Dr. Jayne Goes to AMIA-Wednesday

Today marked the closing of AMIA, with presentations in the morning and a final keynote by Robert Wachter, MD, one of the founders of the hospitalist movement. I had been looking forward to the keynote, but due to an unforeseen crisis at one of my clients, I had to leave earlier than planned. That’s the hazard of being a workforce of one. At least I have enough clean clothes in my bag to pull off an urgently-scheduled board meeting. Unfortunately, my flight was delayed, so I’m now camped out at the San Francisco airport catching up on work.

I mentioned the other day my disappointment at not being able to attend Monday’s ONC Listening Session. ONC Chief Health Information Officer Michael McCoy, MD graciously emailed me to apologize because they did indeed have room for more attendees. I sorted out the problem and the miscommunication was on my end, with my new (and very part-time) assistant confusing the ONC session with another meeting next week that I was also trying to register for. I haven’t had an assistant since I left the health system and I am reminded that “what’s the status on that meeting for Monday” is an ambiguous question. I truly appreciate his reaching out and I apologize for the confusion. I heard in passing that the session went well. I’d be interested to hear specific comments from anyone who attended.

My absolute favorite panel of the conference was on Tuesday and was titled “What Could Go Wrong? Migrating From One EHR to Another.” Since I have done quite a bit of work in the migration and conversion space, I was interested to hear how my experiences stack up against those of others. I was hoping to have the slide deck before I wrote about it, but it doesn’t look like it has been posted yet. Luckily for this session I joined the legions of people snapping pictures of the slides, since not only was it content rich, but had some outstanding clip art ideas.

The session was heavily attended. After some excessive microphone checking “check check, hey hey, check check” it was off to a great start. Richard Schreiber, MD, CMIO of Holy Spirit Hospital (a Geisinger affiliate) talked about the published research literature to date looking at system migrations. It’s scanty at best, with only five peer-reviewed studies and a few surveys. Not surprisingly, there are numerous blogs and anecdotal stories, however. One study looked at a hospital one year after migration and found heavy access of the legacy system. The hospital’s legal team consulted with AHIMA and recommended that even with a data conversion, they may need to have the legacy system live for up to 10 years in a read-only status.

Data conversions were a hot topic, specifically the fact that customers might not get what they asked for or paid for. There was discussion around the need to manage expectations around a system transition, as some sites have noted lower satisfaction due to high expectations that were unrealized. There was some interesting data in some of the studies: that 40 percent of providers are on their second, third, or even more EHRs. As practices and hospitals continue to consolidate, this will only continue. My former employer is on its second ambulatory EHR headed for its third and is consolidating multiple hospital systems into one. Schreiber noted that EHR changes often accompany cultural and political shifts in addition to ownership changes.

He went on to talk about the “think freeze” that occurs around EHR upgrades. Because of code cut-offs and system and environment freezes there is less consideration of what the end users need. With a migration, this is even worse, with that freeze occurring for potentially years rather than months or weeks as the organization prepares for the transition. Community hospitals are particularly challenged by a lack of resources, training, and support. Physicians experience “large efforts with small teams” that mean “army swarms and then retreats.” For providers who aren’t in the hospital consistently, they may have limited support after a go-live.

Sociologist Ross Koppel, PhD of the University of Pennsylvania then took the podium. I got a kick out of the fact that his bio in the AMIA app lists him as, “Among most hated by some vendors, but appreciated by clinicians.” He talked about the fact that the average hospital has between 150 and 400 separate IT systems that link with the clinical system, not counting outside systems such as reference laboratories. “Each one is an opportunity for a screw-up” also known as a “vulnerability.” He talked about how “hospitals are unique fiefdoms” and the fact that new systems bring a loss of institutional memory, such as the work-around done by a unit secretary to actually get things done for patient care.

He discussed the problems that customization can cause with system migrations. Looking at two different Epic systems in neighboring hospitals revealed that the systems were related “like Spanish and Italian” but that “data and interfaces differed enough that assumptions of similarities could be treacherous.” Having gone live on Epic at two community hospitals in the same summer several years ago, I can agree with that assertion. Koppel also discussed issues with calculating return on investment and the difficulties with hospital bookkeeping on some projects. ROI research is also commonly done by vendors, confounding the issue. He discussed the $1.7 billion implementation at Harvard as being $400 million in software, $700 million for Deloitte, and the rest internal.

The next presenter was John McGreevey III, MD of the University of Pennsylvania, talking about the PennChart project. With six hospitals, 2,524 beds, and 84,000 admissions a year, this is a massive project. He talked about their lessons learned:

• Not enough operational leaders. He felt they needed three to four times what they had.
• No health system budget for clinical subject matter experts to design note templates, order set content, etc. EHR tasks were added on to their regular responsibilities. Doing a project like this without SMEs and adequate human infrastructure is like a fire department that tries to fight a house fire by hiring firefighters after it’s already started and paying them zero.
• Not enough “internal housekeeping” prior to the project. He stated that after signing a contract, vendors should tell the hospital “thanks for your check – call us in a year” after you’ve done your housekeeping.
• Vendor liaisons were relatively green – most had only one or two implementations under their belts. They could not cite definitive best practices from other academic medical centers or make good recommendations about decisions. He did note, though, that other customers were very gracious with their time despite being heads-down in their own implementations. This might be a future role for AMIA, as a clearinghouse for best practices.
• Build decisions may have created barriers to interoperability. Standardized approaches to naming, organizing data, etc. are needed. This results in “big data we can’t use and can’t share.” Vendor guidance often oversimplified complex decisions, leading to rework.
• Siloed project teams led to lack of understanding, fragmented work, and wasted time.
• They got a late start on changed management, leading to lack of shared urgency or mission. He recommends “bathing the organization” in change management before any work starts, not just before go-live.

Catherine Craven, MLS, MA of the University of Missouri closed out the panel talking about system migrations among Critical Access Hospitals. There is even less data on these hospitals, because as of 2010, fewer than 3 percent had EHRs. A good number of facilities (300) haven’t attested for MU Stage 1 yet, although 150 did receive Adopt/Implement/Upgrade funding. She completed her doctoral dissertation last year and studied four hospitals. The statistics are shocking: many CAHs have less than 30 days’ cash on hand and often the cost of an EHR is between 75 percent and 100 percent of total cash assets. In other words, these hospitals have to bet the farm on their EHR project. Craven did an excellent Peggy Lee impersonation.

She went on to note that the CAHs she visited did only basic installations without workflow transformation. They often relied wholly on vendors because there was no budget for consultants. They were also rushing to implement, with one hospital having less than five months from contract signing to its go-live.

Tuesday afternoon I ran into a friend from the VA and attended a session on human factors. The room was packed as presenters shared their work. Topics included observational studies of user workflow while accessing both the EHR and a RHIO, cognitive demands of EHR via task analysis, and cognitive support for ICU data. I noticed Brian Dixon in the front row with his jacket from The Walking Gallery, but wasn’t fast enough to get a picture.

Throughout the conference, there were a couple of things nagging at me, although they are decidedly first-world problems compared to the plight of the many homeless in San Francisco:

• The use of “MD” as a substitute for physician, not only in presentations, but in the official printed publications. There are plenty of DO informaticists and international physicians with slightly different degrees.
• Interchangeable use of the terms “sex” and “gender.” Especially among people who are talking regularly about coded data and the need for specificity and interoperability, it’s time to learn the difference between the two.
• Continued references to Epic, even if they’re veiled. We know it’s the predominant system among academic medical centers, but it’s not the only system out there. I got a kick out of two physician users of a less-prominent EHR vendor who looked at each other and said, “Ours does that” when the speaker lamented a particular lack of Epic functionality.
• Late arrivals. The conference encourages people to drop in and out of sessions to “follow the conference buzz,” but that doesn’t mean you need to enter the room like a herd of elephants or climb over and disrupt those that area already there.
• Seating arrangements included excessively close chairs that nearly prevented people from sitting next to each other unless they were both less than 14 inches wide. This led to a lot of empty chairs between people, but that made it a little easier for those with large bags that they’re using as a mobile office. Also the rows were close front to back, making it difficult for people to slip in and out without tripping over legs, feet, and bags.

On the flip side, I was happy to see one of the presenter’s children at the conference, complete with badge and ribbons. I’m sure the conference was a highlight for both of them. I also saw a couple of dogs at the conference, which made me chuckle. They didn’t appear to be service or support dogs, but they were well behaved.

I was considering attending AMIA’s iHealth conference in May since its more focused on clinical and operational informatics. I may already have something on the docket for that week, but would be interested to hear people’s impressions on that conference’s usefulness to CMIOs vs. the annual symposium. I want to make the most of my conference budget, and considering that this one set me back almost $3,500, I want to choose wisely. For those of you in the MOC trenches, that’s nearly $175/hour for the sessions I attended.

What’s your favorite conference? Email me.

Email Dr. Jayne.

Morning Headlines 11/19/15

U.S. Department of Health and Human Services Joins OptumLabs

HHS partners with OptumLabs to bring its data analytics capabilities to the agency’s researchers. The first research project will be led by AHRQ, which will compare Optum’s healthcare utilization database to its own Medical Expenditure Panel Survey dataset.

CHIME Letter To CMS Acting Administrator Andy Slavitt

CHIME sends a letter to CMS arguing that the MU program and quality reporting requirements will need to be streamlined if health systems are going to transition to value-based reimbursement models fast enough to meet transition goals outlined by HHS.

Software is now eating medicine

Andreessen Horowitz Partners announces a $200 million investment fund that it will direct toward digital health startups, specifically those working at the intersection of health data and machine learning.

CVS Health Introduces New Digital Pharmacy Tools to Help Make Medication Adherence Easier and More Convenient

CVS launches a new app that generates medication reminders and allows users to submit prescriptions and insurance cards by taking a picture of them

HIStalk Interviews Michael Pirron, CEO, Impact Makers

Michael Pirron, MBA, PMP is founder and CEO of Impact Makers of Richmond, VA.

Tell me about yourself and the company.

I am a former Andersen Consulting professional who has done both an undergraduate degree and MBA at Kellogg School of Management at Northwestern.

Impact Makers is an IT consulting firm, fully owned by two public charities. If we’re sold, all proceeds from that sale will go to make in-perpetuity community  impact as well as to impact investments in social enterprises.

Our work is project and program management, process improvement work, management consulting for the CIO, governance risk and compliance, and security work. Also digital strategy and mobile and web implementation. The majority of our work is in the healthcare space, both payer and provider, as well as healthcare governmental agencies.

Why would a for-profit company donate all of its profit to charity?

I guess it started with me. I’ll take full blame. I was fascinated in my undergraduate degree with reading a business case on Newman’s Own. We are essentially the Newman’s Own of IT consulting. Newman’s Own is Paul Newman on the side of salad dressing, but they’re a for-profit company that gives all profits to charity and is fully owned by a foundation. I was fascinated by that business case.

I went to work with Andersen Consulting, overseas mostly, and found that I was good at what I did. But I wasn’t necessarily values-aligned with some of our clients that I worked at. As well, the company culture tended to be very money-focused and individual-focused. I found it compelling to think of an idea of creating an Andersen Consulting on the Newman’s Own model. I wrote a paper about it when I went to do my MBA with that in mind.

Non-profits and government do a lot in the world to solve social and environmental problems. I am a capitalist. I have business degrees. But figuring out how to use the power of the free market to solve social and environmental problems instead of  government handouts or non-profits is something that spoke to me. It has actually gotten bipartisan support, which doesn’t happen much these days in the world.

I guess that’s the purpose. How do you transform individuals’ skills, experience, and training through their professional work every day to not just deliver client value and do all the things of job creation that any other for-profit would do, but also not be just a good steward in the world, but actually make a real impact in the world at the same time. Then what does that do for our employees in terms of personal growth and satisfaction? Not just job satisfaction, but speaking to everyone’s desire to leave the world a better place than the way they found it.

It’s interesting that your company is a for-profit that acts like a non-profit, while your non-profit health system customers make dozens of millions of dollars just like a for-profit company. Does it seem strange to explain to a non-profit health system what it’s like being a mission-driven organization?

That’s why healthcare has worked so well for us. So many people in the healthcare industry really care about patients, really care about patient outcomes, and have a deep culture of caring for their members and patients. That culture of caring and wanting to make a difference is pervasive in healthcare. It’s the reason we like working in the healthcare space and why it’s been such a good market for us.

It’s obviously an easy sell to the non-profit healthcare organizations we’ve worked with, although I would say it’s probably about 50-50 in terms of nonprofit and for-profit. We work with large national payers, providers, and healthcare government agencies. Probably a little bit more than half are on the non-profit or governmental side. Newman’s Own, which is a wonderful organization, sells using not just that it has a good product, but it uses cause-based marketing. There’s this class of conscientious consumers that buys socially impactful products.

We’re B to B — we’re not B to C — and we’re services. Our clients buy on capabilities and price. While our model is interesting to C-level folks who care about the company’s community impact footprint, really we’re competing on capabilities and price. As a for-profit company, I think that’s a good thing.

Sixty percent of our work comes from existing clients. It might get us in the door to talk to a C-level person or it might be a tie-breaker on a competitive bid, but that hasn’t been the reason we’ve won work. Although there’s been this immediate mission alignment with some of our non-profit healthcare partners, as you mentioned, which I think helps with the relationship long-term.

An article announcing that you’ve been named to the Inner City 100 list of fastest-growing inner city businesses had a picture of your cool offices. What attracts an employee to a fun, urban location instead of a faceless glass building in a suburban office park?

We’re in Richmond, Virginia, in a warehouse district that’s being renovated. All the warehouses are being turned into breweries and various interesting businesses. It is also a big hipster community. It’s a trendy area in Richmond, which is a wonderful place, You don’t always associate Richmond, Virginia — the home of the Confederacy — with hipsters.

It’s a really neat space. It’s accessible to public transportation. We have solar panels on our roof, which provide 25 percent of our electricity. It was aligned with being in the city. It was aligned with our values and with environmental impact standards. We’re founding B Corp, so we try to not just focus on social impact, but environmental impact and all of those things as well.

It was a good space. It was aligned with our values and aligned with a lot of our staff’s values. It’s an open office environment. People like to work in the space. Although our clients don’t hire us for our model as an IT consulting firm, we’ve had amazing retention. We’ve been Inc. 500 three years in a row and  Inc. 5000 four years in a row. 

The reason we’ve been successful isn’t our model, but because employees want to come work for us and stay. We’ve had 10 people leave in nine years. If you know the IT consulting industry, that’s an unbelievably amazing retention rate. People want to work for a company that’s mission-valued, mission-aligned. That creates values for our clients because our clients get employees that stay for the entire duration of a project. Mission-aligned teams outperform ones that aren’t mission-aligned, all else being equal.

What’s the state of healthcare IT consulting compared to a couple of years ago when everybody was mostly focused on Meaningful Use and ICD-10?

We’re seeing this tremendous interest in transformation, as a keyword, caused by a bigger interest in consumer-focused healthcare and this whole interest in the Triple Aim concept that we’re seeing from our clients – quality, access, and reliability. Those things combined are creating this enormous interest in transformation, whether that’s digital transformation or even just core operational function. Looking holistically at the organization, doing organizational assessment work to align around those goals and values.There’s also the obvious trend of mergers and acquisitions going on across the space.

Those three things — Triple Aim, mergers and acquisitions, and the focus of on consumer-focused healthcare – are revolutionizing the space and creating these large transformation projects that look across security, digital, organizational structure, and how to best align both from an IT perspective as well as a business perspective for delivery. We’ve been really focused on these large, enterprise-wide transformation projects for assessing, planning, designing, implementing these efforts and managing the delivery of those efforts.

Slow-moving and change-resistant health systems are being asked to respond quickly and to assimilate cultures thrown together by merger and acquisition. What are they doing to address their cultural lethargy?

I think it’s streamlining. We’re helping both payers and providers in these transformational roadmaps. We’re seeing a common denominator being, whether it’s Triple Aim or others, that technology needs to provide the right customer engagement, the right information at the right time with optimal cost. It all sounds so obvious, but as you said, they’re really moving into a brave new world that maybe other industries has already transformed themselves and healthcare is being pulled into that same transition.

Providers are suddenly interested in patient engagement now that there’s a financial carrot in place. Why did it take so long to bring patients to the table?

We’re seeing governmental programs and payers creating a financial incentive for providers – whether it’s accountable care organizations, medical homes, or any of the various models – in paying for performance and paying for outcomes. Those things require direct patient engagement and consumer focus, almost like a retail organization would. They need to be creative and not only to do the right thing for the patient, also to be successful financially.

What are providers doing to change from a "here we are, come knock on our door to get services” model to reaching out like a traditional company might do?

There are a number of trends. The one that we’ve been focused on is making sure that we make that connection between the patient and provider. Not the hospital provider, but the individual physician or specialist. Interactive smart provider search engines that are very specific and unique that  make sure the patient with the right keywords get to the right specialist they’re looking for at the right time. Trying to make sure that that interaction happens. For health systems, that it’s the physician that’s within their health system. There’s a desire to ensure the patient stays within the system.

Secondly, using mobile technology to interact with the physician specialist and patients in a way that enhances clinical outcomes. It has to be a secure way, of course.

Those are the areas where we focused within the digital framework to ensure consumer engagement.

Short of changing their business structure, what can companies do to make a social difference beyond the usual employee volunteer day?

We have the ownership structure, but we also give up to 30 percent of our operating margin away to local charitable organizations that are secular, apolitical, 501(c)(3), local to where we do work, and that help people help themselves. We’re governed by a volunteer board. I’m the founder of the company, but I don’t own any of it. Our volunteer board chooses these partners.

Whether you give 30 percent or 10 percent, choose mission-aligned partners that might be aligned in the healthcare space — if you’re doing healthcare consulting  — to support. Make that part of your brand. That’s meaningful to employees. You don’t have to do 100 percent over the life of the company like we do. Even 10 percent or 15 percent is meaningful. Doing good is good business, too. It adds to the value of the brand. It adds to your own employee engagement in what you’re doing.

We also do pro bono consulting for our charitable partners. Having employees being able to, during work hours, work at client sites is meaningful to employees and is a benefit to employees and creates community impact. Having a mission and leading with values. We started with mission and then our values came from that. That’s been the true reason why we’ve been successful, because we are absolutely values-based. Doing the right thing is critical for both clients and employees.

Our executive team says, do the right thing for our client. Do the right thing ethically and morally. If you have to make a decision with the client without going up the chain and you do it, as long as you do the right thing, we’ve got your back.

Having those strong values and articulating those values often. Our performance review process is tied starting to our values at the highest level, and everything follows from there. We repeat that often at every company meeting.

Then the final thing is we’re a founding B corporation, which is a certification standard for companies that aren’t just about making profit, but also taking into consideration the environment, employees, and community and aren’t just about maximizing shareholder value, although they’re all for-profit companies. Companies like Patagonia, Ben and Jerry’s, and Etsy that just went public are shining examples of B corporations. It’s a community, internationally now, of 1,400 companies that are focused on making a difference using the power of the free market to solve social and environmental problems. Any company that has a mission to make a difference can consider that to be part of something bigger than just the company that they’re doing and help spread that ethos within business.

Do you have any final thoughts?

What we’re doing is pretty game-changing. It’s pretty disruptive, actually. If you think about what we’re doing, we’re a group of middle-class professionals doing the same work we’ve always done, but structuring it differently, and collectively making the same impact in the community as foundations, and eventually large foundations.

Our goal is to have, in the next seven to 10 years, a sale of the company that puts $120 million into these foundations that will make in-perpetuity impact and create more Impact Makers through the investments that they do. Not doing it at the expense of employees, because we pay market salaries to employees, and have employees share a little bit in the value that’s created. At the same, have a way to raise capital from the capital markets. We’re in the process of raising preferred stock equity in a way that is still aligned with our model and is largely from the non-profit world.

If we can solve that, that’s creating a new model that no one has ever done before. It’s democratizing philanthropy in a way that’s not even done. I think that’s the disruption, that group of middle class professionals structuring things differently and collectively making an impact in the community like has never been done before.

Dr. Jayne Goes to AMIA–Tuesday

Another busy day at AMIA today. I started the morning with a panel, “Looking Back and Moving Forward: A Review of Public Health Informatics.” Neither of these disciplines is something I do in my daily work, but I’ve always been interested in public health, so I thought I’d check it out.

I admit that global health is entirely outside my comfort zone, but was interested in learning more. I appreciated that the presenters spelled out how the articles and events were selected for review as well as their admission that they slides weren’t quite ready to share with the world yet. I’ve been hunting for presentation slides all week without much luck. They shared a URL link to a Google drive, but said it may be a few days before everything is available. I’m looking forward to getting them.

Presenter Brian Dixon shared a couple of interesting vignettes:

• In one study looking at provider prompts for immunizations, there was no difference between the control and the intervention. The clinical decision support intervention didn’t use data from the immunization information system, only from the local EHR. The authors believe this may be part of the problem. I was surprised that there was no difference, but that’s why we do research.
• Another study looked at direct to consumer portals for self-testing regarding sexually transmitted infections. Essentially patients could go online anonymously and request a testing kit, which was to be mailed to the lab. They could receive their results securely, and if they tested positive, receive a prescription via eRx or telephone. They didn’t have to actually present to a healthcare provider. Out of the thousands of patients eligible, only a few hundred followed through. I would have thought the uptake would be higher since testing in the privacy of one’s home is less embarrassing than going to the office.
• Another study looking at healthcare-acquired infections concluded that most research is done in academic medical centers or the VA, institutions with “considerable financial resources” and technical skills not widely available. Dixon noted that although people in those settings likely feel they never have enough resources, they’re relatively wealthy compared to some public health settings.
• The Biosense surveillance system was rebranded this year to the National Syndromic Surveillance Program and moved to the cloud. The goal is to have it be more about disease surveillance and less about bioterrorism detection, but how well that is achieved remains to be seen.
• Public health applications aren’t just about MU anymore. This year there was a rise in use of mobile solutions, patient portals, and social media. The research base for public health informatics is increasing.

The presentation shifted to global health informatics with presenter Jamie Pina, who explained that typically these are resource-constrained environments and are defined as “low- and middle-income countries” based on the World Bank definitions. Often there is external or donor funding, such as philanthropies or other countries. There is generally a weak market for global health informatics products, so organizations typically use open source or homegrown tools. There were many articles on mHealth and telehealth found in their review.

There are data quality challenges and other limitations, including the fact that traditional medicine doesn’t fall into the same paradigm or concepts that we have in what we consider modern medicine. One study from Bangladesh looked at linking local traditional medicine practitioners with trained physicians through a call center. Another study found (no surprise here) “cultural misalignment between IT and healthcare providers” in Botswana. At least something is consistent globally. Other notable facts: 80 percent of users in rural Africa are computer illiterate or beginners, but more than 95 percent have a positive attitude towards computers. He did also mention the end of the current Ebola crisis as a notable event that solidified the need for attention to global health issues. Programs are starting to focus on implementing the lessons learned from that crisis.

There was also some buzz today about changes to the clinical pathway for board certification in Clinical Informatics. I had a couple of people ask me if I heard anything, but I admit I didn’t. Hopefully someone in the know will see this and provide an update if there really is going to be a change.

I’m going to save writing about my favorite presentation of the day until the slides are available. Some of the ideas put forth are just too good not to share. Of note, today’s multitasking included some impressive knitting by one attendee who was using nearly microscopic needles. I never figured out what she was making, but it was fun to watch.

I ducked out for lunch at the Ferry Building Marketplace with the always-entertaining Matthew Holt. He had just returned from a whirlwind trip including Japan, Finland, the UK, Seattle, and finally San Francisco. There were many stories of lost baggage and adventures including the most polite people in the universe (Japan) and time in the sauna (Finland). Our conversation ranged all over the place and included startups, conferences, HIMSS preparations, and the exorbitant cost of Epic projects. My adventures are not nearly so interesting, but he humored me in listening to stories about my current practice situation (which I dearly love) and my ongoing consulting road show. Next stop, Des Moines!

I hustled back to the conference and caught a panel on “Needs of the Digital Native: Adolescents and Access to PHRs.” It was one of the more compelling panels I attended, with speaker Pam Charney talking about her own experience as a parent of a child with medically complex issues. In her state, patients can’t have access to personal health records or patient portals after age 13 to when they turn 18, which created a lot of complexity due to the loss of online scheduling, secure messaging, and test results. Rather than being able to manage her daughter’s health online, she became trapped in an ongoing maze of phone calls, faxes, and lost test results.

Speaker Fabienne Bourgeois has it a little easier in Massachusetts, where there can be graduated changes in access for adolescents. They initially had a parental consent requirement for portal access, but dropped it after a large number of obviously forged consent forms were returned. She provided an excellent discussion on the various needs of flagging data by category (HIV diagnoses and labs) vs. by patient or provider tagging. Catherine Arnott Smith noted that there have been only 13 studies on PHR use in adolescents and young adults since 1991, which is pretty thin. She gave an excellent discussion of academic accommodations for young adults after they leave the K-12 education system. These patients go from a system where their family is involved in advocating for them to one where they have to advocate for themselves, often without a full understanding of their medical history.

Consider the scenario of a child who turns 18 while away at college and whose parents no longer have access to health information. He or she is expected to manage on his or her own, and if there hasn’t been enough education or transition prior, it can be disastrous. Apparently the process for seeking academic accommodations resembles that for Social Security Disability. Having helped patients through the latter, I can’t imagine trying to manage the reams of data required while adjusting to life as a college freshman. Healthcare entities are often not helpful because they send reams of patient notes and data which may not be relevant or useful to the college in determining a valid disability requiring accommodation. My favorite comment of the day was from an audience member who highlighted the need for “a curated record vs. a raw sewage record.”

There were additional questions and comments on the fact that EHR data is much like the proverbial “permanent record” many of us feared in school – that it persists and can follow adolescents into adulthood, potentially creating difficulties when behavioral health diagnoses may be present. Attendee Adam Davis stated, “EHR is forever, but paper dies.” It’s definitely something to think about in the digital age.

On the fashion and social front, I’m happy to report that overall, bowties are leading standard neckties by a factor of six to one, although I feel I should give double credit to the attendee who paired his traditional tie with a snappy vest. After hitting another panel and a corporate member focus group, I headed out to dinner with some industry movers and shakers. On the way back I breezed by the Dance Party social event, which had several attendees cutting a rug and others continuing to network. By this time, though, my toes were tired and my brain was lagging, so I decided to call it a night.

Tune in tomorrow when I’ll cover the rest of Tuesday’s sessions and wrap up my overall thoughts of the conference.

Email Dr. Jayne.

Morning Headlines 11/18/15

Policy: Certified Technology Comparison Task Force

ONC holds its first Certified Technology Task Force meeting. The group will research and make recommendations on the development of an EHR comparison tool. It will present its findings on January 20.

Cerner raises concerns about Loftin’s new role

Cerner sends a letter to the University of Missouri expressing concerns over its transition plan for Chancellor R. Bowen Loftin in the wake of his announced resignation. Loftin was offered a position as the director of university research at the Tiger Institute for Health Innovation, an organization co-managed by Cerner and UofM.

Does Cambridge University Hospital’s Epic project indicate NHS lacks capacity?

In England, insiders working at Cambridge University Hospital describe the internal culture during an Epic implementation that ultimately led to the resignation of the Trust’s CEO and CFO, saying “There was a plan, there was a vision and it was going to happen. There was no sense or reason to the process, it was bloody-mindedness.”

App Orchard – Trademark Details

Epic secures a trademark for “app orchard,” the name it will use for its upcoming app store.

News 11/18/15

Top News

The Certified Technology Comparison Task Force of ONC’s HITPC held its kickoff meeting Tuesday. The task force is charged with developing a Consumer Reports-type EHR comparison tool.

Reader Comments

From IsIT True: “Re: Daniel Barchi, CIO of Yale New Haven Health System. He will succeed Aurelia Boyer, CIO at New York-Presbyterian, when she retires this year.” I asked Daniel, who verifies that he will be leaving YNHHS and the Yale School of Medicine at the end of this month, joining New York-Presbyterian as CIO in December.

From Repurposed Turkey: “Re: Southern Illinois Healthcare. Has selected Epic to replace Meditech, NextGen, and McKesson Practice Partner. Epic jobs have been posted.”

HIStalk Announcements and Requests

Welcome to new HIStalk Platinum Sponsor National Decision Support Company, the exclusive distributor of ACR Select, the American College of Radiology’s Appropriateness Criteria (ACR AC) that supports value-based imaging. It offers integration-ready Web services  that allow healthcare organizations to present evidence-based ACR AC guidelines to ensure that the right patient gets the right scan for the right indication. Up to 10 percent of the rapidly growing number of diagnostic imaging orders are medically unjustified or duplicated, causing needless expense and excessive patient radiation exposure. National Decision Support Company provides physicians with guidance as they enter orders, presenting an appropriateness score for the selected modality and indications and prompts them to consult a radiologist when appropriate. The score can also be silently recorded to help health systems understand and manage quality improvement opportunities. Medicare will in 2017 require ordering physicians to prove that they have reviewed Appropriate Use Criteria when ordering MRI, CT, nuclear medicine, and PET. Thanks to National Decision Support Company for supporting HIStalk.

Mrs. Buscho from Colorado sent photos of her English as a Second Language students using the tablet and keyboard we provided via DonorsChoose, saying they use it to look up photos and words to boost their vocabularies. Ms. Cassidy says her class of students with autism is using the set of 22 instructional CDs we bought for interactive circle time, with non-verbal students now able to point at the screen to answer questions and remain part of the group.

I ran across 100Kin10, a New York non-profit whose goal is to train and place 100,000 new STEM teachers by 2021. It has 230 public and private partners and has placed 28,000 teachers so far since it was formed in 2011 in response to President Obama’s challenge. Teacher candidates from all walks of life complete a nine-month program.

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 2 (Wednesday) 1:00 ET. “Tackling Data Governance: Doctors Hospital at Renaissance’s Strategy for Consistent Analysis.” Sponsored by Premier, Inc. Presenters: Kassie Wu, director of application services, Doctors Hospital at Renaissance; Alex Eastman, senior director of enterprise solutions, Premier, Inc. How many definitions of “complications” (or “cost” or “length of stay”…) do you have? Doctors Hospital at Renaissance understood that inconsistent use of data and definitions was creating inconsistent and untrusted analysis. Join us to hear about their journey towards analytics maturity, including a strategy to drive consistency in the way they use, calculate, and communicate insights across departments.

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.

December 9 (Wednesday) 1:00 ET. “The Health Care Payment Evolution: Maximizing Value Through Technology.” Sponsored by Medicity. Presenter: Charles D. Kennedy, MD, chief population health officer, Healthagen. This presentation will provide a brief history of the ACO Pioneer and MSSP programs and will discuss current market trends and drivers and the federal government’s response to them. Learn what’s coming in the next generation of programs such as the Merit-Based Incentive Payment System (MIPS) and the role technology plays in driving the evolution of a new healthcare marketplace.

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

Acquisitions, Funding, Business, and Stock

Real-time ADT notifications vendor PatientPing raises $9.6 million from investors that include Google Ventures. The Boston-based company was founded by David Berkowicz, MBChB (Massachusetts General Hospital), Jay Desai (Center for Medicare and Medicaid Innovation), and Lara Sinicropi-Yao (Kyruus). 

Medical scribe provider ScribeAmerica acquires Essia Health, the third competitor the company has absorbed this year.

Sales

Gifford Medical Center (VT) chooses Medhost’s EDIS.

An unnamed “large German government hospital” selects the Visage 7 Enterprise Imaging Platform.

An unnamed Texas ACO chooses ZeOmega’s Jiva population health management solution.

Anne Arundel Medical Center (MD) selects receiving dock software from Jump Technologies. The company is fully confident that everyone who reads its press release already knows or doesn’t care that the hospital is in Annapolis, MD since it failed to mention that fact in its announcement.

People

Shannon Epps joins Divurgent as VP of activation management.

Fujifilm Medical Systems names Johann Fernando, PhD (Accuray) as COO and promotes Diku Mandavia, MD to chief medical officer.

Paul Kleeberg, MD (Stratis Health) joins Aledade as medical director.

Announcements and Implementations

Spok chooses Guthrie Clinic (PA) as winner of its innovation award for having OR nurses text updates to patient families using the company’s Spok Mobile secure texting app.

Nuance announces PowerScribe 360 version 3.5, which includes multimedia reports with embedded PACS images, advanced lung cancer screening registry reporting, and enhanced quality guidance content for radiologists at the point of documentation. The company will demonstrate the product at RSNA.

HealthMyne integrates Epic EHR information into its quantitative imaging analytics platform.

Inspira Health Network (NJ) announces a 26 percent increase in HCAHPS scores for hospital quietness at one of its hospitals that deployed Practice Unite’s communications solution to reduce overhead pages at night.

Privacy and Security

Microsoft announces formation of a 24×7 Cyber Defense Operations Center to detect and respond to threats.

A survey finds that most people don’t mind sharing their health information with their physician and their family, but the percentage expressing a willingness to share drops off considerably after those two. Patients don’t want the government seeing their information, perhaps unaware that CMS knows just about everything about those on Medicare unless they choose to pay cash instead.

A federal judge dismisses an action brought against lab testing firm LabMD by the Federal Trade Commission, which claimed that consumers were injured in two old data security incidents. The first incident was reported by Tiversa, a security vendor who was trying to sell its services to LabMD. A former Tiversa sales manager said its warning to LabMD was “the usual sales pitch” and said no breach actually occurred. The second involved documents recovered in an identity theft investigation. The judge ruled that any consumer risk was theoretical and scolded the FTC for relying on Tiversa’s “unreliable” claims. It appears that Tiversa is still in business selling peer-to-peer cyberintelligence services, while LabMD shut down after being buried in court costs and customer defection due to the now-dismissed charges. LabMD was never charged with a HIPAA violation, only with deceptive trade practices, which seems to make little sense in this case (as the judge validated).

Innovation and Research

Keith “Motorcycle Guy” Boone urges licensed providers to complete an HL7 survey that seeks to determine which data elements are needed to support continuity of care.

Technology

India-based Practo will offer Uber integration with its doctor search app in India, Singapore, Philippines, and Indonesia. It will give users a “call Uber” button along with their appointment reminder so they can get a ride.

Other

Cerner protests the terms under which University of Missouri Chancellor R. Bowen Loftin accepted a demotion following student protests that also triggered the resignation of the president of the entire university system. The separation agreement between Loftin and the university says he will take a leadership role with the Tiger Institute for Health Innovation, which is a partnership of the university and Cerner. Cerner wants references to Cerner and the Tiger institute removed from the agreement, saying that Cerner as a partner should have been consulted or notified in advance before Loftin was promised that role.

Epic trademarks App Orchard as the name of its upcoming app store.

A Politico article recently claimed that Connecticut’s attorney general “has reportedly opened investigations into Epic Systems and hospital networks” for information blocking. I emailed the Connecticut AG and received the response above. That’s Strike 2 against Politico, which previously stirred up a lot of hot air about non-existent EHR gag clauses in a much-cited article that offered no proof whatsoever.

Michael Arambula, MD, PharmD, president of the Texas Medical Board, defends the board against the “continued widespread perception that Texas is behind the times and restricting access to healthcare when it comes to telemedicine.” He was responding to a previous editorial that criticized the board’s requirement that doctors conduct a face-to-face exam on a patient before treating them by video visit. Arambula says “there are very few telemedicine scenarios which are prohibited in Texas.”

AMA President Steven Stack, MD says physicians can’t be blamed for IT failures. By that logic, all automobile accidents, including those caused by careless or unskilled drivers, are the fault of car manufacturers.

In England, insiders at Cambridge University Hospital NHS Foundation Trust blame its struggling Epic implementation on an unrealistic budget, an overly aggressive timeline, and inadequate user training.

A judge will hear the case of two IT professionals who were fired from their jobs at the decommissioned Hanford nuclear power plant in Washington after they complained that the company’s EHR was not tracking medical restrictions correctly. OSHA had previously ordered contractor Computer Sciences Corporation to pay the pair $186,000 in back wages.

Weird News Andy notes that one of several failed insurance co-ops, New York’s Health Republic, may stick hospitals with the $160 million it owes them now that the state has shut it down. The failed insurance company owes physician practices “tens of millions of dollars” as well. The state has ordered the insurer to stop paying some claims even though providers are still contractually obligated to keep providing services to its policyholders. New York denied part of the insurer’s rate hike request earlier this year even though it knew it was failing financially.

Sponsor Updates

• Medical staff scheduling system vendor Lightning Bolt Partners will integrate its product with Imprivata Cortext.
• AdvancedMD reports a smooth ICD-10 transition for its independence practice customers and billing services partners, with 100 percent of them ready on October 1 and the first practice receiving ICD-10 payment seven days after.
• Huntzinger Management Group is named as one of the consulting industry’s fastest-growing firms.
• Premier posts a promotional video for PremierConnect Enterprise.
• EClinicalWorks will exhibit at the New York Health Plan Association 2015 Annual Conference November 18-19 in Albany.
• SyTrue’s natural language processing technology is featured in “Unlocking the Value in Unstructured Data.”
• Healthcare Call Center Times features Healthfinch client Essentia Health’s efficiency gains.
• Built in Colorado ranks Healthgrades ninth in its list of Top 100 Colorado Tech Companies.
• Huntzinger Management Group ranks tenth in Consulting Magazine’s list of fastest growing firms.
• Burwood Group is recognized as a Cisco TelePresence Video Master Authorized Technology Provider Partner.

Blog Posts

• Market Trends: Alarms Moved to #2 on ECRI’s Health Technology Hazards List (Extension Healthcare)
• Galeneers Volunteer: Healing Rides (Galen Healthcare Solutions)
• 5 Steps to Prepare Your Organization for Value-Based Care (Hayes Management Consulting)
• Open Payments: Reporting Changes & Enforcement Actions (Healthcare Data Solutions)
• Measuring the Mission (Healthwise)
• Increase practice revenue through benchmarking, steps 1 and 2 of 5 (AdvancedMD)
• AirWatch 8.2 Has Arrived (AirWatch)
• Bipartisan Budget Act of 2015 changes how Medicare pays for off-campus outpatient services (Besler Consulting)

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. 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.