade arguing with EHR vendor staffers about the concepts of precision and significant digits, and the fact that trailing zeroes don’t belong in fields like these. Since a pulse measurement obtained via traditional clinical skills can’t technically be precise to two decimal places, it shouldn’t be reported as such. Weird News Andy chimed in as well, suggesting that perhaps it was an alert for hummingbirds.

It’s National Public Health Week. Events in our area focused on tobacco, obesity, and diabetes. One of our offices had planned to host a blood drive, but it was canceled by the blood bank due to an “equipment malfunction.” I’m not sure what might be malfunctioning that would prevent us from using disposable collection gear, but we weren’t able to find another agency that had availability. Hopefully we’ll be able to make up for it next month.

Several of my consultant friends have a betting pool running on when CMS will release the MIPS/MACRA proposed rule. It looks like it has gone to the White House Office of Management and Budget, which might mean we could see it sooner than some of us thought. I’m banking on Memorial Day weekend since CMS has made a habit out of releasing it just before long weekends. By law, it has to be released within 90 days, but I think there may have been one recent proposed rule that came out past the 90-day mark. I’m too tired to Google it though, and it doesn’t really matter, so props to those of you who know for sure. I’m seeing a deluge of information from professional societies asking their members if they’re ready for MACRA, which is funny because many of the front line physicians I talk to don’t even have an idea what it is.

I mentioned it before, but the White House petition supporting a voluntary patient identifier doesn’t seem to be getting much traction. Only 6,000 people have signed it since it went live on March 20. It needs nearly 94,000 more signature prior to April 19 in order to receive a response from the White House. Although the Executive Branch can’t actually solve the problem, getting enough signatures on the petition would make a statement. If you’re supportive, please consider signing to have your voice heard.

The AMIA iHealth conference is right around the corner. I’ll unfortunately be attending another conference at the same time, but am interested to hear from readers that may attend. It’s approved for 12 hours of ABPM LLSA credit, so if you’re board certified in Clinical Informatics and haven’t started earning your hours, it would make a nice start. I’m nearly done with my continuing education for the year, which is a good feeling. The only thing I have left is a module for my primary board certification, and I’m waiting until summer when a new MOC paradigm goes into effect for us.

I often have physicians throwing articles at me with ratings and rankings of the “best EHRs.” Such pieces generally drive me crazy, because once you dig into the number of participants and truly dissect the data, it is often poor. In one recent study, the physicians polled couldn’t even correctly identify their vendor and instead claimed they were using systems from vendors such as “CPOE” and multiple acronyms developed by hospitals to brand or market their systems. The prize for the best article of the week goes to GomerBlog, however. Thanks for the laugh because I sorely needed it this week.

What’s your favorite EHR? Email me.

Email Dr. Jayne.

Morning Headlines 4/7/16

Allergan, Pfizer call off proposed $160B merger

Pfizer backs out of its plan to acquire Allegran and move its headquarters to Ireland for tax reasons after the Treasury Department put new rules in places to make tax inversions less lucrative.

National Health IT Coordinator Says Technology Can Help Unblock Patient Data Access

National Coordinator Karen DeSalvo, MD discusses health data portability, information blocking, and cloud technology in a Wall Street Journal interview.

Better Health Care: A Way Forward

Former National Coordinator David Blumenthal writes a JAMA op-ed on improving access, cost, and quality of care.

It’s Time To Stop Pretending Patients Don’t Care About Their Medical Records

Fast Company discusses barriers to expanding patient access to their medical information after an informal internet survey finds that 77 percent of patients are very interested in having access to the information.

Readers Write: The Future of Mobility and Cloud in Healthcare

The Future of Mobility and Cloud in Healthcare
By Joe Petro

For some time now, we’ve been hearing concerns voiced by physicians about how complicated their lives have become due to the mountainous documentation requirements. Among the most difficult is capturing the details a patient shares during a consultation and trying to fit that information into the structured template found in today’s EHRs.

How can we expect a patient’s story to be impactful when all its context and richness is lost to making sure we click and check the right boxes? This is a byproduct of all the initiatives coming out of the federal government. The EHRs are left with no choice but to force the structured capture of clinical documentation.

At the same time that we see these changing requirements, we’re also seeing a change in the technology used by physicians. Physicians are becoming increasingly more mobile and technologies can improve the physician experience and allow them to capture the patient story across the multitude of devices they currently use throughout the day. Executed properly, this ultimately offers physicians a way to streamline this documentation burden as certain technologies, such as speech recognition and language understanding, let them capture the required documentation in a more natural way.

In parallel, we are seeing an emergence of a cottage industry of mHealth app vendors looking to bring innovative technologies to the healthcare workflow. We have reached a tipping point where technical tools make it easier to leverage a large number of advanced capabilities. This makes it easier for the entire industry to create solutions and applications that are immediately impactful. This is a unique time and place in our technological evolution in the healthcare space.

Cloud is an example of a set of technologies that makes things easier and has the potential to deliver high impact. The cloud makes it possible for technologies to meet physicians wherever they are, on any device, at any time. For example, physicians can enter data into their mobile devices/apps any time, anywhere, and on the go. The cloud will be there to broadcast this information far and wide to EHRs or other apps and tools in a more meaningful way no matter where it originated. Thanks to cloud enablement, mHealth apps and other innovations become more useful to the physicians who want to be mobile.

Mobile and cloud innovations are impacting patients as well. Mobile applications and wearable devices are allowing patients to manage their own health, capture their own health data, and turn this data into actionable insights. Our lives and our health are on the brink of being substantially instrumented. We are now tracking sleep and eating patterns and mobile devices are starting to capture valuable information from blood pressure to heart rate to weight and more.

This technology can help patients comply with the treatment plans that physicians prescribe by allowing them to report progress or other important details in real time. The cloud is connecting patients to their own personal health experience, enabling them with the tools they need to better look after and manage their own health. It also connects patients to their healthcare providers and institutions before they actually need to receive care, potentially keeping them out the hospital in the first place. This evolution is taking place today.

We’re transitioning to a phase where we can truly call this “healthcare” instead of “sick care,” a phase where we are shifting to managing our health proactively instead of just managing a sickness after it has already happened. With all this data available via the cloud, EHRs and all health-oriented applications will evolve, making it easier for physicians to leverage the technology to increase productivity and improve quality of care. The value that the EHRs are promising to deliver will be delivered partly through this mechanism.

As we continue down this path, we move towards a setting that seems as if it’s almost from a futuristic movie where everything in healthcare is mobile, connected, and intelligent. We’re going to see patients surrounded by enabling technology in such a way that intelligent services in the cloud will help their mobile devices keep track of important information that can then be used during visits with their physicians or, more importantly, prior to visits.

Physicians will be primed for the visit with everything they need on a device, reducing the time patients spend having to tell the same thing to three different people upon entering a health system. Present-day documentation requirement problems will eventually fade into the background as technology advances and interacting with these systems become more human-like and natural. Physicians will be able to focus fully on what got them into medicine in the first place: caring for their patients.

Joe Petro is senior vice president of healthcare research and development of Nuance of Burlington, MA.

Readers Write: Tax Rebate? Insurance rebate!

Tax Rebate? Insurance rebate!
By Richard Gengler

Now that tax season is in full swing and the eventual rebate is around the corner, it is an ideal time to think about another kind of rebate. This one stems from the changes in healthcare policy with the Affordable Care Act (ACA) with the increasing push of the triple aim of improved patient experience, improving the health of populations, and reducing the per capita cost of healthcare.

With the individual markets becoming the fastest-growing part of the payer sector and increasingly competitive, payers are searching for any potential leverage to obtain, retain, and grow their membership base. There is more discussion on the importance of net promoter score (NPS), whereby payers can utilize their existing members to act as promoters.

By utilizing new innovations and alternative service modalities, insurance companies are able to hit all three parts of the triple aim. Almost on a daily basis we are hearing about innovations that have greater than 90 percent user satisfaction rates and significantly having positive impact on population health at potentially a fraction of the cost.

Health plans are required to have an 80 percent or 85 percent medical loss ratio (MLR), meaning that they spend this amount of the premiums they collect on medical expenses. The rest can be used for administrative, profit, and marketing. Any difference in this percentage must be refunded to the members, according to law. Great idea, but does this actually work?

Looking back to 2014, there are plentiful insurers offering rebates to their members in a wide variety of markets from individual, small group, and large group. Take, for instance, Celtic Insurance Company in Arkansas, which had $6,774,488 in rebates to its individual market. Or how about California Physicians Service ,with an astounding $21,819,095 for its small group market. In the large group market, Cigna Health and Life Insurance Company of DC sent back $5,608,359.

One would think this is an opportunity to fully engage and grow membership. Data from the Kaiser Family Foundation shows that many insurance companies are not meeting the medical loss ratio standards. This signals a missed opportunity.

To calculate the MLR is quite simple.

Let’s take, for instance, a population of 3 million Americans using a service that traditionally costs $1,751 per person per year. If there was an alternative service modality that is clinically equivalent for $30, this would create a savings of $1,721 and a percentage difference of 98 percent. If the premiums and other elements remain the same, this could be extrapolated out to provide bountiful rebates to the members.

Next time you are thinking about innovative strategies to increase the NPS of your members while increasing membership, think about your taxes. Your members will thank you, tell their friends, and increase your membership.

Richard Gengler is founder and CEO of Prevail Health of Chicago, IL.

Readers Write: All Claim Attachments are Not Created Equal

All Claim Attachments are Not Created Equal
By Kent McAllister

According to the 2014 CAQH Index, responding health plans representing 103 million enrollees returned data on claim attachments. There was approximately one claim attachment for every 24 claims during 2013 from those same responses.

Interestingly, the vast majority of claim attachments were submitted manually via paper delivery or fax. CAQH counted approximately 46 million claim attachments processed among the plans reporting, which can be extrapolated to roughly 110 million claim attachments industry-wide.

CAQH also estimates another 10 million prior authorization attachments. This statistic suggests a total of 120 million attachments annually across healthcare.

There’s a clarification, however, that must be made when dealing with attachments. Electronic attachments, in and of themselves, are not always the same despite industry rhetoric claiming that there is little difference between the healthcare sectors.

When dealing with the substance of attachments, there are two major distinct segments that providers must accommodate. These two segments are vaguely similar at the highest level, but distinctly different at the business process level for a few reasons. These two segments align with respective accountable payer organizations:

1. Health and dental plans: commercial health plans and federal and state fiscal agents and administrators,
2. Workers compensation (WorkComp): property and casualty insurance carriers and third-party-administrators.

The majority of the 120 million attachments are processed by health plans. Dental plans also manage an essentially equivalent business process for handling attachments, often through the same technical channels and human resources with similar skills.

Workers compensation claims, on the other hand, while voluminous, have a notably different set of business processes because of a number of distinctions in both the property and casualty insurance business and in the nature of “claims” in WorkComp parlance.

A WorkComp claim is generally related to an individual injured on the job. That claim may have a life of many months, or, in some cases, years. Resulting from that claim are typically many bills (or e-bills) that usually have an attachment. The e-bill submission process is more similar to property and casualty processes — such as auto physical damage — than to traditional health and dental plan processes.

An interesting contributor to this distinction is that property and casualty insurers are not considered “covered entities” under the 1996 HIPAA legislation. This is important, and any industry observers not recognizing this are failing to accommodate a major consideration.

Just as not all claim attachments are equal, neither are all vendors. For example, some companies that are heavily involved in the P&C space don’t work with the medical side, while others focus almost exclusively on medical. Vendors usually serve one of the two often-unrelated markets.

Providers must be aware of the differences. P&C electronic attachments, even though they may sound as if they’re in the healthcare setting, just don’t carry the same weight as electronic claims actually exchanged to support patient claims generated within a health system. Likewise, those vendors that work almost entirely in healthcare have little claim, if any, to the P&C market.

In a market filled with healthcare claims-related vendors, healthcare organizations must be able to place their trust in partners that understand the complete landscape of the healthcare space. They should also know that even though WorkComp may appear on the surface to be medical, it requires an entirely different scope of work than their counterparts working in the space. In this burgeoning sector of healthcare administration, messages are often painted too broadly with too wide a brush and healthcare leaders should be wary when entering into conversations that broach the subject of electronic attachments.

For the improvement of all parties involved, vendors should recognize and articulate the differences between health and dental attachment processes and WorkComp attachment processes in their public messages. The industry will be better served if vendors accept a mandate to clarify market confusion and to paint clearer lines as to their roles in electronic attachments.

Kent McAllister is chief development officer of MEA|NEA|TWSG of Dunwoody, GA.

HIStalk Interviews Paul Brient, CEO, PatientKeeper

Paul Brient is CEO of PatientKeeper of Waltham, MA.

Tell me about yourself and the company.

I’ve been CEO of PatientKeeper for almost 14 years. Our company is focused on automating physicians, primarily in an inpatient setting. We offer an overlay solution that allows doctors to automate their entire days, regardless of the back-end system that they are working on in their hospital.

Given the data entry that’s expected of physicians, is it possible to make usability better?

Certainly usability has come to the forefront as we have gotten past the adoption question and people are using it. But now the question is, can people use it in a way that saves them time? Clicks and keystrokes are the enemy of saving time. Lack of intuitiveness is as well. If you have to puzzle over a screen and figure out what is being asked of me, or how do I find that order that I’m looking for, those things all kill productivity.

Clearly we think it’s possible to create systems that save physicians time, but it requires a very thoughtful set of work. Not only on software design, but also on, what are we going to ask the physician to do? 

Obviously in our current healthcare environment, there are a lot different people in different organizations that have very legitimate things they would like physicians to do. Unfortunately, without some sort of filter or prioritization of them, you end up with all of them being thrust on the doctors. That just kills their productivity.

How do you go beyond the technical definition of usability to design software that physicians will at least tolerate and maybe even enjoy using?

In healthcare, that is a particularly challenging question. If you go back to the days of Hewlett-Packard, they were engineers building software or systems for engineers. They had this next-bench idea, where literally they would be building a tool for an engineer at the next workbench at Hewlett-Packard. They had this great environment for design.

In the healthcare world, that’s just not practical. You can’t just go sit in a hospital and have doctors write software while they are taking care of patients. That would be a bad thing for lots of reasons.

We think the best approach is get as close to that as you can, though, which is to have full contact with practicing providers to get feedback on what the real world is in healthcare delivery. Not a theoretical world, a theorized world, or a world they way we would like it to be. The actual world of all the crazy data patterns and situations that occur.

Then, get experienced designers who have usability training who understand how to build good software. If you don’t expose them to the chaotic and complicated world that physicians face every day, they just can’t build software that works for them. It’s really hard. It’s a difficult challenge to get access to that environment and then also to digest it in a way that makes sense.

The handful of significant inpatient EHR vendors are running decades-old code. Are they challenged to meet customer demands without rebuilding their products from the ground up?

Cerner Millennium — which I think is the most modern of the systems — was released before the millennium, in 1997. They certainly all have some legacy aspects to them in terms of technology. They weren’t built yesterday. You couldn’t have built them yesterday, because it takes a long time to build these systems. They’re big and complicated and they have many, many elements to them.

But I do think that some of the vendors — with the move towards interoperability and some of the standards that are being proposed, the FHIR concept if not the standard — pressure is starting to get applied that will allow these systems to become more open and allow innovation to occur that hasn’t before. Even a system as old as Meditech Magic can be made very open. It’s not a technological limitation, it’s a philosophical limitation. The push towards interoperability is helping to get the philosophy aligned more where we would like the technology to go.

When we talked three years ago, you said that healthcare is the only area left where it’s OK to have a monolithic, closed system that doesn’t support interoperability or an ecosystem. Where do you see that going?

Certainly in the last three years it has improved a lot. The FHIR standard has come out. At HIMSS, we saw Cerner demonstrating applications running against Millennium and moving across and running those same applications against Epic or even PatientKeeper, since we support it as well.

That’s a big change. That’s awesome. But it’s not yet sufficient. Even if you make the software interoperable, the data underneath in many hospitals isn’t yet. It’s not LOINC encoded and all that stuff like it would be if you started from scratch. But they did their implementations 30 years ago as well.

There’s still a lot of work to do as an industry. It’s a little bit chicken-and-egg. The more we open stuff, the more people can innovate and invent and other vendors can create cool applications that motivate people to want to exercise interoperability. That says, we’ll make more interoperability. It becomes a virtuous cycle. Without that pull, it’s just theoretical, “Hey, you should be interoperable and make some new APIs available” and no one really uses them. That isn’t going to drive it.

I think we’re starting to see that cycle start a little bit. You see a variety of organizations — like xG health, for example — taking some products that Geisinger has written for in-house and trying to bring them out to the market. It’s starting. It will be really cool to see that happens over the next three or four years.

How will that impact your business? PatientKeeper has been connected to these systems for more than a decade and new entrants will then have the bar lowered to do the same.

We had to spend a tremendous amount of money building all these integrations, but we would just as soon not have to build them. We built them so that we could build the software that we expose to physicians and that they use.

We embrace it. We’ve implemented the FHIR standards on both ends of our application. Somebody can run FHIR on top of us. We can run using FHIR on top of something that is FHIR enabled.

We think openness is philosophically the way to go. That means if someone finds a better application than we have, well then, shame on us. Our job is to have the best applications, and if we don’t, then someone should buy one that is different from ours and have it work with ours that they do think are best.

That’s the way innovation works. That’s the way it works in the tech world. That creates a great ecosystem, an ecosystem that has all ships rising because it puts competitive pressure on everybody. I’m a huge fan, philosophically. I think it can do nothing but good things for us and for other vendors like us.

You just added imaging appropriate use criteria to your product. Are you seeing more interest in having point-of-care systems offer guidance, reminders, or other features that keep providers on the best practices track?

Hopefully it’s the tip of the iceberg. I believe the reason that we as a country spent $40-plus billion getting doctors onto electronic systems isn’t so that we can just get rid of paper, although that was nice. It’s so that we can take this next step of improving healthcare and making the computer an essential tool for physicians.

The analogy I like to use is if you go to most doctors today and say, "Would you write this order on paper instead of putting it into the computer?" Depending on what kind of computer they have, they might gladly say, "Yes, please give me that paper. I can’t wait to write it on paper." If we do our job right as informaticists and as healthcare IT providers, the answer to that should be, “No. I would never write it on paper, because that’s dangerous. I get so much good information and so much help from the computer to do my job that I would never consider practicing without the computer.”

We’re not there yet. PatientKeeper isn’t there. I don’t think anyone is there. But that is the ultimate test. Imaging criteria is one small step. As we start to deploy more advanced techniques, with all the big data analytics techniques, we’ll have computers that know everything about that patient that is all codified. 

The computers aren’t really helping the doctors that much. In some cases, the computer asks the doctor questions the computer knows about. Did you give aspirin to this patient? Well, yes, because I put the aspirin order in the system — why are you asking me? It’s even worse.

The next four, five, six years is going to be that renaissance, helping the physicians with what they do in a way that works for them. Interoperability is such a key to that because it’s going to require the entrepreneurial horsepower of an industry. It’s not going to be one company that solves that problem.

We’re seeing early steps in using little data, where instead of waiting years for big clinical studies to be completed, doctors are getting immediate data analysis from their own systems, such as, “If I have 10 patients in my database who are somewhat like this one, how many of them benefited from this treatment option I’m considering?” Is that concept ripe for development?

I am so excited about that concept. If you think about clinical trials the way they have existed to date, we have a molecule or we have a procedure or a hypothesis. We go out and recruit people, we do all kinds of stuff, and we see whether it works or not.

But every day, there are millions of clinical trials being done. Patients are seeing providers. Things are happening. Outcomes are happening. If we can learn from all of that, even in the smaller cohort, that here are patients like you and and let’s observe how they work. Here are different protocols.

Our parent company HCA has been doing clinical research essentially by just observing different practice patterns across their hospitals. They have done groundbreaking research around sepsis prevention and what things worked and what things didn’t work around preventing infection. Just by observing that there are three or four different ways people do this in terms of washing hands, prophylactic antibiotics, et cetera. They figured out which ones work better without a clinical trial — just by observing the data they have.

That is the future. It might even change the clinical trials industry. At some point you still have to come up with new molecules, but when you start getting into these practices and procedures and off-label use, there is a lot we can learn.

I haven’t heard much about the HCA acquisition since it was first announced. What has changed since?

Certainly the goal of the acquisition was to have exactly what you just described happen, which is business as usual for PatientKeeper from a customer perspective and from an organization perspective. I’m pleased to report that we have achieved that goal. We’re a year and a half in to the acquisition. I’ve talked to some of our customers and they didn’t even know we were acquired. That’s awesome.

The big thing that has changed, which our customers will start to notice over time, is that we’ve made some very big investments in our R&D organization and our hosting center operations. We now have a world-class hosting operation. We had a pretty good one before, but we have a much better one now.

That’s really the big change that we have made. We’ve accelerated R&D efforts and accelerated a variety of projects that we had on the back burner. We’re in the pipeline that we’ve now pulled forward. We haven’t gotten those out to the market yet, so if you are a customer of ours, you haven’t seen the benefits of that. But in the next six to 12 months, you’ll start to see those things hitting the release cycle.

Otherwise, it is just business as usual for us. We’re deploying our advanced clinical software throughout the HCA hospitals and having a great time continuing to go against our original vision.

Do you have any final thoughts?

We’re at the beginning of a new era in healthcare IT. Up until now, it’s been, get rid of paper, get stuff automated. We’ve mostly done that. I wouldn’t say we’re complete, but that phase is coming to an end, where you’re taking processes that have never been automated and automating them.

Now it really is about that next generation. If you think of the evolution of the Internet, we now have concepts like Facebook and EBay that were not possible on paper. They are new concepts. What we’re going to find is a whole new set of innovation in healthcare IT around concepts that were not possible until everybody is electronic. As a company, we’re excited to participate in that. We’re excited to see the ecosystem and the healthcare IT industry itself blossom as that occurs.

Morning Headlines 4/6/16

Variation in Quality of Urgent Health Care Provided During Commercial Virtual Visits

A study published in JAMA finds significant clinical variation among care delivered by commercial telehealth vendors. Researchers suggest vendors begin developing industry best practices aimed at standardizing care.

Mass. General launches Epic health records upgrade

Massachusetts General Hospital, Massachusetts Eye and Ear, and Newton-Wellesley Hospital all go live on Epic over the weekend as part of Partners Healthcare’s $1.2 billion Epic implementation.

Hackers Broke Into Hospitals Despite Software Flaw Warnings

The Associated Press reports that MedStar Health’s recent ransomware attack was executed by exploiting known vulnerabilities from as far back as 2007. MedStar’s failure to apply security patches in time could leave them legally exposed.

Survey Finds Hospital Executives Increasing Focus on Patient Expectations and Engagement

An Advisory Board Company survey of healthcare CEOs finds that the most common executive action items include minimizing clinical variation, redesigning services for population health, meeting rising consumer expectations, deploying patient engagement strategies, and controlling avoidable utilization.

News 4/6/16

Top News

A study of scripted standardized patient encounters performed by physicians of six virtual visit companies finds significant clinical variation. Remote physicians didn’t ask the right questions or didn’t perform the correct examination steps in 30 percent of visits and gave the wrong diagnosis or no diagnosis at all 23 percent of the time. They ordered urine cultures for only 34 percent of recurring urinary tract infection patients and failed to order the recommended X-rays for ankle pain 84 percent of the time. The authors conclude that while virtual visits may involve lower rates of inappropriate testing, remote physicians often don’t order even medically indicated tests, possibly because of the complexity involved in following up on test results from the patient’s home location or concerns about insurance coverage.

The authors also note that some of the companies performed better than others and suggested they share best practices. The virtual visit companies tested were Ameridoc, Amwell, Consult a Doctor, Doctor on Demand, MDAligne, MDLIVE, MeMD, and NowClinic.

While the virtual visits weren’t perfect, they were not compared to face-to-face visits. Those probably have a similar lack of conformance to best practices, but there’s no good way to send standardized (i.e., fake) patients into an exam room to serve as mystery shoppers.

Reader Comments

From PHE: “Re: Sandlot Solutions. Has ceased operations. They were down to a skeleton crew as of last week, looking for last-minute funding to maintain core operations, but I was told that the board had already voted to close down if nothing came through as of Friday. No evidence of ongoing operations this morning.” Unverified. However, the logo of Sandlot Solutions was recently removed from the banner of parent company Santa Rosa Holdings – it was there in a March 13, 2016 cached copy but is gone now.

From Luxardo: “Re: NYC Health + Hospitals going live on Epic. Reports say it went OK, but 900 Epic installers were on site at the two facilities whose combined census was 700. No wonder these installs cost a small fortune – that has to be at least $2 million per day to have a tech person standing next to each clinical person all day. The real test will be 30 days from now when all those installers have gone back to Wisconsin.”

From Concerned Customer: “Re: Vocera. Do you put in any stock into this?” SkyTides, which sells “deep due diligence” to hedge funds in “targeting over-hyped stocks and outright frauds,” calls Vocera and Chairman Robert Zollars “purveyors of fraud and obsolete, defective products.” It says Zollars previously ran two companies that paid $591 million to settle fraud charges (Neoforma alone paid $586 million, it says) and claims Vocera strong-armed customers into accepting early product shipments so that the resulting revenue could help the company hit forecasts. It says insiders have been aggressively selling their shares and that Vocera’s one product hasn’t had a major upgrade since 2011 and “appears to be inferior” even though it’s the most expensive. SkyTides accuses Vocera of committing accounting fraud in the three of 16 quarters it reported a profit, says the company has lost $110 million, and predicts that Vocera will have to cut prices to compete. Vocera shares had little reaction to the announcement and have risen 29 percent in the past year vs. the Dow’s decrease of nearly 2 percent. A federal judge gave initial approval a month ago for Vocera to pay $9 million to settle securities class action litigation that accused it of telling investors during its March 2012 IPO that the Affordable Care Act would boost its business, then admitting in May 2013 that ACA was actually hurting sales, sending shares down 37 percent. I’ll be interested to see if Vocera responds, although since it’s an analysis firm making the claims rather than a regulatory agency or litigant, they wouldn’t have much to gain and would instead call attention to the unflattering charges.

HIStalk Announcements and Requests

We funded the DonorsChoose grant request of Mr. Cho in providing 15 scientific calculators for his Bureau of Indian Affairs high school math classes in South Dakota, replacing the 99-cent models he was using. He reports, “These calculators have made it easier for us to do more in the 47 minutes I’m allotted each day per class. The students are now able to move into higher level math. We just started 4th quarter on Monday and your calculators have, over the past three months, allowed us to go into pre-calculus in my Algebra 2 class. My Algebra 1 students were able to use the calculators and fly through it and are now starting Algebra 2! We will continue to use these calculators weekly for many years.”

Also checking in is M. Feeley from New York, whose pre-schoolers are experimenting with the light kits and games we provided.

Webinars

April 8 (Friday) 1:00 ET. “Ransomware in Healthcare: Tactics, Techniques, and Response.” Sponsored by HIStalk. Presenter: John Gomez, CEO, Sensato. Ransomware continues to be an effective attack against healthcare infrastructure, with the clear ability to disrupt operations and impact patient care. This webinar will provide an inside look at how attackers use ransomware; why it so effective; and recommendations for mitigation.

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

Acquisitions, Funding, Business, and Stock

Sunquest acquires GeneInsight, a genetic testing software firm created by Partners HealthCare (MA). Sunquest had previously invested in the company. which will operate as a wholly-owned subsidiary from its Boston office.

Cumberland Consulting Group acquires 50-consultant  Oleen Pinnacle Healthcare Consulting, expanding the company’s payer market capabilities.

Credentialing software vendors Symplr and Cactus Software merge.

Healthcare software vendor Ability Network acquires EHealth Data Solutions, which offers software for senior living providers. Minneapolis-based Ability, whose chairman and CEO is former McKesson President and CEO Mark Pulido, has made four other acquisitions in the past two years following a $550 million investment by Summit Partners.

Announcements and Implementations

St. Luke’s University Health Network (PA) goes live on Bernoulli’s medical device integration and connectivity in six of its hospitals as part of its Epic implementation.

NYC  Health + Hospitals goes live on Epic at its Elmhurst and Queens hospitals, reporting no major problems.

Massachusetts General Hospital and two other Partners HealthCare (MA) facilities go live on Epic, with 1,000 Epic employees participating in Boston.

ESD celebrates its 26th year in the consulting business, noting that its implementation team members worked 30,000 hours in March.

McKesson signs up 2,111 of its employees to the Gift of Live Bone Marrow Foundation’s donor registry.

Government and Politics

The Federal Trade Commission creates an online tool for developers of health-related software that asks questions about how their software works and then suggests specific federal laws and regulations (such as HIPAA and the FDA) that might apply to them.

Privacy and Security

The Associated Press reports that MedStar Health’s ransomware attack exploited known flaws in the Red Hat’s JBoss Application Server that date back to at least 2007. Red Hat and the federal government have for years urged JBoss users to apply patches that correct a common configuration error that allows external users to take control of the server. The article notes that MedStar may be fully exposed to lawsuits or sanctions if it (or its vendors) failed to apply the patch and therefore could be construed as not having exercised reasonable diligence in protecting its systems and data. MedStar criticized media coverage of its attack, saying the publicity will encourage copycat hackers.

Other

Epic’s trade secrets lawsuit against India-based Tata Consultancy Services goes to trial in federal court.

A Wall Street Journal op-ed piece called “How Not to End Cancer in Our Lifetimes” says the White House’s proposed changes to patient consent policies may impede research. The author, dean of Weill Cornell Medicine, says proposed HHS regulations will limit the number of patients who consent to having their leftover medical samples de-identified and stored for future research. It would also require providers to obtain new specimens from each patient every 10 years and to manage their consent documents.

Hospital executives surveyed by The Advisory Board Company state their top concerns as minimizing clinical variation, retooling for population health management, meeting rising consumer expectations, developing patient engagement strategies, and controlling avoidable utilization.

Sponsor Updates

• AirStrip will exhibit at the Health Evolution Summit April 13-15 in Dana Point, CA.
• Besler Consulting will exhibit at the HFMA Hudson Valley Annual Institute 2016 April 7 in Tarrytown, NY.
• Crossings Healthcare Solutions will attend the Cerner Southeast RUG April 20-22 in Charlotte, NC and the Great Lakes RUG May 31-June 2 in Chicago.
• Crain’s Chicago Business names Burwood Group as one of the Best Places to Work for Women Under 35.
• Caradigm will exhibit at the Care Coordination Institute April 7-9 in Greenville, SC.
• Clockwise.MD will present at the 2016 Spring Healthcare Tour and Conference April 5-6 in Nashville, TN.
• CompuGroup Medical will exhibit at G2 Lab Revolution April 7-8 in Phoenix, AZ. 
• Direct Consulting Associates will exhibit at Health Connect Partners – Hospital & Healthcare IT Conference April 13-15 in Atlanta.
• Divurgent will exhibit at the Health Information Technology Summit April 10-13 in Washington, DC.
• EClinicalWorks will exhibit at the NCCHC Spring Conference on Correctional Health Care April 10-12 in Nashville, TN.
• HCI Group CEO Ricky Caplin earns recognition from Consulting Magazine, KPMG, and the University of Florida Entrepreneurship & Innovation Center.
• Healthgrades releases its 2016 Outstanding Patient Experience Award and 2016 Patient Safety Excellence Award recipients.
• HealthMEDX will host its annual user group meeting April 12-14 in St. Louis.
• Healthwise will exhibit at the Allscripts Central Region User Group April 13-15 in Minneapolis.

Blog Posts

• Little Known Facts About Doctors Day (AdvancedMD)
• What We Learned from the Microsoft Build Keynote #Build2016 (AirWatch)
• Transforming Clinical Care: Why Optimization of Clinical Systems Can’t Wait (Impact Advisors)
• Automating Documentation and Billing Makes Chronic Care Management More Achievable (Aprima)
• Platform Openness and the Art of Integration (PatientSafe Solutions)
• Ohio’s HB 188 Permits Pharmacists Broader Authority in Patient Care (CoverMyMeds)
• Spring Clean Your Work Life (CTG)
• Mixed Use Patient Access Centers Improve the Patient Experience (Culbert Healthcare Solutions)
• ICD-10: Focusing on Assessing & Maintaining (E-MDs)
• The University of Maryland Dramatically Improves National Resuscitation Program Compliance with Extension Engage (Extension Healthcare)
• Are You Ready for Real Health Leadership? (Galen Healthcare Solutions)
• HCC Model: Down to the Basics from Coding to Documentation (Hayes Management Consulting)

Contacts

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

HIStalk Interviews Miles Beckett, MD, CEO, Silversheet

Miles Beckett, MD is co-founder and CEO of Silversheet of Los Angeles, CA.

Tell me about yourself and the company.

I’m originally a medical doctor. I went to med school at UC San Diego. I was a plastic surgery resident at Loma Linda Medical Center. I left the surgery program. I was very interested in the technology world. I ended up moving back to LA and starting a digital media company that I sold in 2012.

After selling that company, I was excited about re-engaging with healthcare, taking my tech knowledge and partnering up with a friend of mine from medical school who’s an anesthesiologist — Dr. David Rakoff — and then a product and engineering guy Patrick Cheung, who ran product in my last company. We founded Silversheet.

The idea was to improve life for doctors and other providers and the administrators at healthcare facilities, to make the whole process of interacting with medical staff more efficient. We’re starting out with a credentialing and privileging product to try to automate as much of that process as possible and make it easier for everyone.

You helped create the lonelygirl15 Web series that was massively popular in 2006-2008. What did you learn from that experience?

First and foremost, when the market’s ready for an idea, it’s going to happen. Back in 2005-2006, video was becoming possible online and big platforms like YouTube were emerging. Lonelygirl was obviously a big hit and it was awesome, but there were a lot of other Web series emerging at the time. We were part of a bigger movement.

As I was thinking about new companies and new ideas and things to work on, healthcare was appealing. Not just because of my personal background, but also because for a variety of reasons, change is happening. The Affordable Care Act, adoption of EMR technology, and the general sentiment from doctors and administrators that they want things to be better and to be more efficient. That’s one big lesson.

The second one — and a core of our current company as well — is that by building communities, by connecting people together with technology, that’s really where the power is. Silversheet is a great software product, but even more importantly, it’s connecting the doctors and other providers to the facilities. It’s that exchange of information and ideas that makes the magic.

Healthcare IT doesn’t seem all that exciting compared to what you’ve done in the past and other companies already offer electronic credentialing. Do you see Silversheet expanding into new areas?

We’re not 100 percent sure exactly what direction we want to go in down the road. Most of the investment in time and energy so far has been spent on the way that doctors interact with patients or nurses interact with patients. EMRs are probably the best example, but then other types of services and applications that are focused on that. I just don’t think there’s been a lot of energy on, how does the healthcare system actually function behind the scenes? How do the facilities interact with their doctors and their staff?

We’ve talked to a bunch of hospitals and health systems. We’ve been focused right now on the outpatient setting, almost exclusively with surgery centers initially. We’re trying to learn, how do those medical staff offices and how do the administrators in them, what are the different functions that they’re performing? Any of those areas that we think we could improve through a platform like Silversheet that makes it easier for them to exchange information, we would want to do.

What’s the prevalence of electronic credentialing?

Credentialing itself is a decent-sized market. There’s a billion or so dollars that’s spent on it annually. There actually is a lot of credentialing that’s done both by surgery centers and hospitals and other institutions and insurance companies and medical groups that are doing provider enrollment. It’s fairly big in and of itself.

Most importantly, a lot of the ways that it’s been done before, it’s either outsource agencies that may have some technology but maybe not as much as you might think, or software that still requires huge amounts of data entry on the part of the administrators. The thing we’re doing a little bit differently is trying to automate a lot of those processes.

We automate a bunch of the primary source verifications. We hook into different databases to pre-populate information about the doctor. 

The biggest difference is that because the doctors have accounts, there’s a network. Once a doctor has their credentials in Silversheet, it’s portable. When they go to a new institution that’s using Silversheet, it automatically synchronizes. If they’re not using Silversheet, they can share their credentials with a click. I think that’s fairly unique to our approach.

Do you foresee a more consumer-facing aspect to the business, such as a physician directory or a tool to help consumers make choices?

People have asked us about that. I don’t know. It’s certainly not a focus right now or for the foreseeable future, but anything’s possible.

As someone who works with investors and technologists in Silicon Valley, how do you think they view healthcare IT?

There are two different views. Some people are playing in between.

If you look at the classic Silicon Valley VC, there’s this general attitude of disruption and wholesale change of industries. That’s going to be tough to do in healthcare. The reality is that people’s lives are on the line and there’s a lot of rules and regulations for good reason. There have been some companies that started and ideas that sound great on paper, but when you actually get into the weeds, they don’t work out so well.

On the flip side, there are more older-school healthcare IT vendors that are using old code or old processes or old development strategies. They’re not taking advantage of the network or connected databases and things like that.

There is middle ground. A fair number of new startups that are like that. We hope that we’re one of them. Definitely my perspective and my approach is that I am a doctor. I didn’t practice long, but I did work in urgent care for a year or two after I left the surgery program. There is a component of having a visceral understanding of what it’s like to be a doctor or what it’s like to interact with nurses or to be nurse and be an administrator.

You have to both really understand how people are working in the system, how they’re currently using software, and what they would like to see improved. Then on the flip side, understand the need to go after big markets and do things in new ways and things that are exciting for investors. We’ve tried to do that obviously with Silversheet. We’re tackling a problem that’s like very real and it’s very much burdensome in the lives of both admins and doctors, but there’s big opportunities down the road.

Where do you see company evolving over the next several years?

Certainly over the next year or two, we are focused on making the credentialing and privileging solution amazing. I’d say we’re 90 percent of the way there. There’s always room for improvement.

Software development is an endless process. The best companies like Facebook or LinkedIn are constantly improving. That’s the big focus of ours. There’s a lot of room for improvement. If you look at existing systems, there’s just a lot of things that are not being taken advantage of. When a lot of these systems were first built, email was not really being used much by anyone, so it wasn’t even considered as a part of a lot of the work processes.

Honestly, we’re pretty focused on that at least for the next year or two. There may be other adjacent areas that the medical staff office handles that we might get into. The Affordable Care Act has put a lot of emphasis on quality measures and things like that, so we might get into some of that.

We are still figuring it out and listening to our customers. Almost all of the features that we’ve built since we launched publicly last year have been from customer feedback.

Do you have any concluding thoughts?

I feel like the time is now. Change is happening. As we’ve talked to admins at surgery centers and as we’ve talked to hospital administrators and certainly doctors and other healthcare providers, everybody’s excited about technology and sees a role for it to improve their working lives and the lives of the patients that they treat. I see that as a marked contrast to when I was in my internship in medical school and it was still very much a scary thing for people. I’m really excited. We’re going to see more and more awesome things over the next decade.

Morning Headlines 4/5/16

New York’s Epic EHR ‘go-lives’ please officials, staff

Two NYC Health & Hospitals facilities are live with Epic after an April 1 go-live that a spokesman for the health system went well, explaining, “There were minor issues, but they were dealt with right away.”

Theranos Devices Often Failed Accuracy Requirements

A newly released CMS inspection report confirms that Theranos’ proprietary blood testing analyzer, Edison, failed internal quality control tests 29 percent of the time, while its California lab was also cited for doing tests with unqualified personnel and storing samples at the wrong temperatures.

Proteus Digital Health Presents Interim Results at ACC From a Randomized Controlled Clinical Study of Proteus Discover

Proteus Digital Health announces interim results from an RCT study of its smartpill technology, finding that its smartpill technology improves blood pressure control in hypertension patients significantly. 85 percent of patients using the smartpill achieved their target blood pressure within four weeks, while only 33 percent of participants in a control group receiving traditional care were able to do the same.

AMA taking bigger role in key IT initiatives

Michael Hodgkins, MD, CMIO of the American Medical Association, discusses interoperability and his role on the board of the Sequoia Project, formerly Healtheway.

Curbside Consult with Dr. Jayne 4/4/16

I had lunch with some of my former colleagues the other day. One of the hot topics was the relatively new Patient-Centered Specialty Practice Recognition program from NCQA. Several of the specialty physicians who were at the table are employed by a health system and are being encouraged to participate in the program as part of an overall accountable care strategy.

The program is designed to recognize specialty practices that are committed to access, communication, and care coordination. Although it should be fairly easy to “encourage” employed physicians to participate as a condition of their employment, the physicians around the table were unconvinced that the independent specialists would be interested.

Our community has many more independent specialists than owned/employed, while the majority of primary care physicians are no longer independent. Several primary care physicians spoke up about the difficulty of trying to achieve Patient-Centered Medical Home recognition since they felt they were being asked to do more but were not allowed by their employers to add staff.

However, at least as primary physicians, they felt they had experience in coordinating care where they didn’t feel that some of their specialty colleagues were ready to take that on. Several complained about narrow insurance networks that require them to work with specialists who have poor communication and coordination skills, using words like “atrocious” and “radio silent” to describe how they hear back from consultants.

I suppose I was lucky to start my career in the days when my employers supported my ability to refer to the specialists I felt were most appropriate and when most of the specialists in the community were credentialed with nearly all third-party payers. The only payer I had difficulty finding specialists for was Medicaid.

As I determined that a given specialist had poor communication skills or was lacking in follow-up or coordination, they quickly fell off my list of consultants. That got me in trouble more than once with senior members of the hospital medical staff, who complained bitterly that a certain new physician wasn’t giving them the referrals they felt they were due. When I was approached about it by a hospital VP who had been assigned to “mentor” me, I explained that I was referring to the junior partners in their practices who were friendly, collaborative, and actually acted as though they wanted to care for my patients. The fact that I was at least referring to the practice seemed to provide cover, but the idea that a specialist would be “owed” referrals due to seniority or status was (and still remains) offensive.

Referring to the specialists I prefer is a bit more difficult now. Our office gets frequent callbacks from patients who are unable to see the specialists that we recommend due to insurance issues. I try to give patients subtle warnings when I am forced to refer them to physicians I would normally not select. I’ll go ahead and provide multiple referral names, putting the people I prefer at the top of the list. but warning the patient that they need to check with their insurance to determine whether they are covered.

Should the patient choose to go out of network, they can. I explain that the less-desirable provider (without using those words, of course) is more likely to be on their insurance and dance around the fact that although they may have strong technical skills and are a “good surgeon” that the patient might experience some “inconvenience” with the office and getting the paperwork back and forth. I hate to have to use a euphemism for “poor care coordination,” but at least it gives the patient a small bit of warning.

My personal friends who are specialists pride themselves on cultivating their referral base and treating their referring physicians well. Should they decide to pursue recognition, I would foresee their main barriers would be dealing with the documentation requirements from NCQA and educating their staff on any tweaks to process or documentation that may result. I know several of them have unwritten policies for how communication and care coordination occur and they’ll need to get these pinned down and consistent across everyone working in the practice.

Another barrier might be cost. NCQA has a reputation for charging more for the PCMH recognition process than other organizations. Specialists have been fairly insulated from some of the nickel-and-dime treatment that primary physicians have been battling for years, so I’ll be happy to have them on board with our cause.

Others may resist in that they believe they are already providing high quality are and don’t feel the need to have someone else tell them they are. We saw that kind of thinking in the early days of PCMH, but things are getting to the point where physicians almost have to have the formal recognition to stay ahead.

I recently read an article about the CareFirst BlueCross / BlueShield program in Virginia, Maryland, and the District of Columbia. Nearly 90 percent of the plan’s physicians are participating. Those that do receive a 12 percent participation fee regardless of performance metrics and without any penalties or risk assumption. It also treats online visits the same as face-to-face ones. CareFirst’s analysis shows that in looking at 2014 data, participating practices took in an additional $41K in revenue above the participation fee. Additionally, 75 percent of its patients had established a relationship with a primary physician.

The program asks physicians to group together in panels that are graded on patient engagement, access, and appropriate use of services. The engagement score holds the most weight and includes patient satisfaction indicators. The panels of physicians are expected to meet monthly to discuss performance and compare notes.

From the provider standpoint, this sounds like the kind of work we need to be doing to help physicians move forward under new care models. Rather than just tell them they need to do a certain thing or achieve a certain outcome, they’re creating support structures for physicians who can work within the collaborative environment to make changes. Participating providers should also receive reinforcement from their peers when they are doing well, in addition to suggestions for changes proven in other practices.

It remains to be seen whether these types of initiatives will appear in the Patient-Centered Specialty Practice realm. I’ll be watching to see whether specialty physicians start gravitating towards this on their own or whether they’ll only head in that direction when forced to by their employers or other external pressures. I’ll be interested to hear what they think of the process and whether it elicits sympathy for the primary care physicians who have gone before them.

What do you think about Patient Centered Specialty Practice recognition? Email me.

Email Dr. Jayne.