Dr. Herzenstube Goes to AMIA–Monday

Dr. Herzenstube is a practicing family physician who can make nothing of it.

The first session I attended today was a panel on ICD-11 given by representatives of WHO, IHTSDO, and academic organizations involved in developing ICD-11. ICD-11 will be the next version of ICD. The general idea behind it is to harmonize ICD with SNOMED to facilitate the use of SNOMED’s polyhierarchy while retaining ICD’s capability to meet the needs of epidemiologic analysis.

Bedirhan Ustun, a psychiatrist who manages terminology work for the WHO, was the first presenter. He explained that, unlike prior versions of ICD, ICD-11 will have an explicit content model. This means that each ICD-11 code will have underlying definitional modeling (as do SNOMED concepts). The work to build this has been initiated in collaboration with IHTSDO. 

Jim Case of NLM and IHTSO came next and explained that the goal of ICD-11 is to link SNOMED CT and ICD so that data can be captured once at the point of care and avoid the need for duplicate coding effort. He explained one important point about ICD, that as classification system, categories are mutually exclusive. This is important to support use cases of epidemiology and statistics, and explains why “other” codes are needed in ICD (something that never really made sense to me until now).

Chris Chute followed with a discussion of the SNOMED-ICD common ontology, which will provide the semantic anchoring of ICD-11.  Jim Campbell from University of Nebraska discussed some of the areas where the SNOMED CT and ICD-11 hierarchies were at odds and need to be reconciled and Harold Solberg discussed the process of building the links between ICD and SNOMED, either through equivalence maps (A = B) or cases where ICD is described as a compositional SNOMED statement, and automated testing for potential disconnects in the respective hierarchies. 

This panel provided a really helpful degree of clarity on ICD-11 from the people at the very center of building it. It will likely be years before this gets used in the US, but it is good to have a sense of where things may be heading.

I also attended a presentation on the Clinical Quality Framework (CQF), an effort to harmonize standards for clinical decision support with those for quality measurement (nope, they’re not already harmonized; yep, they definitely should have been from the beginning, hindsight is 20-20, etc. etc.)

Dr. Julia Skapic from ONC kicked off the presentation by describing a bit of the regulatory context around clinical quality measurement and clinical decision support and the need to develop a unified way of representing the underlying logic that expresses the standard of care involved. The holy grail to which this work strives is that, if a provider organization configures their system to measure quality using a particular quality measure, they can enable clinical decision support functionality based on the same underlying logic without any additional logic editing work. 

Marc Hadley from MITRE described current standards for CQM and CDS and the output of ongoing work under the umbrella of CQF to harmonize them. One such output is Clinical Quality Language”(CQL), which has been issued as an HL7 draft standard for trial use (DSTU). CQL is a Turing-complete, XML-based language designed to be a human-readable way of expressing clinical rules that is also machine-computable and agnostic to data model. 

In addition, Quality Improvement and Clinical Knowledge (QUICK) has been developed as a data model for use along with CQL, automatically derived from FHIR Base Resources and FHIR Quality Improvement Core (QICore) profiles. Kensaku Kawamoto described several pilots of using data artifacts based on these standards, which were able to represent rules for things like chlamydia screening and routine immunization. Tom Oniki discussed the Clinical Information Modelling Initiative (CIMI), a community of interest that has become an HL7 working group.  While this work is not yet ready for prime time, the amount of progress that has been made is really impressive and the momentum seems substantial. The large lecture hall was filled to capacity, an indication of how vital the need is for a solution to this thorny problem.

The first session of the afternoon I attended was on ACOs, moderated by Gil Kuperman of New York Presbyterian. David Bates of Brighan and Women’s Hospital discussed the use of claims data to identify patients at high risk for hospitalization, who then get an assigned care manager. They have seen a significant reduction in hospitalizations in this population since starting their work. 

The most interesting part of his presentation, to me at least, was the use of what he calls Standardized Clinical Assessment And Management Plans (SCAMPs). Basically, SCAMPs consist of a small set of data elements clinicians are asked to document in particular clinical situations. For example, for distal radial fractures, a few details on the fracture type and whether or not the fracture was treated surgically. After a few weeks of data collection, it is shared with the physicians and collection continues. 

What he found was that the practice patterns at the start were highly divergent from one physician to another. After sharing the data, the variances all but disappeared without any attempt to coerce or persuade any of them to change their practice patterns. A remarkable example of the Hawthorne effect. 

David Dorr from OHSU described the state of Oregon’s experiments with developing approaches to coordinate healthcare for vulnerable populations. His research involves figuring out how to help medical practices perform medical home-related activities such as establishing care management plans, ensuring close follow-up from hospitalizations, and doing clinical quality measurement. While he and his colleagues have developed a population management tool, they have observed something that most practicing clinicians will be familiar with — clinicians need point-of-care reminders, care management workflow tools, etc. within the same system they use to manage other patient information (within the EHR, in other words).

David Kaelber of MetroHealth spoke of some of the real-world challenges of meeting payors’ rules around ACO payments, including the fact that different payors often have slightly different requirements around data collection, population definitions, and quality measurement, requiring duplicate work for what amounts to very similar quality measurements. 

David Bates described his work at NYP with the Delivery System Reform Incentive Payment (DSRIP) program, an ACO-like program operated by the New York State Medicaid program. NYP’s programs include everything from patient navigation services in the ED to an HIV chronic care program to a program to deliver palliative care. They did a formal analysis of IT requirements, such as the ability to trigger notifications when key events occur, like a patient being hospitalized or new patient status values in their EHR. Among the lessons learned were that not all of the information flow can be EHR-based since many of the providers they are collaborating with don’t have EHRs.

One of the other highlights of the day was the poster session. The posters were fairly varied, and as is typical for any scientific conference, a bit hit or miss. One that I found amazing was by Matthew Rioth and Jeremy Warner, two physicians at Vanderbilt, titled “Visualizing High Dimensional Clinical and Tumor Genotyping Data.” When understanding data requires looking at it and two dimensions just aren’t enough, innovative data visualization is necessary. While the examples they provided were primarily research-focused, such as generating new hypotheses regarding what genes are important in cancer behavior, some applied directly to clinical practice, like one that showed patterns of ordering of molecular profiling tests across multiple clinics in their organization.

As with earlier days of the conference, the accidental conversations with other attendees were as valuable as the presentations. One memorable such encounter was with Lisa, an epidemiologist working in a reproductive health program at a state health department. She is becoming an informaticist by necessity since to support her research, she needs to figure out how to get more and better data from the clinical practices that her team funds.

To get data to the health department, these clinics currently either complete paper forms (!) or enter data manually through a Web-based portal. A few clinics have set up data entry forms within their EHRs to capture the necessary data, but it still requires duplicate data entry since these forms can’t pull in data from elsewhere in the patient record.  So if the patient has been screened for chlamydia, even if that data is in the EHR, it needs to be entered a second time to into the data element that will be sent to the health department. 

It was a sobering moment, amidst the promise of future progress all around us at AMIA, to realize how pedestrian the current state is in so many ways. It also drove home to me the ever-increasing burden we’re putting on practicing clinicians to engage in data-entry activities that, while they may serve a noble goal, make it harder and harder to focus on the immediate needs of the patient in front of them.

Dr. Jayne Goes to AMIA–Monday

After having seen the long lines for breakfast in the hotel over the weekend, I stocked in some provisions and enjoyed sleeping a few minutes later. I’m glad I did since the line to just get coffee was well over 60 people long when I passed by. The meeting has felt significantly more crowded today, although the conference center’s slightly wacky multi-level, multi-building layout helps spread things out. I’m also very pleased that there is plenty of seating throughout the common areas for those of us who want to get to know new friends, catch up with colleagues, or just take a break.

My morning session was a panel on “Harmonization of ICD-11 and SNOMED CT.” Yes, ICD-11. Experts have been working on it for years and particularly in how they plan to address some of the challenges in mapping between the two systems. Since mapping can lead to errors, they’re leaning towards a common framework of sorts that will make things better for those of us who have to use both systems.

This is going to require some changes in how both systems are currently structured. However, it will reduce the need for crosswalks and therefore errors. It took owners of the two systems nearly three years to agree to a memorandum on collaboration and I’m sure it will take years to work it all out. I personally hope to be retired before it hits.

Looking around the room, at least 10 percent of the people were using their phones or tablets to take pictures of the slides at one point or another. This really underscores the need to have the slides available to participants. At another conference I attended earlier this month, the presentations were linked to the entries in the conference application, which made it nice to follow along and to magnify slides that were difficult to read. So far, the didactic panels I have attended have featured 5-6 speakers giving mini-presentations on a main topic and that would help sort out who said what.

I spent a little time in the exhibit hall, which was significantly less crowded today. Although there are a few vendor booths, there many booths representing various informatics training programs and graduate schools. I had a good conversation with IMO about their work not only in the US but with health systems in other countries. We’re all facing the same issues, but it sounds like there are many approaches to solutions. Having been a user of their tools embedded in several different vendors’ EHRs, I’m looking forward to their next generation of solutions to make physicians’ lives easier.

Break service was again offered in the aisles of the exhibit hall, which made it crowded and difficult to move, especially with people stopping randomly to check their phones regardless of the people flowing behind them.

My next session was a very-well attended one about the “Clinical Quality Framework Initiative to Harmonize Decision Support and Quality Measurement Standards.” Presentations (again in the multiple mini-talk format) included some of the federal initiatives via HHS to align various measurements and reporting systems.

There was quite a bit of laughter when a slide was shown asserting a government mandate for “full interoperability” by 12/31/2018. In addition to aligning existing systems, though, the US government is also adding new metrics, such as the appropriate use criteria for advanced diagnostic imaging studies. Providers are going to be asked to document whether they’re using clinical decision support to avoid ordering expensive tests. Although this is a good thing at face value, I’d like to also see it coupled with a patient-facing program to educate patients on the fact that they don’t need these tests.

Front-line physicians in the United States are constantly barraged by patients wanting the most high-tech (and often expensive) tests whether they need them or not. There is a cultural “need to know for sure” that something is or is not OK and patients see technical studies as the means to reach that end. In many cases, patients don’t want to play the odds or listen to statistics — they just want a test. If physicians don’t order the test and are insufficiently able to talk the patient away from it, our patient satisfaction scores suffer. We’ve seen this phenomenon with antibiotic use as well. I’m a huge fan of how England’s NHS does it. They have many direct-to-consumer campaigns about how healthcare should work. I’ve included my favorite above.

I attended a corporate member roundtable over the lunch hour. I’m not going to name the vendor because there were very few women in attendance and my cover might be blown. It was interesting to see where various participants were in their journey with informatics in general with specific kinds of technology. There was a nice mix of participants from research, training programs, large health systems, third-party firms, and end users.

I tried to attend the ONC listening session that also occurred over the lunch hour but wasn’t able to register. Space was limited to 65 seats but the session was to include Chief Medical Information Officer Andrew Gettinger, Chief Health Information Officer Michel McCoy, and Chief Nursing Officer Rebecca Freeman. They were seeking specific feedback regarding the federal IT strategic plan, interoperability roadmap, precision medicine initiative, and other key initiatives. I’d be interested to hear from anyone that made the short list of cool kids attending.

I spent some time after lunch cruising the poster presentations in the exhibit hall. My favorite was one from a group in Japan, who created a “Smart Snack Box” system to record snacking behavior. They’re looking at the timing of meals on metabolism and how it impacts health and disease. Using Raspberry Pi technology and Python, they created a box that records how many times it is opened as a method of tracking snacking without patient self-reporting. Currently they’re limited because it only tracks the opening of the box, not the amount of snacks that were consumed or if the patient was only window shopping. I have a pre-teen nephew who is all about Python, so I sent it his way. Maybe there’s a future for him in biomedical research.

The AMIA format lends itself well to session hopping and I did that a fair amount today. Topics included social media within consumer health informatics, natural language processing, precision medicine, patient portal use in safety net healthcare systems, and care team communication. Although intellectually stimulating, it is truly exhausting trying to attend all the presentations that grab my interest.

There were a couple of social events tonight: the “Top of the World” Meet-up and Tweet-up and a movie premier for “No Matter Where,” which is a documentary following the journey of some of our field’s pioneers as well as how health information has impacted patients, providers, and other interested parties. I ended up opting instead for dinner with an old friend and former colleague who helped me stand up my first HIE way back when. Usually we only run into each other in the whirlwind that is HIMSS, so it was good to catch up in a lower key setting. We wound our way through Chinatown to the Marina District and various points in between and I’m grateful for him not making fun of my white knuckles on the near-vertical streets.

Email Dr. Jayne.

Morning Headlines 11/17/15

FDA Says More Regulation Needed on Lab Tests

The FDA will testify in favor of regulating laboratory developed tests at a House Energy and Commerce subcommittee meeting on Tuesday. The agency put out a collection of case studies supporting the position ahead of its testimony.

Telemedicine is already working in Texas

Texas Medical Board president Michael Arambula, MD publishes a letter in the Statesman responding to recent criticism of its telemedicine policies. The board requires an in-person visit establishing a patient-provider relationship before remote visits are authorized. Though there are situational exceptions to the rule, the policy has the effect of restricting telehealth vendors, like Dallas-based Teladoc, from effectively operating in the state.

As Hawaii Health Systems Corp. founders, CIO/CFO Money Atwal mulls next move

Healthcare Finance profiles Money Atwal, former CIO/CFO of Hawaii Health Systems. Atwal oversaw the health system’s Meditech 6.0 implementation, earning HIMSS Stage 7 status and a 2015 Davies Award. As a CFO, he used technology to drive accounts receivable days down from 200 to 54.

Readers Write: Health Data Security – Who Do You Trust?

Health Data Security – Who Do You Trust?
By Jeff Thomas, MS, CISSP

I don’t know about you, but I certainly don’t want to be associated with the next health data breach in the headlines. But we all likely rely on outside vendors for a variety of services and products, entrusting them with data and information. A recent report by Gartner Inc., “Trust and Resilience – the Future of Digital Business Risk,” lays out the stark reality: “malicious actors and increasing complexity create systemic threats to trust and resilience.”

Like the old 1950s game show “Who do you trust?,” care to roll the dice? Use that old dartboard?

Say you’re looking at new SaaS applications, mission-critical stuff. Naturally vendors are going to tell you that your data is safe with them. That’s what you want. But how can you tell if they are telling you the truth or not? Is there some “truthiness” going on? How can you tell those that are competent from those that are not?

Gartner predicts that IT spending on security and risk will double in the next five to 10 years, going from about 15 percent of overall IT spending to 30 percent. That’s huge. You’ve got to wonder – is your vendor keeping pace with their security needs or are they perhaps cutting a few corners, exposing your data to risk to save a buck?

You’re going to need some help. An important tool to get an insider’s view is a third-party audit report. Has your potential vendor had their data security procedures audited?

Everyone claims to be “HIPAA compliant.” But that gives you no real assurance that your vendor truly knows data security. Let’s look at one of the most widely-used and rigorous audits available, the SOC 2 Type II.

The SOC (Service Organization Controls) series of reports are governed by the American Institute of Certified Public Accountants (AICPA). These reports are designed to build trust and confidence between services organizations that operate information systems and their customers by having their service delivery processes evaluated by an independent auditing organization.

The SOC 2 is relevant for companies handling sensitive data as it reviews controls related to AICPA’s trust principals for Security, Availability, Processing Integrity, Confidentiality, and Privacy. (Controls may range from being technical in nature to manual processes). If those areas are of interest to you when choosing a vendor, reviewing their report is something you will likely wish to do.

A common question I hear is if a SOC 2 is good, isn’t a SOC 1 better? But in reality, it’s an apple-to-orange comparison. SOC 1 revolves around financial reporting and is often used as part of Sarbanes-Oxley compliance. If you’re selecting a vendor to handle your sensitive patient data, it’s not the right fit.

Or how about a SOC 3? A SOC 3 report is a summary report that does not have the detail of a SOC 2 report. It is generally used as a marketing tool, where the SOC 2 is a restricted document. If you want to see what controls are in place and how these controls are tested, the SOC 2 report is what you will want to read. To do so you’ll likely need to sign a non-disclosure agreement.

So you’ve signed the vendor’s NDA and have the report. Now what?

If you’re comparing vendors, it’s important to know that not all SOC 2 reports are the same. For starters, the biggest difference is that there are two types— a Type I and a Type II. A Type I reviews the vendor’s system and the suitability and design of the controls in place. Think of it as a point-in-time review indicating that the design of the controls was deemed to be reasonable on a specific day. A Type II goes further, and tests the operating effectiveness of the controls over a period of time. Accepted testing periods range from six to 12 months.

Once you have the report, what should you look for? First, there will be a summary, in which the auditor will summarize the engagement to include information about the scope of the engagement, as well as their opinion of the controls audited. This is a good place to see if there are any overall concerns.

Another section will be the vendor’s description of their controls. This will be a lengthy description of all the controls in place to meet the SOC 2 principles. After this, you will find a description of the tests for each control and the results for each test. This will map each of the vendor’s controls to the different SOC criteria and list the test performed and if any exceptions were noted. Ideally, you will find controls that meet your needs, along with a report of the tests finding “no exceptions noted.”

A SOC 2 report, especially the Type II, will not be a quick read. The time spent reading it will give you good insight into what measures a vendor uses to protect and process your data. The best part is that you don’t have to take their word for it—it’s coming from a trusted third party.

Don’t roll the dice or use darts when it comes to security. Insist on an industry-accepted, third-party audit or attestation. In this day and age of increasing digital business risk, you’ll be glad you did.

Jeff Thomas, MS, CISSP is chief technology officer of Forward Health Group of Madison, WI.

Readers Write: The Complexity of Maintaining Compliance

The Complexity of Maintaining Compliance
By Megan Tenboer

Clinical research presents a unique challenge when it comes to billing compliance. Often it’s left to clinical staff to understand Medicare and third-party guidelines, Clinical Trial Policies and other internal and external regulations, and to stay current in a fluid regulatory environment. Non-compliance puts the institution’s financial and ethical well-being at risk.

Two timely illustrations of just how complex compliance can be for research institutions came into play earlier this year. One revises the submission process for investigational device exemption (IDE). The other is the introduction of Condition Code 53 (CC-53).

Not satisfied with simply expanding criteria for coverage of IDE studies, the Centers for Medicare and Medicaid Services (CMS) also decided to centralize the review and approval process.

Previously, research institutions were responsible for submitting the require documents to their respective Medicare Administrative Contractor (MAC)[i] for device trials. Now CMS requires the sponsoring organization to secure approval of coverage for IDE device trials that obtained an FDA approval letter dated January 1, 2015 or later.

If this change is overlooked, it could have a devastating financial impact on the study and could delay treatment for patients in critical need. Failure to seek coverage approval through appropriate channels will delay or negate reimbursement for expenses related to the use of an FDA-approved device—even the device itself depending upon whether it is a Category A (Experimental) or Category B (Non-experimental) IDE study (Category A devices are statutorily excluded from coverage[ii]).

Another layer of complexity hit research institutions on July 6, 2015. An updated code details the process/requirements when generating a claim to local MACs, titled, Condition Code 53 (CC-53). This code is designed to identify and track medical devices that are provided to a hospital by the manufacturer at no cost or with full credit due for a clinical trial or a free sample.[iii]

Previously, hospitals used either CC-49 (Product Replacement within Product Lifecycle) or CC-50 (Product Replacement for Known Recall of a Product) along with value code “FD” (Credit Received from the Manufacturer for a Replaced Medical Device). However, these codes described only procedures surrounding replacement devices and not a reduced cost for non-replacement devices. The latter may be provided to Medicare beneficiaries as part of medical device trials.

It seems straightforward, and its intent was to fill the void by describing initially implanted medical devices that are not replacements. However, critics have been vocal about the lack of clarity about the new code. This new code adds to an already overflowing cache of device-related services that must be reported.

These two mandates may appear to be obscure regulations that impact only a small fraction of the overall healthcare market, but that’s not the case. According to business intelligence provider Visiongain, the worldwide market for clinical trials over the next five years will experience a cumulative growth of more than 50 percent.

Further, clinical research organization global revenues are expected to reach $32.73 billion in 2015 and to exceed $65 billion in 2021. Add the growing number of strategic alliances between full-service clinical research organizations and big pharma organizations that have outsourced drug development and the impact of errors skyrockets.

The best defense is to assign one individual to become the “regulatory mandate” expert tasked with staying up-to-date on proposed and finalized changes to ensure timely compliance.

Megan Tenboer is director of strategic site operations at PFS Clinical of Middleton, WI.

[i] Centers for Medicare and Medicaid Services: Medicare Coverage Related to Investigational Device Exemption (IDE) Studies. Available at: http://www.cms.gov/Medicare/Coverage/IDE/

[ii] Department of Health and Human Services Health Care Financing Administration: Medicare Carriers Manual Part 3 – Claims Process. Transmittal 1701. May 25, 2001. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1704B3.pdf

[iii] Centers for Medicare and Medicaid Services. “Implementation of New National Uniform Billing Committee (NUBC) Condition Code “53” – “Initial placement of a medical device provided as part of a clinical trial or a free sample.” MLM Matters. Medicare Learning Network. Available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8961.pdf

Dr. Herzenstube Goes to AMIA–Saturday and Sunday

Dr. Herzenstube is a practicing family physician who can make nothing of it.

Saturday

AMIA is the professional society for health informatics. The AMIA annual symposium is the largest scientific informatics conference in the US. It brings together researchers, policymakers, industry leaders, and practitioners of health informatics from dozens of countries. I have been attending regularly since 2000 and it has been amazing to see the attendees and conference content grow in diversity as clinical information systems become more widespread.

AMIA always offers tutorial learning sessions before the official start of the conference and I have always tried to attend at least one. The chance to take a full day to participate in a structured, deep learning activity, taught by experts in the field, is a rare joy.

In line for coffee, I struck up a conversation with another tutorial attendee, a neonatologist at a major medical center. He also has a degree in informatics and spends “as much time as they’ll let me” on applied informatics projects in his institution, though there is no dedicated informatics department or team. Much of his time is spent working on their Epic system, into which he says they have “shoehorned” their neonatology workflows. 

He is here to attend a CMIO workshop, hoping to learn ways to elevate his level of influence within his organization. It is heartening to see someone dedicated enough to the promise of informatics to push on against the headwind of an organization that doesn’t yet know how to effectively use him, but it is a shame that those headwinds are still so prevalent.

At the tutorial, I found myself sitting next to one of the luminaries of the informatics field, someone who has occupied most of the leadership positions at AMIA and is now a senior executive of a very large academic medical center. To my surprise, he explained that he, too, makes a point of attending at least one tutorial at every AMIA conference. There are few things as impressive to me as someone at the top of their field who still thinks they have something to learn.

At the morning break, I chatted with Jose, another tutorial attendee. Jose is an internist and part of the clinical informatics team at a large East Coast medical system. His interests include population health and chronic care management. One of the projects he’s working on is development of a homegrown application for their health coaches. Among the workflows this application will support is capture of PHQ-9 questionnaire results. 

Jose recognized that there are LOINC codes for both PHQ-9 questions and answers and has been working with his development team to make sure that those codes are stored along with the questionnaire, increasing its ability to be re-used for reporting, decision support, interoperability, etc. Another great example of how informatics knowledge can make a difference in how health care organizations operate.

The NLP tutorial itself was certainly worthwhile, with instructors who were very knowledgeable and well-prepared. At the same time, it illustrated one of the challenges that faces AMIA and the field of informatics in general. Informatics is a “big tent” field whose adherent come from a wide variety of professional backgrounds and are working to solve a wide variety of problems. While this is a tremendous strength, it also creates challenges. In some cases, informaticists assume of each other familiarity with a particular set of knowledge or a shared set of priorities and interests. 

This was evident in the NLP tutorial. The presenters spent much more time describing the steps in using a set of open-source tools to create NLP engines (including the mechanics of setting up the processing queue for new documents in a data repository) than they did describing the logic by which NLP engines work and how that can be optimized. It would have been a great introduction for a grad student considering building an NLP engine for their dissertation. The clinician attendees, hoping to learn how NLP could help manage clinical information and patient care at their organizations, seemed less well served. Still, without AMIA, the “in the trenches” folks and the “in the ivory tower” folks would rarely come into contact. I believe that both benefit from the interaction.

Sunday

AMIA officially opened today with a plenary session with a keynote from Avi Rubin, an information security expert from Johns Hopkins, who gave a widely-viewed TED talk back in 2011 pointing out some serious security vulnerabilities of modern technology, including medical devices. His keynote today expanded on this landscape, which has only worsened. It was a very unsettling talk to hear and a cautionary tale to those who develop IT-enabled implantable devices or take care of people who have them.

After the keynote, the first set of conference sessions began. I attended a paper session on “Deep Phenotyping.” AMIA paper sessions fit four brief presentations into 90 minutes with a few minutes at the end for questions. If you’re not already very familiar with the topic and current research in the area, it’s tricky to keep up. 

Phenotyping refers simply to solving the problem of identifying the phenotype of a person, i.e. classifying them according to some biological or health-related category, such as determining whether they’re diabetic or not diabetic. It’s an important problem if you are trying to do something that requires knowing the phenotype of individuals in a population (for population management, knowledge discovery, etc.) 

The most interesting paper in the session, in my opinion, described “semi-supervised” machine learning for phenotype identification from free-text notes. In traditional (“supervised”) machine learning, a system is given a set of documents and manually-applied labels as to their contents (the “answers”). Based its analysis of the associations between the contents of the documents and the labels, it develops an algorithm that it can use to infer the appropriate labels for an unlabeled document. 

In semi-supervised machine learning, following the supervised process, the system refines its algorithm based on its own inferences on the contents of the data. To my knuckleheaded family physician brain, it’s as if you teach someone that an AMIA attendee with a backpack is more likely to be a grad student than one without a backpack, and then they notice that the AMIA attendees with backpacks are more likely to be wearing sneakers than those without backpacks, and then that person starts inferring that AMIA attendees wearing sneakers are more likely to be grad students. In other words, after learning from being taught explicitly, the computer starts to be able to learn just from what it’s seeing. Intriguing stuff.

Following the session was the welcome reception in the exhibit hall. Among the folks I chatted with was John, the medical director of quality for the Medicaid program of a Midwestern state. It was his first AMIA.  He was excited about the potential of sophisticated data analysis for assessing quality, but also mentioned that at present, the only data he has to work with is claims data — he has no way to get any data from EHRs.  While we’re making great strides in thinking about how we might use healthcare data in positive ways, the options for much of the real world are limited.

Stepping outside the San Francisco Hilton, the realities of human misery are stark and obvious. The Hilton is right in the middle of the Tenderloin district, full of individuals who are clearly mentally ill and/or intoxicated. It is an important reminder of the urgent need to expand knowledge about human health and how to improve it, in which informatics has a critical role to play. As we dive deep into the intellectual challenges of our field, we must never lose sight of whom we’re doing all this for.

Dr. Jayne Goes to AMIA – Sunday

This morning was the last of my pre-symposium sessions. I attended a talk on clinical decision support led by some heavy hitters in the field: Jerry Osheroff, Robert Jenders, Jonathan Teich, Robert Murphy, and Dean Sittig. I was pleased to see that they provided clear objectives and a time-boxed agenda up front. Although a lot of the content may have been review for those of us who have been championing clinical decision support projects, I managed to pick up a couple of useful tidbits including a new term “ehrophilia,” which is your positive disposition towards EHRs.

I appreciated learning “Murphy’s Rule of CDS” which is that everyone wants the alert to fire to someone else. I’ve found that to be true and most egregious when operational people want to put physician-facing alerts on patient charts. We lost a fair number of people at the coffee break, but those that returned took part in small group discussions moderated by the presenters. It had been a bit rainy this morning (much needed here, but I don’t think it made the AMIA Fun Run very fun), so I took advantage of today’s longer lunch break to hit the streets and get some fresh air.

The afternoon started with an opening session. AMIA Board Chair Blackford Middleton highlighted the presence of 2,100 attendees as well as some member perks, including the fact that the Journal of Applied Clinical Informatics is now an official AMIA journal with online access. AMIA has over 5,000 members and it looks like a good chunk of them are here. Also during the opening remarks, the Morris F. Collen Award of Excellence was presented to Jan van Bemmel, one of the pioneers of medical informatics.

Keynote speaker and security specialist Avi Rubin thoroughly entertained the crowd with some great stories about “security researchers – some people call them hackers.” Interesting tidbits included that the Nest thermostat has roughly 10 million lines of code, which is comparable with a 1995-era operating system. Since the number of bugs is a function of the number of lines of code, complexity of development is leading to more points of exploitation for those intending mayhem.

He also schooled the crowd on buffer overflow attacks. You could tell from the ears that perked up in the seating areas which attendees were more or less techy than others. I did spot a couple of people multitasking including Facebook and Sudoku. For those of you who weren’t playing along, the USB Banana was a hoax. Rubin closed with a great quote: “Just because you can connect something to the Internet does not mean you should.”

The opening session was slightly marred by people in front of me who could not stop talking despite multiple shushing and meaningful stares. Finally, someone walked up from the back of the room and told them to be quiet and they generally complied.

Following the keynote, I attended a panel on “Wearable Health Data and the Quantified Self.” It featured five panelists speaking on different mini-topics. I’ve not been to a session like this and have to say I liked it, although I missed the more formal opening we usually see with continuing education sessions, where presenters list their objectives.

I hope the slide deck gets posted because it was a great presentation. I would like to have had it in advance so I could annotate on it, but didn’t find it on the conference website. I got some interesting examples of the Quantified Self movement to use with some of my peers, including an anecdotal story about one patient who tracked his sneezes for two years to discover how allergies were actually affecting his day-to-day life. I also was not aware of the Open Humans Project, which allows research participants to receive their own data and helps match people with future studies.

The final speaker of the panel was patient Craig Braquet, a self-described “gadget geek” who began to use wearables to analyze his symptoms of fibromyalgia, degenerative disc disease, and chronic fatigue syndrome. It was great to hear from the patient’s point of view. It sounds like having his own data has made a difference in how he manages some of his conditions.

The evening was chock full of social activities, starting with a welcome reception in the exhibit hall. The exhibit hall was extremely crowded during the reception with appetizer stations set up in some of the aisles, which made navigating difficult. I did happen to run into a medical school classmate that I haven’t seen since graduation. There are several of us from my class and the class following who have landed in the field of informatics. Even though it was a very quick catch-up it was good to see him.

I breezed by the Clinical Informatics Diplomate reception on the way to dinner with a colleague, hitting the NavigateAMIA reception on the way back. It is targeted to new members and first time symposium attendees and featured desserts in addition to networking opportunities.

I didn’t stay long because I wanted to head up to the Women in Informatics Networking Event (WINE) at the Cityscape restaurant on the 46th floor. It was a great way to cap the evening with lovely views of the city in all directions. I chatted with a doctoral student doing work in predictive modeling for ICU patients and a couple of other students in nursing informatics programs. It was fairly crowded, but I didn’t see any other CMIOs there so I headed back to my room for some much-needed rest. Tomorrow is definitely going to be a day for (sigh) flat shoes.

Are you attending AMIA? What’s your take on the meeting? Email me.

Email Dr. Jayne.

Morning Headlines 11/16/15

OH Muhlenberg, LLC Identifies and Contains a Security Incident at Muhlenberg Hospital

Muhlenberg Community Hospital (KY) discovers keystroke loggers installed on several hospital computers after receiving a notice from the FBI warning of suspicious network activity. A forensics investigation conceded that the breach could have happened as early as January 2012.

Many Say High Deductibles Make Their Health Law Insurance All but Useless

The New York Times covers the rise of high-deductible insurance plans on ACA marketplaces, which in some states make up more than half of the available options. One customer explains their experience, “The deductible, $3,000 a year, makes it impossible to actually go to the doctor. We have insurance, but can’t afford to use it.”

HHS calls in all players for health IT strategic plan

In an interview with Federal Times, Karen DeSalvo, MD discusses the efforts that went into creating the Federal Health IT Strategic Plan and the influence that ongoing VA/DoD interoperability issues had on the final product.

HealthCare.gov sign-ups top 500K

Healthcare.gov enrolled 540,000 people into health plans during the first week of open enrollment, one-third of which were new customers. The results represent a modest increase over week one 2015 enrollment figures.

Monday Morning Update 11/16/15

Top News

Muhlenberg Community Hospital (KY) notifies all patients, providers, and employees prior to July 1, 2015 that their information may have been exposed by a keystroke logging program that had been running on some PCs for several years. Interestingly, the FBI noticed “suspicious network activity involving third parties” and told the hospital it might have a problem.

I’m surprised it’s taken so long for a hospital to be hit by keylogger software since it is widely available and inexpensive (even Sears sells a USB memory stick version). This software is sold by B&H  Photo for $40 and promises to run in stealth mode and to disable spyware detectors.

Reader Comments

From Blues Traveler: “Re: CareZone. My 90-year-old father is using it to share medical information. He can take smartphone photos of his medication bottles and it will convert those to create a med list that is 90 percent accurate (would love to see that technology in physician EHRs). You can set up reminders to take meds and order refills. Now my dad has his med list with him at all times and can print it. I also stored his insurance cards on it. You can make health notes and track your vitals. It’s great for managing the health of an older parent and I have access to his account for an emergency.” I mentioned Seattle-based CareZone when it was launched in early 2012 by former the former CEO of Sun Microsystems, but the company seems to have had nothing new to say since then.

From Parse Person: “Re: Bitcoin blockchain for storing patient information. As you mentioned, it’s a giant database that appends data to itself without every deleting anything. The problem is that even if you encrypt and anonymize EHR information, it still sits around forever. While it may be uncrackable now, 10 years from now the technology will probably advance enough that anyone interested can find and read your old health records. The only way around this is to just use the blockchain to link to some other database, which it sounds like the hackathon group did, but in that case you might as well not bother with the blockchain and just send your providers to the EHR database in the first place.”

From Pam Ramhofer: “Re: Voalte’s first user group conference. This was one of the most relevant conferences I have attended this year. Communication and alarm management challenges resonate throughout the healthcare industry. The user group shared creative solutions and best practice to provide communication efficiencies that result in getting critical patient information to the right person at the right time.” Pam is CIO at Sarasota Memorial Hospital. 

From The PACS Designer: “Re: ICD. With the specificity that we get with ICD-10-CM/PCS, it makes real-time clinical decision support systems more practical. By using real-time processing, we get more efficient usages of resources and clinical staff with better patient treatment outcomes. What do you think about this concept?”

HIStalk Announcements and Requests

Slightly more poll respondents consider the impact of VC/PE as positive rather than negative. Frank Poggio added a comment, “The simple positive is VC/PE money funds the development that would not occur if there were no, or limited, funds available. But this real positive usually gets over run by the big negative. That is, VC/PE has a relatively short-term time horizon which typically forces decisions to be made based on near term ROI criteria first, and end user requirements (product) last.” New poll to your right or here: are recently announced Quality Systems (NextGen) changes positive or negative?

Mrs. Jones in South Carolina sent photos of her students, all of whom have been identified with intellectual or emotional disabilities, using the math manipulatives provided by our DonorsChoose grant. She says the students have so much fun with the tools that they don’t even realizing they are doing math practice, adding that the items will help close the educational gap between her students and their peers. Also sending photos was Ms. Sobczak, whose special need students in Grades 1-2-3 love the math games that “are a really fun way for the kids to learn and interact with one another while practicing some much-need skills.” I noticed that I’ve deployed $22,000 in reader donations and matching funds so far in 2015, with outside matching funds increasing the value of funded projects to a much larger amount.

Ben Rooks of ST Advisors sent $500 to my DonorsChoose project as part of his company’s program to donate a percentage of revenue to charity. The company’s donation provided these items:

• Two Chromebooks, math manipulatives, and easel pads and markers for Mr. Weber’s math class in Kealakekua, HI,
• A document camera for Mrs. Twigg’s elementary school class in Kansas City, MO.
• Printer supplies and paper for Mrs. McKnight’s first grade class in Columbia, SC to replace what they lost in the recent flooding there.
• A large math book library for Ms. Ahrstrom’s third grade class in Bronx, NY.
• Hands-on math games for Ms. Keplinger-Williams’ second grade class in Erwin, TN.
• A LEGO Mindstorms programmable robot for Mrs. Gamache’s gifted class in Davenport, FL.
• A Dot and Dash Wonder Pack and launcher to develop basic coding and problem solving skills for Mrs. Pryor’s kindergarten class in Woodward, OK.

One of the teachers we supported emailed to say that students will decide by fourth grade whether they love or hate math, so we’re hopefully influencing some of them in time to make a difference.

Last Week’s Most Interesting News

• Bloomberg Businessweek puts hospital medical device vulnerability to hacking on its cover.
• BIDMC CIO John Halamka, MD expands his call to dismantle the Meaningful Use program to reduce interference with patient care, free up vendors and providers for more innovative work, and prevent auditors from adding regulatory burden.
• Walgreens integrates MD-Live-powered video visits into its app and expands the program to 25 states.
• Quality Systems replaces its board chair as founder and board chair Sheldon Razin retires to make way for Jeffrey Margolis.

Webinars

November 18 (Wednesday) 2:00 ET. “Making VDI Secure and Simple for Healthcare.” Sponsored by Park Place International. Presenters: James Millington, group product line marketing manager, VMware; Erick Marshall, senior systems engineer of virtual desktop infrastructure, Park Place International. Deployment of a virtual solution can optimize the experience of clinician users. Attendees will learn how to address the evolving demands of security and mobility in clinician workflow to improve the quality of care.

November 20 (Friday) 2:00 ET. “The Athenahealth Leadership Institute Presents: Dr. John Halamka Interviewed by Jonathan Bush.” Sponsored by Athenahealth. Presenters: John Halamka, MD, MS, CIO, Beth Israel Deaconess Medical Center; Jonathan Bush, CEO, Athenahealth. Providers are fed up with interface fees and the lengthy, fragmented narratives we’re exchanging today. But what is the right course of action to help deliver better care across the continuum? Bring your questions as we join Dr.Halamka and Jonathan Bush to discuss the current state of healthcare and how we can improve care coordination and interoperability.

December 2 (Wednesday) 1:00 ET. “The Patient is In, But the Doctor is Out: How Metro Health Enabled Informed Decision-Making with Remote Access to PHI.” Sponsored by Vmware. Presenters: Josh Wilda, VP of IT, Metro Health; James Millington, group product line manager, VMware. Most industries are ahead of healthcare in providing remote access to applications and information. Some health systems, however, have transformed how, when, and where their providers access patient information. Metro Health in Grand Rapids, MI offers doctors fast bedside access to information and lets them review patient information on any device (including their TVs during football weekends!) saving them 30 minutes per day and reducing costs by $2.75 million.

December 3 (Thursday) 2:00 ET. “501(r) Regulations – What You Need to Know for Success in 2016.” Sponsored by TransUnion. Presenter: Jonathan Wiik, principal consultant, TransUnion Healthcare Solutions. Complex IRS rules take effect on January 1 that will dictate how providers ensure access, provide charity assistance, and collect uncompensated care. This in-depth webinar will cover tools and workflows that can help smooth the transition, including where to focus compliance efforts in the revenue cycle and a review of the documentation elements required.

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

Announcements and Implementations

Voalte announces integration with Uber in a pilot project at Sarasota Memorial Hospital (FL), which will discharged patients a pre-arranged Uber ride to their medical appointments. The company also announces its work with UCSF to develop a clinician-facing patient wall that will use Twitter-like social media symbols and an upcoming reporting and analytics tool.

TeleTracking launches a cloud-based patient flow platform called TeleTracking IQ that integrates the user experience with multiple modules and reduces upgrade complexity.

Government and Politics

FDA launches a closed beta of PrecisionFDA, an open source cloud-based platform that allows researchers to upload and share precision medicine data such as reference genomes, bioinformatics pipelines, and genomic data.

Privacy and Security

A Verizon Enterprise Solutions analysis finds that PHI breaches happen in all industries, not just healthcare, as insiders and hackers can get insurance and other health demographic information from information stored by all kinds of companies. Many companies aren’t even aware that they are storing PHI, which has a high value to hackers.

North Carolina’s HHS reports that the information of 524 people was exposed when one of its employees sent a worksheet to health directors via unencrypted email.

Technology

Southern Hills Hospital (NV) pilots AccendoWave, tablet-powered software that monitors a patient’s EEG via a headband and earbuds to detect and report pain levels. The tablet also provides video and audio content to distract from the pain.

Apple co-founder Steve Wozniak tells conference attendees that the Apple Watch is improving, but he still isn’t a big fan of anything that comes between him and his phone. He also likes laptops better than tablets and adds that he’s not an Apple fanboy: “I don’t like being in the Apple ecosystem. I don’t like being trapped. I like being independent.”

Other

In England, the family of a woman who died in 2011 when her referral for gall bladder removal was lost between two hospitals in the same NHS trust that use different IT systems is awarded an unspecified settlement.

San Francisco Magazine gushes about the new UCSF Medical Center at Mission Bay and its 65-inch flat screen patient room TVs with built-in social media, robot-delivered meals, rooftop gardens, a teen lounge, and weekly bingo games. The 289-bed hospital and medical complex should be pretty swanky given that its first phase was estimated to cost $1.5 billion. Let’s see if outcomes improve.

The New York Times covers an ominous phenomenon I reported weeks ago after playing around with Healthcare.gov, Stride Health, and insurance company sites: ACA-mandated plans may or may not carry reasonable premiums, but the real gotcha is in annual deductibles that can range from $3,000 to $6,000 and more. The paper found that more than half of Healthcare.gov plans have a deductible of at least $3,000, leaving patients (especially the desirable young and healthy ones) with insurance they can’t afford to use. That encourages them to simply drop their policies since they’ll be paying all of their medical expenses out of pocket anyway. It’s bad enough that middle-class patients have to come up with thousands of dollars before their hard-won insurance contributes anything, but another to providers who have to try to collect the money patients owe them (knowing that people don’t rank medical bills high on their must-pay list). It’s obvious to me that both patients and providers are going to be complaining loudly about what they thought ACA was going to do for them vs. what has actually happened. Not many people have a spare $5,000 lying around to pay an unexpected ED or surgery bill. Providers had better (a) look at point-of-service collections; (b) figure out ways to get patients on payment plans; and (c) expect their income and cash flow to take a beating due to commercially insured patients rather than just Medicare recipients. “Real” insurance is starting to look like that fake, late-night TV hawked “insurance” from years ago that was really just a discount card that few providers would accept.

This tweet by Nick Dawson of Sibley Memorial Hospital provides a good story that explains how uncoordinated healthcare (and healthcare information) is.

Sponsor Updates

• Valence Health and ZeOmega are named to Deloitte’s 2015 Technology Fast 500 list.

Blog Posts

• HIT Breakdown 12 – Healthy Planet: Opportunities and challenges (Nordic)
• T-System CHART Awards: Recognizing this quarter’s recipients (T-System)
• Operational Command Centers Yield Positive Results at Carilion & Rush (TeleTracking)
• Best Practices for HEDIS Record Retrieval (Verisk Health)
• Learning the Lessons of MHealth History (Voalte)
• Is Your Patient-centered Care Management Approach Really Patient-centered? (ZeOmega)
• Xerox Recognized as a Military Friendly Employer (Xerox)
• HCAHPS scores expected to determine up to 2% of hospital Medicare payments by 2017 (ZirMed)

Contacts

Mr. H, Lorre, Jennifer, Dr. Jayne, Dr. Gregg, Lt. Dan.

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us or send news tips online.

Dr. Jayne Goes to AMIA–Saturday

Since I live in a city with multiple academic medical centers, I expected to run into a friend or two on the way to the conference. I was surprised, however, to see two other physicians on my parking shuttle. Although one was headed to AMIA, the other was headed to The Liver Meeting 2015, which is also being held in San Francisco.

Given my crazy frequent flyer status, I was one of the first on the plane and watched at least a dozen other physicians and health informatics professionals pass by. I was relieved that if the question was to be asked whether there was a doctor on the plane, I would have backup (although as an emergency department doc, I’d likely be a better choice than the pediatric hepatologist for most in-flight issues).

I had the chance to catch up on the flight with a friend of mine who works for my former health system. They’re on a journey to a massive rip-and-replace. There is no shortage of informatics work to be done as they retire dozens of major systems in the name of single-database efficiency.

There was another informaticist seated near me and it was interesting to eavesdrop on his chat with his seat mate. He was explaining what he does. There was a brief discussion about data sharing and the difficulties of doing it not only technically, but also about the nervousness of physicians in sharing some of the more sensitive health information that is out there.

We’ve gotten to a point where the incidents of hacks and breaches are too numerous to count. I get the sense that physicians are at the tipping point of being more worried about unauthorized access to medical data than they are about patients having the data. In some ways, that’s a good thing because my peers are getting over their resistance to patient ownership of their own health information. It’s been a long time coming.

The Hilton Union Square was also hosting a nursing convention, where I spotted several people wearing this tee shirt. I’m going to have to seriously think about ordering a few for some of the people I’m working with right now.

I was able to check in to my room a couple of hours early, which was much appreciated and allowed me to head to Union Square. I got a kick out of watching the ice skaters, most of whom didn’t have much experience, but were giving it a good try. Several were watching one man who was there teaching his son and who clearly had spent some time on the ice. I was tempted to rent skates and show off my winter sports skills, but decided to head to the cable car line instead. No less than 30 minutes after I left Union Square, there was a horrific crash of two double-decker tour buses. I wish a speedy recovery for all those injured.

After a couple of hours roaming the city, I returned to the hotel to register for the conference. I loved the Wall of Ribbons and picked up a couple of gems to wear during the week. The conference program guide had a lot of helpful information such as “remove your lanyard when you leave the hotel so you’re not immediately recognized as a tourist,” but it didn’t include a warning that apparently in San Francisco, you’re expected to bring your own bag for carry-out restaurants. Oherwise, there is a bag charge. I’m pretty good at the reduce/reuse/recycle game, but got caught off guard when picking up lunch earlier in the day. That kind of local color information might be helpful in future programs. I appreciated the adjustability of the AMIA lanyards, which allows those of us on the shorter side to hang our badges somewhere north of our navels.

Fast forward to Saturday, when the pre-symposia sessions began. I attended one on “Health Information Exchange Challenges and Methods.” There was a lot of good information covering the different models of HIE and the evolution from early systems to where we are today. There are still quite a few barriers to effective data exchange, including lack of a unique patient identifier or universal physician directory. I learned about a couple of new approaches to bridging between centralized and federated models, but based on the amount of multitasking going, on I’m not sure everyone in the room was as interested.

Maybe they were distracted by the “Data Mining for Medical Informatics – Predictive Analytics” session being held in the next room that must have been pretty exciting judging by the seven rounds of applause heard through the wall in the first 90 minutes of the presentation. For the people who were multitasking, though, may I recommend 3M’s lovely line of privacy screens to keep your neighbors from seeing everything you are doing if you choose to multitask? Surfing Facebook doesn’t make you look like a serious informaticist, although debugging code does. I felt for the gentleman who was doing the latter.

At the break, I ran into HIStalk songwriter extraordinaire Ross Martin, who happened to be seated next to a friend from my customer days at a shared EHR vendor. It’s the first AMIA meeting for both of us and neither of us had dinner plans, so I appreciated the serendipity of running into her.

During the afternoon, I attended a session on “Practical Modeling Issues: Representing Coded and Structured Patient Data in EHR Systems.” Presented by Intermountain Healthcare’s CMIO Stan Huff, it definitely earned its stripes for Maintenance of Certification credit. The session was highly detailed and I got a lot out of it, but I’m sure it was overwhelming for some. I hadn’t heard about the Clinical Information Modeling Initiative becoming one of the HL7 workgroups, but it sounds like it has a lot of potential.

One of the interesting points Stan brought up was the challenge of handling data from a subject who might not be the patient. For example, information on fetal characteristics documented when treating a pregnant woman, or information on tissue donor characteristics for the recipient’s chart. It’s not something I’ve had to do much of in the ambulatory space, but it grabbed my attention. I also enjoyed watching a physician at the next table doing origami with dollar bills. It just goes to show that informatics professionals are a talented bunch.

Do you multitask during conferences? Email me.

Email Dr. Jayne.

Morning Headlines 11/13/15

It’s Way Too Easy to Hack the Hospital

Bloomberg Business profiles white hat hacker Billy Rios, the analyst whose work exposing cybersecurity vulnerabilities in medical devices led to the recent FDA safety warning on Hospira infusion pumps. He says, “hospitals seemed at least a decade behind the standard security curve.”

Epic Systems forum addresses hot topic in medical records: interoperability

Cerner and Epic square off on interoperability at a Madison, WI health IT conference, with Cerner once again inviting Epic to join CommonWell, and Epic declining, saying it should not have to buy into an exchange network that wouldn’t be good for its customers or patient care.

NHS children monitored using McLaren Formula One technology

In England, patients at the Birmingham Children’s Hospital are being monitored with technology designed for racecar drivers from the McLaren Formula One team. The system monitors heart rate, respiration rate, and oxygen levels in real time and alerts the care team if the patient’s condition deteriorates.

News 11/13/15

Top News

Bloomberg Businessweek puts medical device hacking on its cover, profiling a security expert who was criticized for announcing that he had found that medical devices are full of security holes. “All their devices are getting compromised. All their systems are getting compromised. All their clinical applications are getting compromised and no one cares. It’s just ridiculous, right?” The security expert was hospitalized himself and played around with an automated dispensing machine for medications just outside his room, which he easily penetrated using a known, hard-coded password that let him open any drug drawer he wanted. He’s buying his own medical devices to prove how vulnerable they are.

Experts say hospitals rely on device manufacturers to implement security, but they remain a weak link in exposing a hospital’s entire network. A security firm describes what it learned by creating a “honeypot” fake medical device to see who tried to penetrate it:

The decoy devices that TrapX analysts set up in hospitals allowed them to observe hackers attempting to take medical records out of the hospitals through the infected devices. The trail, Wright says, led them to a server in Eastern Europe believed to be controlled by a known Russian criminal syndicate. Basically, they would log on from their control server in Eastern Europe to a blood gas analyzer; they’d then go from the BGA to a data source, pull the records back to the BGA, and then out … In addition to the command-and-control malware that allowed the records to be swiped, TrapX also found a bug called Citadel, ransomware that’s designed to restrict a user’s access to his or her own files, which allows hackers to demand payment to restore that access.

Reader Comments

From Occasional Angel: “Re: Theranos. I thought you’d get a laugh out of the company’s job posting for a communications director, which includes the requirement for an ‘agile thinker ability to respond quickly in shifting situations.’” Theranos certainly continues to experience shifting situations, nearly all of them causing further damage to the company. The latest headline is that grocery store chain Safeway is trying to wangle its way out of a previously unannounced Theranos partnership going back several years to put draw stations in 800 of its stores. The chain’s executives noticed that Theranos results sometimes differed wildly from the same test run by other commercial labs. Safeway also questioned why Theranos often drew samples from both a finger stick and by vein, with one of its executives astutely questioning “If the technology is fully developed, why would you need to do a venipuncture?” Safeway spent $350 million on the in-store clinic areas that featured granite countertops and video monitors, but is now using those areas only to administer vaccines.

My most positive impression of Theranos is that they were able to get the funding to invest in what must have been an ultra-expensive array of automated lab testing equipment (Nanotainer-powered or otherwise) that allowed it to undercut the price of huge-scale competitors. Lab testing is a lot more like a factory than a Silicon Valley startup and it requires brick-and-mortar drawing stations that send samples off to centralized labs, which as why I assume Theranos tries to convince everyone it’s the next Apple instead of an ambitious drop-off dry cleaner. It’s hardly a national diagnostic powerhouse given that its only locations are in California, Arizona, and Pennsylvania. In addition, most of those locations are in the drugstores of  Walgreens, which seems to be distancing itself from Theranos pending review of its test process.

From Marketeer of the Beast: “Re: your rebranding of a health system to the made-up name Blovaria. Here’s how I would explain it. ‘Blovaria is a unique way to recognize our evolution in the marketplace. Our new name is the ideal platform to help us deliver market-leading bloviation with extreme variation in patient outcomes’… and on and on.” I like marketing folks that see the humor in what they do. I disdain marketing-speak and committee-driven company depersonalization into a “brand” that often tries to rewrite history and overpromises future company performance, but I believe strongly in much of what makes up marketing. Honest marketing tries to effectively convey a company’s values and vision in a noisy market, which is problematic when the paying customer wants marketing to cover up their incompetence or misplaced mission of simply pocketing cash by any means possible. Marketing people usually write well and are entertaining, so I’d be interested in running a guest article (anonymously, if that helps) from someone willing to explain the goods and bads of what they are asked to do.

HIStalk Announcements and Requests

Mrs. Read from Florida sent photos of her students using the STEM exploration tools we provided via her DonorsChoose grant request. She says they’re working on a project where they’ve programmed the Sphero app-enabled robotic ball to detect underwater forces, adding that some of the students have been motivated to join the school robotics team as a result. Ms. Santoro from Connecticut sent photos of her first graders working with the tablets we provided, saying some of them don’t have access to technology at home and are asking to use them even when their assigned work is finished.

I got a kick out of this tweet from Nick Kennedy, who apparently enjoyed my mhealth Summit rant. He has history in healthcare IT, but is now the founder and CEO of a private flight-sharing company. It’s fun knowing that someone reads HIStalk just because it entertains them.

This week on HIStalk Connect: Walgreens expands its telehealth offering to 25 states and updates its wellness app to capture glucose and blood pressure readings from its line of wireless medical devices. Researchers from Cedars Sinai Medical Center and UCLA find no improvement to 30-day readmission rates or six-month mortality rates when enrolled in a remote patient monitoring program. The American Association for Cancer Research has launched a data-sharing campaign that will create a central repository for researchers to store and analyze tumor gene mutation data. TigerText raises a $50 million Series C investment to help it expand its healthcare-focused communications platform.

This week on HIStalk Practice: The Wright Center receives the 2015 HIMSS Ambulatory Davies Award. Rep. Tom Price introduces the Meaningful Use Hardship Relief Act. The Patriot Promise Foundation launches to help connect veterans with better, technology-enabled care. PracticeMax acquires Medical Management Corp. of America. Greenway Health’s Rob Newman dishes on the KLAS Keystone Summit. The Retina Group of Washington selects a new EHR from Modernizing Medicine. New DreamLab app crunches cancer research data while you sleep. Ask the Doctor acquires Patients Connected.

Webinars

November 18 (Wednesday) 2:00 ET. “Making VDI Secure and Simple for Healthcare.” Sponsored by Park Place International. Presenters: James Millington, group product line marketing manager, VMware; Erick Marshall, senior systems engineer of virtual desktop infrastructure, Park Place International. Deployment of a virtual solution can optimize the experience of clinician users. Attendees will learn how to address the evolving demands of security and mobility in clinician workflow to improve the quality of care.

November 20 (Friday) 2:00 ET. “The Athenahealth Leadership Institute Presents: Dr. John Halamka Interviewed by Jonathan Bush.” Sponsored by Athenahealth. Presenters: John Halamka, MD, MS, CIO, Beth Israel Deaconess Medical Center; Jonathan Bush, CEO, Athenahealth. Providers are fed up with interface fees and the lengthy, fragmented narratives we’re exchanging today. But what is the right course of action to help deliver better care across the continuum? Bring your questions as we join Dr.Halamka and Jonathan Bush to discuss the current state of healthcare and how we can improve care coordination and interoperability.

December 2 (Wednesday) 1:00 ET. “The Patient is In, But the Doctor is Out: How Metro Health Enabled Informed Decision-Making with Remote Access to PHI.” Sponsored by Vmware. Presenters: Josh Wilda, VP of IT, Metro Health; James Millington, group product line manager, VMware. Most industries are ahead of healthcare in providing remote access to applications and information. Some health systems, however, have transformed how, when, and where their providers access patient information. Metro Health in Grand Rapids, MI offers doctors fast bedside access to information and lets them review patient information on any device (including their TVs during football weekends!) saving them 30 minutes per day and reducing costs by $2.75 million.

December 3 (Thursday) 2:00 ET. “501(r) Regulations – What You Need to Know for Success in 2016.” Sponsored by TransUnion. Presenter: Jonathan Wiik, principal consultant, TransUnion Healthcare Solutions. Complex IRS rules take effect on January 1 that will dictate how providers ensure access, provide charity assistance, and collect uncompensated care. This in-depth webinar will cover tools and workflows that can help smooth the transition, including where to focus compliance efforts in the revenue cycle and a review of the documentation elements required.

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

Here’s the recording of Thursday’s webinar titled “Top Predictions for Population Health Management in 2016 and Beyond,” sponsored by Medecision.

Acquisitions, Funding, Business, and Stock

TigerText raises $50 million in Series C funding to expand the rollout of its secure messaging app.

The HCI Group acquires UK-based High Resolution Consulting and Resourcing. HCI CEO Ricky Caplin says the company is in “major expansion mode” and will likely announce additional acquisitions shortly.

Arizona-based HealthiestYou gets a $30 million investment from Frontier Capital. The company offers video visits, insurance connectivity, a provider director, and drug pricing lookup.

Turing Pharmaceuticals, the most-hated company in America after pharma-brat founder and former hedge fund manager Martin Shkreli jacked up prices on ancient but vital drug Daraprim, records a $15 million loss on revenue of $5.6 million for Q3. The privately held company will soon start clinical trials for drugs for treating epileptic encephalopathies and PTSD, introducing both hope and despair among those patients who might benefit from the drug but know how hard Turing will put the financial screws to them or their insurance company to obtain it. The first drug earned the FDA’s fast track designation, which makes it surprising that Shkreli didn’t just sell that certificate on the open market since they’ve gone for as much as $350 million. Shkreli is also looking for producers for his upcoming (c)rap album. Those with artistic aspirations but minimal talent always seem to settle for being posers in recording rap, writing children’s books, or appearing on reality TV shows.

People

Galen Healthcare Solutions hires Steve Brewer (Origin Healthcare Solutions) as CEO. Former CEO Jason Carmichael will remain on the board.

Former IDX CFO Jack Kane joins the board of Health Catalyst. He also serves on the boards of Aesynt (which was just sold for $275 million), T-System, and Athenahealth. He’s also involved with several other former IDXers (including former CEO Jim Crook) in OpenTempo, which offers staff scheduling and workforce management solutions for large medical practices.

Practice Fusion names interim CEO Tom Langan to the permanent role.

Jeff Surges (Healthgrades) will join health plan enrollment technology vendor Connecture as CEO.

Gene Amdahl, who went from being educated in a one-room South Dakota school without electricity to leading the development of the IBM’s System/360 mainframe and later the formation of compatible mainframe competitor Amdahl Computing, died Tuesday at 92.

Announcements and Implementations

Caradigm adds electronic prescribing of controlled substances (EPCS) to its Identity and Access Management solutions (single sign-on, context management, and identity management).

Privacy and Security

A proof-of-concept medical records project wins the Blockchain Hackathon in Ireland. It uses the blockchain to anonymize a patient’s electronic records and make them viewable to doctors or others to whom the patient gives their public identifier, retrieving the information via BitTorrent. A blockchain database securely stores a public ledger of transactions, in essence an ever-growing, append-only transaction log that does not require the participation of any third party to change hands. If you’re excited about the potential healthcare use of blockchain, consider writing an HIStalk guest article so educate the rest of us who have heard the word but don’t know much about it.

Technology

The Philadelphia-based Health Care Innovation Collaborative issues a call for chronic disease health project ideas, from which it will choose winners who will work with one or more of its partners that includes CHOP, Drexel University, Independence Blue Cross, Jefferson Health, and University of Pennsylvania Health System. The group was formed by the Greater Philadelphia Chamber of Commerce to increase Philadelphia’s health IT activity. 

In England, hospitalized children are being monitored by early warning software originally developed for Formula One race drivers. The pilot project involves wireless vital signs sensors attached to the chest and ankle that send data for real-time analysis and alerts. 

Other

BIDMC CIO John Halamka, MD expands on his observations and recommendations for the Meaningful Use program, which he says served its purpose but should be dismantled as it tries to do too much and interferes with patient care. Some of his observations:

• EHR certification threatens usability, interoperability, and EHR quality while also diverting resources away from more important work.
• Nobody is intentionally blocking information exchange – it’s really “incompetence that feels like blocking.”
• Government regulation isn’t the answer to solving societal problems and each new requirement adds a layer of clueless auditors.
• Prescriptive regulation, additional structured data elements, and new quality measures don’t help create disruptive innovation. A business imperative is required.
• The MU program should be rolled into other CMS incentive programs such as Alternative Payment Models and MIPS.
• ONC has become distracted by political agendas, excessive focus on certification, and issuing grants, where it would provide better results as a policy shop that addresses specific problems such as safety and error reduction.
• Stop blaming health IT vendors and providers as the enemy.
• Focus on the few things that really matter, not the 117 goals in the Federal Interoperability Roadmap.

A Health Affairs article says the Meaningful Use program increased hospital EHR adoption, but the effect of penalties as opposed to rewards is uncertain and small and rural hospitals continue to lag. Hospitals cited their challenges as cost, lack of physician cooperation, and the complexity of the MU program.

The San Diego paper profiles startup Doctible, which has created a network of local providers who offer discounted cash prices and online booking for people with high-deductible medical insurance. It bugs me that, like most other sites that list physicians, it puts “Dr.” in front of their name and “MD” after, which is incorrect.

Epic and Cerner face off on interoperability at the Disruptive Healthcare Conference at UW-Madison. A Cerner VP again calls for Epic to join CommonWell, while Epic’s VP says the company already helps its customers connect to CommonWell and shouldn’t have to “buy in” to CommonWell just to keep doing that, explaining, “There is not a magic future down the road in which there is one health information exchange network called CommonWell.” Both VPs agree that hospitals and practices need more incentives to share information.

Sponsor Updates

• AdvancedMD offers a $10 Amazon gift card to anyone who requests their information kit.
• PDR will exhibit at the McKesson Chain & Health System Pharmacy User Conference November 17-18 in Pittsburgh.
• Stella Technology is sponsoring and attending the NYeC Gala Awards to promote health IT in New York City November 18.
• Liaison Healthcare will exhibit at the PointClickCare Summit November 16-19 in Palm Desert, CA.
• LiveProcess will exhibit at the first annual Association of Healthcare Emergency Preparedness Professionals Conference November 17-18 in Omaha, NE.
• MedData will exhibit at the HFMA Region 9 Conference November 15-17 in New Orleans.
• Recondo Technology, the SSI Group, and Streamline Health will exhibit at the HFMA Region 9 Conference November 15 in New Orleans.
• PatientPay sponsors the iPatientCare National User Conference.
• PerfectServe will exhibit at the American Association for Physician Leadership Fall Institute November 13-17 in Scottsdale, AZ.
• Lexmark will exhibit at RSNA15 to benefit Camp Invention’s STEM programs for children across the US.
• ZirMed is sponsoring and will present at “Data-Driven Revenue Cycle” November 18 in Atlanta.

Blog Posts

• Insider Theft: The Human Version of Malware (ID Experts)
• Nothing but Net (Ingenious Med)
• Ask the Expert: EMV, Encryption and Reducing your PCI Scope (InstaMed)
• Pro Tips for Implementing Epic’s MyChart (Nordic)
• One Size Doesn’t Fit All (NTT Data)
• Dictation Made Easy (NVoq)
• New Survey Benchmarks Patient Engagement Tactics (Oneview Healthcare)
• Telemetry Care: Cure smartphone alerts (PatientSafe Solutions)
• The Other Socialized Medicine (PatientKeeper)
• Inaccurate Provider Data can be Very Costly! (Phynd Technologies)
• What’s New in Meaningful Use Stage 3? (Sagacious Consultants)
• Reducing Waste by Applying Interoperability Best Practices Presented at Lab Quality Confab (Sunquest Information Systems)
• Technology and Electronic Prescribing Aids in the Fight on Prescription Drug Abuse (Surescripts)

Contacts

Mr. H, Lorre, Jennifer, Dr. Jayne, Dr. Gregg, Lt. Dan.

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us or send news tips online.

EPtalk by Dr. Jayne 11/12/15

I’m headed to San Francisco for the AMIA meeting and will be reporting from there for the next several days. I haven’t been to a conference that is this academic in a long time and I have to say that planning for it has been more rigorous than I expected.

From everything I hear as well as from the pre-symposium orientation webinar, there is going to be more to do, see, and learn than one person could possibly do. There are more than 2,000 pages of content available already, plus a few hundred pages of questions and answers for Maintenance of Certification (MOC).

There are also Twitter feeds and an event app for managing your schedule. I’ve enjoyed going through everything and flagging the sessions I plan to attend or that I want to keep on my list as a backup. For someone like me who dabbles in many different areas of informatics, it’s a bit like being a kid in a candy store.

I’ll be attending some of the pre-symposium sessions as well. Dealing with them has been the only negative part of my experience so far.

When I signed up for AMIA several months ago, the list of sessions that are available for MOC credit for clinical informatics wasn’t available. Even though they’re no charge, the pre-symposium sessions required advance registration. Once the list of MOC-approved sessions was available and I had time to go back through them and see whether they matched what I had registered for, those that I wanted to switch to were full.

Attending conferences is expensive. Given the status of MOC for Clinical Informatics, I want to maximize the amount of credit I bring home. Although I’m not choosing sessions strictly by whether they are approved or not, given two sessions at the same time that I’m equally interested in, I’m going to lean towards the one that will give me credit.

I suspect AMIA is seeing a spike in registrations due to being one of the few providers of relevant and approved continuing education credit for our subspecialty. It will be interesting to see how it shakes out. In the mean time, I’m going to continue refining my battle plan to get the most out of the conference.

Whenever I head out for an extended trip, I gather up any hard-copy publications that can be read during taxi, takeoff, and landing so I can read and recycle them on the way. I saw this Healthcare IT News headline and it just struck me as somewhat offensive. Although IT is a key player in most industries, to say that a hospital would be “nothing” without its IT department is obnoxious. It would still be a hospital, it would still provide patient care, and it most certainly wouldn’t crumble to the ground.

The associated article is about best hospital IT departments, so I don’t expect it to address the fact that there are worse things than having no IT department – namely, having a bad IT department that creates chaos. Or one that behaves aggressively towards clinicians and doesn’t respect the input of various stakeholders. Or one that’s flat-out incompetent.

As a culture, we’ve become obsessed with these “best of” lists. I always think about one of my good friends that continued to make the “best doctors” list in my city despite having moved away several years prior.

The loss of any department — whether clinical, administrative, support, or other disciplines — would negatively impact any hospital. Headlines like this don’t help bring people together. I’d love to drop this in the physician lounge and see what kind of responses it gets. Maybe that’s an idea for a reality show – kind of a candid camera for healthcare IT users. I know some people who would watch.

What’s your idea of good entertainment? Email me.

Email Dr. Jayne.

Morning Headlines 11/12/15

The Path Forward for Meaningful Use

John Halamka, MD and CIO of BIDMC, publishes a blog outlining his assessment of the MU program. He explains, “Clinicians cannot get through a 12 minute visit, enter the necessary Stage 3 data elements, reconcile problems/allergies/medications from multiple institutions, meet the demands of the  Stage 3 clinical quality measures, make eye contact with patients, and deliver safe medical care. There needs to be a new approach.” 

For US Hospitals, A Mixed Report In Electronic Health Record Adoption

A study published in Health Affairs finds that by 2014, 75 percent of US hospitals had adopted a basic EHR, while 40 percent had implemented the functionality needed to meet MU2 criteria.

Boston Children’s looks to IBM’s Watson for rare-disease help

Boston Children’s Hospital will work with IBM’s Watson team to bolster the supercomputer’s nephrology database and enhance its logic to help spot rare kidney disorders..

Safeway, Theranos Split After $350 Million Deal Fizzles

The Wall Street Journal continues with its Theranos coverage, recounting a failed deal with Safeway that cost the grocery store merchant $350 million spent on in-store clinics designed to house Theranos analyzers that were never delivered.

Readers Write: Supply Chain Data Meets Clinical Outcomes: The Holy Grail

Supply Chain Data Meets Clinical Outcomes: The Holy Grail
By Andy Cole

The term “Holy Grail” has always been intertwined with stories of epic searches to find the Holy Chalice used at the Last Supper. From Dan Brown’s bestselling novel “The Da Vinci Code” to the always entertaining Spielberg/Lucas film “Indiana Jones and the Last Crusade,” fans have been drawn to the idea of finding something so elusive…so mysterious….so game-changing.

When I think about what it will take to dramatically change the cost, efficiency, and effectiveness of our healthcare system, the solutions too often seem as unattainable as the Grail itself. It dawned upon me that the “search for the Holy Grail” is a perfect metaphor for the ongoing efforts to deliver high-quality, medically-necessary and cost-effective healthcare across this country and beyond.

But as I think even deeper about the dilemma, I realize that the healthcare providers who are charged with solving this crisis already have the tools they need to do so. It’s at the tip of their fingertips. Literally.

For decades, healthcare providers had been in the dark about how much it cost to deliver their services. More importantly, thanks to inefficient reimbursement models, they really didn’t need to know. As long as payers (both private and public) paid them based on how much they charged, there was no incentive to truly understand those costs, and in turn, wrangle them in.

Soon, payers and policy makers realized this model was unsustainable and changes started to happen. Once they understood that reimbursement was driving care, they realized the only way to drive lower cost of care was to reduce reimbursement. With less money coming in the door for their services, healthcare providers had to undergo a paradigm shift. They had to cut costs wherever they could to meet the thin margins that were now in the marketplace. Efficiency was the name of the game, and classic cost-reduction strategies entered the arena.

Cut throat supply competition and Group Purchasing Organizations began playing a huge role in offering the lowest possible prices for supplies and bringing economies of scale to healthcare providers. CFOs began paying attention to how many supplies were being purchased and at what price. With a keen eye on the bottom line, cutting supply expense was usually low-hanging fruit that met their cost-saving objectives. With this need came slick analytic tools that aggregated supply and service spend data and clearly suggested areas for savings, whether that be utilizing a less-expensive vendor or taking advantage of a GPO contract.

We have fallen into our current state of “quality data” as an unintended consequence. Providers had historically focused on collecting data for every service they performed in order to receive maximum reimbursement from various payers. More services =  more money. As a result, claims data was serving only as an excellent vehicle to capture charges and little else was being done with it. As the environment shifted, and reimbursement focus shifted from fee-for-service to pay-for-value, the industry didn’t have to look very far to find the data they needed to analyze.

Since charge data provides a detailed representation of all of the services rendered in a healthcare facility, it was a logical next step to begin analyzing a patient’s data holistically, rather than just from an episode by episode basis. Payers and providers could now longitudinally piece together a patent’s entire health record and use it either increase reimbursement for positive outcomes or decrease it based on negative ones.

When the government bought in and incented providers to use certified EHRs, this only increased the amount of data that was collected. That’s where we find ourselves now — swimming in a sea of healthcare data. The objective now is to harness the power of data and take that next step to uncover new solutions to our cost problem.

With the right tools, we can now take a look at clinical outcomes and supply cost together, whether that’s for an individual patient stay, across many for the life of that patient, or all patients. For the moment, I’ll put myself in the shoes of the CFO of a multi-facility IDN.

Taking a deeper look at a cardiac rhythm management supply analytics reports may suggest that I could get a better deal on my pacemakers if I buy them from a vendor named Jolt instead of my current vendor, KickStart. In fact, with my agreement that I just signed with my GPO, I could save upwards of 20 percent this coming year if I convert to Jolt. A quick review online of Jolt products show no red flags. My chief cardiologist has heard good things and gives me the go ahead. I sign the deal and warm up my calculator to count my savings.

My argument is that there is a crucial step missing in that process, the one that takes into consideration the universal value of making that conversion. Having access to quality and outcomes-based data allows me to cross-analyze the cost of the new pacemakers with the outcomes of patients that use them across my facilities. Perhaps I would save 20 percent on them next year, but I see that patients who have them have higher readmission rates, which would result in Medicare penalties and reduce my reimbursement.

Additionally, I am now taking on risk for my patients because of the Accountable Care Organization arrangement we have negotiated with a major private payer. My goal is to deliver the highest quality care at the lowest cost. The payer gives me a set fee for each “covered life” I take on. If a patient utilizes an over-abundance of services in my network, I will most likely lose money on them. However, if I keep them healthy and can avoid expensive treatments and services, I keep anything left over from my payment. Since data is telling me that patients with Jolt pacemakers are twice as likely to take a costly trip to the ER than those with KickStart’s, I will take a much harder look to determine if that conversion truly makes sense.

With this “Eureka” moment fresh on the minds of healthcare CFOs around the country, they are now tasked with changing the paradigm of purchasing. Marrying clinical outcomes and supply chain costs takes new tools, a new culture, and a new vision. It is an essential shift that will help providers and payers stay financially solvent, and in the end, keep the patient healthier.

Our industry has the information we need to make smarter purchasing decisions. We just need to act on it. We actually have an advantage over Indiana Jones, who traveled the globe searching for his Holy Grail. We already have the Holy Grail we’ve been searching for at our fingertips. All we need is to look closely, smartly, and polish it to a glittering shine. This is a game changer.

Andy Cole is national director of PremierConnect Supply Chain solutions at Premier,Inc.

HIStalk Interviews Joshua Mandel, MD, Harvard Medical School

Joshua Mandel, MD is on the research faculty at Harvard Medical School and is the lead architect for the SMART project collaboration between HMS and ONC.

Tell me about yourself and your job.

I am on the research faculty at Harvard Medical School. I’m in the department of biomedical informatics there. I work on making it easier for patients, clinicians, and researchers to work with electronic health data. I got there via medical school, where as a medical student I realized there was a lot more that computers could be doing for us than they were doing.

Describe the SMART project and how it relates to FHIR.

SMART Health IT, which is an acronym for Substitutable Medical Applications and Reusable Technologies, is a project that was originally sponsored by the federal government, by the Office of the National Coordinator for Health Information Technology, with a goal of building an app platform that allows third-party apps to plug into various kinds of health information systems. We specifically focus on apps that plug into electronic health records, which might be apps that clinicians use, apps that plug into patient portals, personally-controlled health records the patient would use, or apps that plug into data warehouses that researchers might use.

The goal is to provide apps with everything they need to be able to present a consistent user experience. The apps shouldn’t have to know about all the internal details of each different health IT system. The goal is to abstract the apps from those details. That’s the high-level goal of SMART.

We use a number of technologies under the hood to make that work. We use a set of open technologies everywhere we can. We use an emerging specification from HL7 called Fast Healthcare Interoperability Resources, or FHIR, to provide the data layer of access. FHIR gives us a set of data models and it gives us a Web-oriented REST API that application developers can use to query an electronic health records system for data.

Then on top of that, we layer a security model using OAuth 2 and OpenID Connect so that users can sign into apps using their existing accounts so they don’t have to create a new account for every app they want to use. That includes a permissions model, so you can give apps access just to the data that they need and you don’t have to give apps access to everything in your system.

We wrap all that together with a little bit of glue so that we can actually plug these apps into, for example, an electronic health records system. You might be a clinician working with an EHR system from Cerner, Epic, or any number of vendors beginning to implement these specifications. When you’ve got a patient record open inside one of these systems, you can launch an app and it knows about the context of what you were doing inside of the EHR, so that app can launch directly on the patient that you already have open and help you get some new jobs done that the original EHR didn’t have any functionality for.

How will that be positioned against vendors who have declared themselves to be open and created their own equivalent of an app store or an ecosystem with partners that they’ve approved?

We’re seeing interesting trends from the electronic health record vendors towards allowing certain kinds of third-party tools to integrate with these EHR systems. There’s still some big, open questions about the extent to which we’ll see standards as the basis for that integration versus vendor-specific data access.

We can actually separate out two questions. One question is, what are the technical mechanisms by which the access works? Are we using standards like FHIR? Are we using vendor-specific APIs? That’s the technical piece of it.

Then there’s a policy piece. Regardless of whether you use standards or whether you use vendor-specific APIs, there’s a policy piece about which apps are going to be allowed to talk to a given system and how are vendors and healthcare provider organizations together going to control that access.

What levels of capability or interest in SMART are you seeing from the three significant inpatient EHR vendors?

Overall, the goal of SMART is to provide an interface where apps can plug into outpatient systems, inpatient systems, and various other kinds of health information systems, including health information exchanges and researcher-facing systems. We don’t have an exclusive focus on the inpatient world, but of course it is an important area.

We’ve been very encouraged over the last few months by the participation of a number of the big EHR vendors in a project called Argonaut. Argonaut is running an open implementation program, where anybody who’s building an app or an EHR can join for free and go through a series of development steps with us, where they can build out support for SMART on FHIR one step at a time. We’re running this open implementation program and we’ve had a couple of dozen organizations actively participating. That includes many of the big-name electronic health record vendors.

EHR vendors and even providers themselves don’t have much incentive to let patients choose and use whatever apps they want that tie into their legacy systems. How hard will it be to gain traction when the patient is the only obvious advocate?

There’s a lot of moving parts to an ecosystem like that. I talked a little bit about what’s the technology to make the platform work. I talked a little bit about what’s the access control policy. The other big question is, who’s the audience? Who’s using these apps?

We see a very clear motivation on the side of provider organizations to be able to rapidly adopt, and even to build, new applications that serve direct business interests or direct clinical interests. We see a strong internal motivation from healthcare organizations to be able to launch new apps.

For example, we have an app that we deployed at Boston Children’s Hospital that helps take better care of children with high blood pressure. It takes data from the EHR and uses them to compute blood pressure percentiles, which are normalized by a child’s age, height, and gender. That’s how you’re supposed to make a diagnosis of high blood pressure in children, by calculating those percentiles.

The EHR has all the data, but it doesn’t do the calculation, so we built an app to do the calculation. There’s a very clear motivation on the part of the clinical organization to be able to deploy an app like that –it runs inside the hospital, runs on top of hospital data, helps take better care of patients. We can think about other kinds of apps, which might be patient-facing applications, where a patient says, "I want to use this new health management tool I found." That represents a paradigm shift for provider organizations.

It’s still an open question how internally motivated these organizations will be to let patients bring these apps to the table, but I’m very encouraged by the recent Meaningful Use Stage 3 final rule, which came out and said that patients should have the right to access their own health data using whichever apps they want.

It’s been said that people didn’t know they needed an iPhone until it came out. What would be the equivalent that would tell patients that they need interoperable health apps?

I don’t think we’ve seen our first killer app, so to speak, in this space yet, but we certainly see a strong interest along the lines of patients who are managing chronic diseases, where they have to see a number of healthcare providers and the system is not tight knit enough today that the healthcare providers from these different organizations really communicate very well. A patient is very motivated to improve that communication, so apps and tools that help them do that are a powerful selling point.

Another area which we’re only just beginning to explore is apps that help you shop around for the right healthcare services, whether it’s deciding on the healthcare insurance that’s the best fit for you given your actual usage patterns or shopping around for a procedure or drug given the insurance that you have. The more data that apps can access, both about you individually and about other patients in the ecosystem who might be like you, the better you’ll be able to make decisions that work for you.

What data sources would you need to provide an estimation of utilization? Would it be claims data plus EHR data?

I think looking at a combination of electronic health record data plus insurance claims is a very good place to start. There are some open kinds of claims data at the population level the government makes available that you can use for a very rough cut, but I think we’ll also see more partnerships being formed with aggregated data being shared that can help compute better decisions.

Geisinger formed XG Health to commercialize their apps that tie into Epic. Is that an early example of the kind of ecosystem that could be created around legacy EHRs that aren’t necessarily done through vendor-specific proprietary technology?

We’re seeing a trend in several places and Geisinger is a great early example of an institutional drive to innovate and to find a broader market based on these innovations. If you invest a lot of institutional time and money building a tool that works inside your own organization, that’s great — you can reap the benefits internally.

But more and more, there’s a desire to be able to share these tools, or sell these tools, outside of an organization. Anything you can do to build apps in a vendor-agnostic way, to build them in a standards-compliant, openly integrated fashion, lowers the cost of integrating this app with more systems downstream, makes it easier to export innovations beyond your own organization.

Vendor of mobile apps haven’t usually done the research to prove that the product improves cost or outcomes. They also often seem to target users who are already health focused. Will app developers need prove the value of what they’ve created?

I think there’s a few ways to measure the value of an application. One is to figure out how people like it and how they perceive that value. Two is to try to measure objectively how the app performs on some metrics that you define.

One of the really exciting things about this health app ecosystem is you can start to use apps as the instruments of research. We see examples of this happening along traditional institutional lines. For example, Duke Medicine has built an app that they’re using as part of a research project to evaluate how well patients know their medication regimen — how well they know which medications they’re supposed to take at which time of day. They’ve built a tool as a SMART on FHIR app that provides a patient with an interface for saying, "Here’s what I take in the morning, at noon, and at night." They’re able to drag and drop pictures of pills from a virtual pill box into these various categories. Then researchers can correlate how well patients perform at this task with other measures of medication adherence and start to figure out whether tweaking the parameters of this task can lead to improved adherence.

Whether you think that’s a great idea or not, the fact is we can use an app to do a measurement and to produce a traditional clinical research result, which you would never be able to do if you had to start from scratch and integrate this thing into the EHR just to fetch the med list. The fact that you can get the med list from the EHR and get all the patient demographics from the EHR out of the box with standards is what makes that kind of research possible.

Then we also see research happening in other new and exciting ways, for example, with mobile applications that collect data explicitly through surveys and implicitly through sensors. There’s a lot of good work happening, for example, on the iOS platform with ResearchKit in that direction today.

Are patients involved enough in the design of what they want, need, and will use instead of letting health systems manage app design?

I think the healthcare industry always struggles to figure out where and how to involve patients. Frankly, there’s a lot of bottom-up work that’s happening today in the patient application space, where companies are starting to build consumer-facing tools that don’t always make sense to the traditional healthcare ecosystem. But as consumers adopt them, we have a better and better idea of what’s really interesting and useful from the patient perspective.

I think it’s very hard for institutions, in a lot of cases, to do the right thing by involving patients. But we’re seeing very good bottom-up innovation that happens from outside of the institutions, and that might be the best indication we have of what really matters.

What do you expect to hope and see in the next five to 10 years in terms of how systems are opened up or interconnected?

Looking out to the longer term, my main hope is to see connectivity become more and more invisible, to have established pipelines where data arrive where they need to, and are available at the point of care, and are available at home without our having to take many explicit steps to make it happen.

What I’d like to see are clinical systems that understand the job that a user’s trying to do. Understand what it means to make a diagnosis or choose a correct treatment, taking into account clinical practice guidelines, the particular clinical situation at hand, taking into account patient preferences, and making it much easier to understand the risks and benefits across the board.

We need readily accessible data, both from the individual patient level and from the clinical knowledge domain. We need all those kinds of data available at the point of decision-making. My hope is that, by standardizing the core of these data access protocols, we can get there in the next five to 10 years.

Do you have any final thoughts?

From the perspective of the SMART Health IT project, we’ve seen an incredible amount of interest and enthusiasm around these APIs that, when we started building them in 2010-2011, the feedback we often got was that it felt like a science fair project and it wasn’t ready for the real world. The interesting thing is that not that much about the technology has changed, but given the overall landscape of EHR adoption and an increasing level of demand from end users for tools that fit their needs better, suddenly this technology has become incredibly mainstream in really short order. It’s been really humbling to be part of that experience.

Morning Headlines 11/11/15

Walgreens Announces New Digital Health Initiatives

Walgreens updates its app to provide users from 25 states integrated telehealth services. The company is also launching a program that will pay users 20 Walgreens Balance Points per day to sync their blood pressure or glucose monitor with the Walgreens app and log daily readings.

Physicians Use Nuance Cloud-Based Voice Recognition Solutions to Tell More than 100 Million Patient Stories Annually

Nuance reports that its cloud-based clinical voice recognition service sales are up 30 percent month-over-month since the start of the year.  Stock prices are up 20 percent over the same timeframe.

Proposed National Patient Matching Framework Dramatically Increases Health Exchange Partner Match Rates

The Sequoia Project and Care Connectivity Consortium publish a proposed framework for a national patient matching solution. They are now soliciting public feedback.

2016 Top 10 Health Technology Hazards

ECRI publishes its annual top 10 list of healthcare technology hazards, with improperly sterilized endoscope tubes topping the list. Missed alarms, poorly configured HIT workflows, and misuse of USB ports on medical devices also made the list.