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Morning Headlines 12/2/15

December 2, 2015 Headlines Comments Off on Morning Headlines 12/2/15

Joint: API Task Force

The Health IT Policy Committee’s API Security Task Force, organized to work through security issues associated with an open API infrastructure, held its first meeting this week.

Allscripts Announces Share Repurchase Program

Allscripts announces that it will repurchase up to $150 million of its common stock, representing 5.2 percent of the company’s outstanding shares.

Why the US Pays More Than Other Countries for Drugs

The Wall Street Journal analyzes the many forces contributing to exorbitant drug prices in the US, compared to other developed nations.

UNC, Duke hospitals post record 2015 revenue as WakeMed reports loss

WakeMed (NC) posts a $50 million operating loss for its 2015 fiscal year, blaming the loss on a number of one-time expenses including its Epic implementation, construction of a new 61-bed hospital, and operating a chronic disease management program.

Comments Off on Morning Headlines 12/2/15

News 12/2/15

December 1, 2015 News 5 Comments

Top News

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The Health IT Policy Committee’s API Security Task Force held its first meeting Monday, co-chaired by Josh Mandel (Harvard Medical School) and Meg Marshall (Cerner). The group is charged with identifying privacy and security issues with open APIs. Its next meeting is this week.


Reader Comments

From Frying Burrito Brother: “Re: DonorsChoose. Our company would like to donate and I don’t see instructions.” I have matching money left, which I will apply to your donation made as follows:

  1. Purchase a gift card in the amount you’d like to donate.
  2. Send the gift card by the email option to mr_histalk@histalk.com (that’s my DonorsChoose account).
  3. I’ll be notified of your donation and you can print your own receipt for tax purposes.
  4. I’ll pool the money, apply the matching funds, and publicly report here (as I always do) which projects I funded, with an emphasis on STEM-related projects as the matching funds donor prefers.

From Equine Hindquarters: “Re: EHR databases. You wrote a long time ago that they should all use the same basic schema and compete on additional tables as well as their UI.” I’ll update my suggestion as follows. Each EHR should contain a basic set of tables with a universal format so that any authorized party can retrieve patient demographics, visits, medication lists, etc. That eliminates the need to convert proprietary tables or run the query through an HIE that may or may not be translating correctly. That also places onus for the data accuracy and completeness on the EHR vendor, who is best equipped to manage that task. Those interoperability tables would be separate from the existing EHR tables to avoid exposing proprietary information or methods. It’s like exporting a CCDA or other document except that it resides permanently in the vendor’s database with real-time updates and could be accessed via standard APIs with minimal effort or system knowledge. The vendors know their own systems, so let them populate these standard tables instead of forcing everybody who needs access to their patient information to figure it out for themselves.

From Pippi Longstocking: “Re: Microsoft Lync. Does anyone know of an acute care facility that has fully converted to it? If so, how was HL7 addressed and is backup and stability similar to a traditional communication platform?”


HIStalk Announcements and Requests

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Welcome to new HIStalk Platinum Sponsor Spok (pronounced “spoke”). The Springfield, VA-based company is a market leader in critical communications solutions – clinical alerting and notification, secure hospital communications, physician and nurse scheduling, paging, and contact center technologies. The company chose its new name in 2014 following the 2011 acquisition of Amcom Software by USA Mobility. The Spok Mobile secure texting app allows users to send images and video along with text, with full logging and HIPAA compliance. Spok Critical Test Results Management helps meet National Patient Safety Goal #2 in quickly sending radiology and lab results to the right clinicians on their mobile devices, accelerating the treatment plan and discharge process as appropriate and protecting against malpractice lawsuits. The FDA-approved Spok Messenger sends mobile alerts from nurse call systems while routing non-clinical requests to the appropriate team member. Paging remains relevant as an essential part of critical healthcare communications due to its high reliability and low cost and Spok offers both wide-area and onsite versions of it. Thanks to Spok for supporting HIStalk.

Here’s a YouTube video case study that describes Banner Health’s use of Spok solutions to create patient-centric communications.

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I’m among the one-third minority who pronounce the name of this site “H-I-S-talk” rather than the “Hizz-talk” preferred by two-thirds of 335 poll respondents. Dean says he doesn’t like turning acronyms into words and was baffled when people at his previous employer pronounced “URL” as “earl,” which reminds me of my annoyance at people pronouncing Joint Commission back in its JCAHO days as “jayco,” which makes no sense at all but is at least less annoying than lowbrow humorists who gleefully turn FHIR into tediously non-clever “fire” puns. Two respondents offered a variation I hadn’t though of in “hisstalk.” At least nobody said they incorrectly assume that: (a) the “his” is the opposite of “hers,” or (b) the name has a religious connotation.

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Mrs. Jarrell from Louisiana reports that her seventh graders are learning about integers as they use the math manipulatives and electronic quiz tools we provided via DonorsChoose.

I get a bit queasy when I see how HIMSS advises its vendor members on how to sell their products to its provider members, as evidenced by the pitch for its recent webinar that gets me going in several ways:

  • It uses “social” as a synonym for “social media,” which it is not (although I’m at least happy it’s not the retch-inducing “sosh”). It also bleats out “leverage” and “utilize” instead of the less-pompous and perfectly serviceable “use.”
  • It pitches the use of social media to “generate excitement about your brand before and during HIMSS16 utilizing its expert team,” with the expert team to be “utilized” being that of HIMSS Media, which seems to have happily eliminated the firewall between alleged news reporting and for-hire pitching. I’ve yet to experience tweet-induced excitement about a company, especially when the tweets in question emanated from those folks.
  • It claims that screwing around with Twitter and Facebook will result in “transforming yourself from a vendor into a trusted advisor.” That’s asking a lot from simply assigning some 20-something kid to post unoriginal, corporate-approved thoughts that decision-makers will never read because they have far better things to do than monitoring Twitter. It’s usually a really bad idea to make a vendor your “trusted advisor” unless the advice you seek is that you should buy whatever they’re selling.
  • It reminds me that HIMSS makes millions from pimping low-paying provider members to high-paying vendor members while also selling itself. I like some of what HIMSS does, but the emphasis on its own bottom line keeps increasing. They’re almost as bad as AAA, which bombards me trying to sell insurance, car repair, vacations, sponsor-supported products, credit cards, and even used cars when all I want is roadside assistance and maybe an occasional hotel discount.

Webinars

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 2 (Wednesday) 2:00 ET. “Creating HIPAA-Compliant Applications Without JCAPS/JavaMQ Architecture.” Sponsored by Red Hat. Presenters: Ashwin Karpe, lead of enterprise integration practice, Red Hat Consulting; Christian Posta, principle middleware architect, Red Hat. Oracle JCAPS is reaching its end of life and customers will need a migration solution for creating HIPAA-compliant applications, one that optimizes data flow internally and externally on premise, on mobile devices, and in the cloud. Explore replacing legacy healthcare applications with modern Red Hat JBoss Fuse architectures that are cloud-aware, location-transparent, and highly scalable and are hosted in a container-agnostic manner.

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) 12 noon ET. “Population Health in 2016: Know How to Move Forward.” Sponsored by Athenahealth. Presenter: Michael Maus, VP of enterprise solutions, Athenahealth. ACOs need a population health solution that helps them manage costs, improve outcomes, and elevate the care experience. Athenahealth’s in-house expert will explain why relying on software along isn’t enough, how to tap into data from multiple vendors, and how providers can manage patient populations.

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.

December 9 (Wednesday) 1:00 ET. “Looking ‘Back to the Future’ on Clinical Decision Support and Data Warehousing.” Sponsored by Health Catalyst. Presenter: Dale Sanders, SVP of strategy, Health Catalyst. Dale will use a 2006-era slide deck (complete with old-school graphics) on using an enterprise data warehouse in clinical decision support, as it was originally presented to several masters-level informatics classes nearly 10 years ago. Some of the information in the “time capsule” will be laughably wrong, while some will still be relevant. Either way, reviewing the past will help inform the future. A highly interactive Q&A will follow.

December 16 (Wednesday) 1:00 ET. “A Sepsis Solution: Reducing Mortality by 50 Percent Using Advanced Decision Support.” Sponsored by Wolters Kluwer Health. Presenter: Stephen Claypool, MD, medical director of innovation lab and VP of clinical development and informatics for clinical software solutions, Wolters Kluwer Health. Sepsis claims 258,000 lives and costs $20 billion annually in the US, but early identification and treatment remains elusive, emphasizing the need for intelligent, prompt, and patient-specific clinical decision support. Huntsville Hospital reduced sepsis mortality by 53 percent and related readmissions by 30 percent using real-time surveillance of EHR data and evidence-based decision support to generate highly sensitive and specific alerts.

December 16 (Wednesday) 1:00 ET. “Need for Integrated Data Enhancement and Analytics – Unifying Management of Healthcare Business Processes.” Sponsored by CitiusTech. Presenters: Jeffrey Springer, VP of product management, CitiusTech; John Gonsalves, VP of healthcare provider market, CitiusTech. Providers are driving consumer-centric care with guided analytic solutions that answer specific questions, but each new tool adds complexity. It’s also important to tap real-time data from sources such as social platforms, mobile apps, and wearables to support delivery of personalized and proactive care. This webinar will discuss key use cases that drive patient outcomes, the need for consolidated analytics to realize value-based care, scenarios to maximize efficiency, and an overview of CitiusTech’s integrated healthcare data enhancement and analytics platform.

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


Acquisitions, Funding, Business, and Stock

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Allscripts announces a share buy-back of up to $150 million.

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Sunquest Information Systems will move its Tucson, AZ headquarters to an office building on the north side. Google Maps indicates that it’s a 26-minute drive between the offices, just in case you’re an employee trying to assess your quality of life impact. I’ve had my hospital commute involuntarily changed a few times by an office move, where the folks in charge seemed surprised that most employees weren’t thrilled about wasting more hours driving every week just to stare at the same cubicle walls moved to a further-flung part of town. My limited analysis was that somehow the new building was always closer to the wealthier neighborhoods where hospital executives lived and featured an even nicer version of Mahogany Row on whose plush carpet the peons rarely trod except as guests at their own termination.

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Blue Cross Blue Shield of Michigan acquires insurance company software vendor IkaSystems, which has some executive team members who have worked for various health IT vendors.


Sales

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University of Chicago Medicine (IL) chooses Valence Health to support its clinically integrated network, the 30th such organization to implement the company’s unified clinical information solution.

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Skagit Regional Health (WA) chooses Epic at an estimated cost of $72 million over five years. ECG Management Consultants, which managed the selection, says Skagit will displace Meditech in the hospital and NextGen in its clinics.


People

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Online second opinion provider 2md.MD hires Kirk Rosin (Aetna) as chief strategy officer and Kristin Herrera (UnitedHealthcare Global) as chief growth officer.

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Florent Saint-Clair (DR Systems) joins Dicom Systems as EVP.

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CTG promotes Amanda LeBlanc to VP/chief marketing officer.

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Kate Crouse (Smart Exec Tech LLC) is named network CIO at Kings County Hospital – Central Brooklyn (NY).

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Vital Images names Paul Markham, DBA (Origenetics) as VP of marketing.

Rob Senska, Esq., MBA (Somerset Medical Center) joins Besler Consulting as director of compliance services and associate general counsel.


Announcements and Implementations

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Yale-New Haven Hospital (CT) implements Mobile Heartbeat’s MH-Cure clinical smartphone app, with three-fourths of its physician users saying it has improved patient workflow and safety.

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Naunce and the National Decision Support Company announce their collaboration to support ACR’s Imaging 3.0 by offering NDSC’s ACR Select appropriate use criteria along with Nuance PowerScribe 360 and PowerShare Network.

National Decision Support Company also announces that it has signed an exclusive agreement with Cerner to make its ACR Select imaging appropriate use criteria available to Millennium users.

Craneware will demonstrate a new version of its Pharmacy ChargeLink solution at the ASHP Midyear Clinical meeting, which includes predefined formulary mapping to Epic Willow and Cerner PharmNet.


Privacy and Security

In Canada, a former administrative assistant of Alberta Children’s Hospital is charged with 26 counts of inappropriately accessing patient records. She had already been fired for snooping.


Technology

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Microsoft announces PowerApps, which it says will allow non-technical employees to create apps that work on any device by using Office-like templates, a drag and drop workflow designer, and connections to cloud and on-premises services such as Salesforce, Dropbox, and databases. That would be pretty cool if it works as described since subject matter experts typically struggle when trying to move handy, Office-powered workgroup apps to web or mobile environments without technical help.


Other

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The US Supreme Court declines to hear the case of a retired Texas veterinarian whose license was suspended for offering online pet advice in yet another clash between Texas professional boards and telemedicine providers. The vet says the state’s requirement that he physically examine an animal before offering telephone advice violates his free speech rights. He was offering only advice, not the writing of prescriptions.

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WakeMed (NC) blames its $50 million FY2015 loss on major expenses that include its Epic implementation, construction of a new 61-bed hospital in Raleigh, and running a care management program, but says the numbers are deceiving because the investments will pay off later. Meanwhile, neighboring Duke University Health System, which reported $355 million in profit on $3 billion in revenue, says its Epic-related financial hit from last year is history and Epic is now delivering the expected results. UNC Health Care System made $119 million on $3.2 billion in revenue.

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Coca-Cola’s chief science and health officer retires following a New York Times report that described how the company secretly funded a non-profit that urged Americans to exercise more instead of drinking less soda as advocated by what Coke called “public health extremists.” The CEO of the non-profit, which has since shut down, accepted honoraria and travel expenses from Coca-Cola before he formed the group. He’s a professor at the University of Colorado School of Medicine, which returned Coke’s $1 million donation following the article’s publication. Coke also paid $500,000 to University of South Carolina, which says it’s not giving the money back.

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A Wall Street Journal investigative report finds that Americans provide most of the global drug industry’s profits because of pharma’s political clout, an unwillingness by Americans to limit use of expensive drugs regardless of proven therapeutic benefit, laws that prohibit Medicare from negotiating drug prices, the fragmented US healthcare system in which lack of a single government buyer allows drug companies price their products however they like, and demand-generating direct-to-consumer advertising that most countries don’t allow.

In the Cayman Islands, the former board chair of the health services authority is on trial for defrauding the public after the HSA awarded a patient swipe card contract to a firm in which he held partial ownership. Witnesses testified that the technical committee’s choice of Cerner angered him to the point he a sent a copy of Cerner’s proposal to the owner of eventual winner AIS Jamaica, with whom he planned to open a pharmacy business.

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Facebook CEO Mark Zuckerberg announces in a letter written to his newborn daughter Max that he and his wife Priscilla Chan, MD will give away 99 percent of their Facebook shares – worth $45 billion today – via a foundation that will focus on personalized learning, curing disease, connecting people, and building strong communities.

A KPMG survey finds that 80 percent of organizations report their ICD-10 transition as smooth, although its methodology of surveying 300 attendees of an ICD-10 webinar is lazy.

A tiny observational study finds that doctors who enter information into the EHR during patient visits not only communicate less as you might expect, but also argue more with their patients and earn lower satisfaction scores. That may mean that those doctors don’t communicate well, but it could also indicate that the observations made involved patients who were sicker or newer, thus requiring more data entry and less catering to the patients’ every whim. The most telling aspect would be how the computer and monitor were positioned in the exam room, which heavily drives patient perception as being either exclusionary or participatory.

Websites that offer estimated medical procedure costs, including those run by insurance companies, often give consumers incorrect cost information that leaves them paying higher-than-expected expenses out of their own pockets, according to an NPR review. Reasons include health systems that quietly buy other providers and increase their prices, use of historic or aggregated prices, and not knowing exactly what procedures a doctor might perform during a visit or how the doctor will code and bill it. Price transparency is also nearly non-existent as prices are hidden inside non-public contracts between payers and providers.

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Weird News Andy enjoyed the programmer jokes I ran recently and offers “Mr. Boole Comes to Tea” in a belated celebration of George Boole’s 200th birthday.


Sponsor Updates

  • Anthelio Healthcare Solutions will exhibit at the HIMSS Gulf Coast Chapters event December 4-5 in Birmingham, AL.
  • Capsule will exhibit at the IHI National Forum on Quality Improvement in Health Care December 6-9 in Orlando.
  • Divurgent ranks amongst CIOReview’s 50 most promising healthcare solution providers.
  • Fujifilm debuts an updated version of Synapse RIS at RSNA.
  • Visage Imaging is demonstrating Visage Ease mobile imaging results enhancements at RSNA.
  • Healthfinch will exhibit at The Institute for Healthcare Improvement Annual Conference December 6-9 in Orlando.
  • Huntzinger Management Group interviews client ProMedica CIO Rose Ann Laureto about the organization’s Epic go live.

Blog Posts


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.

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Morning Headlines 12/1/15

November 30, 2015 Headlines Comments Off on Morning Headlines 12/1/15

UnitedHealth Sees 2016 Revenue Slightly Below Estimates

Ahead of its Tuesday investor day, UnitedHealth projects 2016 revenue of $180 billion to $181 billion, short of analyst expectations. The insurance giant noted earlier this month that its public exchange business as underperforming and would cut into profits.

Highmark Medicare Advantage members to retain in-network access to UPMC

The Pennsylvania Supreme Court issues a ruling preserving in-network access to UPMC doctors and facilities for Highmark Medicare Advantage health insurance customers.

Glens Falls Hospital picks single electronic health record, data provider to streamline systems

Glens Falls Hospital (NY) will expand its current inpatient Cerner install to replace Epic in its ambulatory space and GE Healthcare in patient registration and billing.

Lahey Clinic computer theft leads to $850,000 HIPAA settlement

Lahey Clinic (MA) will pay an $850,000 fine and enter into a corrective action plan to settle privacy and security violations filed by the OCR after a 2011 unencrypted laptop theft exposed the records of 599 patients.

Comments Off on Morning Headlines 12/1/15

Curbside Consult with Dr. Jayne 11/30/15

November 30, 2015 Dr. Jayne 2 Comments

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I wrote last week about open enrollment for health insurance and other benefits. A reader sent me this screenshot of his company’s enrollment management system, giving it an “F” for usability. Although the rolling hills are probably supposed to calm employees before they see what their premiums will be this year, the fact that they obscure half of the labels is likely to increase anxiety. Not to mention, can you trust a company that doesn’t care if you can read the password requirements or not?

Another reader wrote about the expanding list of employee-paid options his company offers. In addition to medical, dental, and vision insurance and flexible spending accounts, employees also had the option of choosing pet insurance and a legal services PPO.

I admit that I don’t know anything about contract legal services, but found it kind of funny that lawyers would start down the slippery slope that got physicians to where we are today. We’ve seen what having third-party payers has done to the healthcare system and are still trying to cope with payments that are spiraling down while insurance company profits continue to climb. If anyone has inside knowledge on this trend, I’d be happy to run comments.

Nearly everyone I’ve talked to about open enrollment and health care coverage has mentioned that they get either a premium discount or a penalty (whichever way you look at it) depending on the presence or absence of certain health-related behaviors. Anecdotally, the most common are discounts for being a non-smoker or participating in a smoking cessation program.

Close behind are discounts for having certain lab screenings done, although the results aren’t taken into account. My former employer required lab screening for all employees to get the lowest rate, regardless of whether the labs were evidence-based or indicated. Although I’m sure they got a volume discount for having the lab work done, the concept of coercing people into having screening tests isn’t exactly driving down the cost of healthcare.

Looking at my former team (which was fairly young), only 20 percent of them were in an age bracket where the blood work was actually indicated. I’ve had plenty of conversations with Medicare patients who want a specific test regardless of whether it’s indicated simply because “Medicare covers it and I’ve earned it,” which is no way to practice medicine. Seeing this type of behavior reinforced by private payers is disappointing.

The other troubling thing about the whole business is the aspect of coercion. Those of us who believe in evidence-based medical care have spent our careers trying to order the right tests for the right patients at the right time, not just doing things because they’ve always been one way or another. Even simple laboratory tests are not without risk. There is a chance that they will uncover an “abnormal” but irrelevant value that will lead to patient distress or to further unnecessary testing. There is also the loss of the patient’s time in going to have the test and jumping through related biometric screening hoops.

Additionally, I’m not aware of a significant amount of high-quality research that shows that these programs actually work as far as driving healthy behavior or reducing overall healthcare expenditures. There are a handful of papers but the design and execution are somewhat variable. I’m not sure how I feel about employees being part of an experiment – when I was in academics, I would have to get approval from the Institutional Review Board to do something like that with my staff. Employers, however, have carte blanche to do whatever they want.

Everyone is awfully keen on these “wellness” programs, but they’re of varying quality. I saw a patient at the office last week who just needed documentation that he had a “physical” so he can get a discount on his insurance. There was no description of what exactly was to be included in the physical. The general “physical” has not been shown to reduce morbidity or mortality. Age-appropriate preventive and wellness visits can have an impact, but they’re best performed by a primary care physician who knows the patient and his or her history.

Unfortunately he showed up at our urgent care, where in the absence of specific criteria (such as pre-participation sports physical or a pre-employment physical), the content can be somewhat variable. Half our physicians are Emergency Medicine certified and they’re not that into continuity of care. He also presented to the office the day after Thanksgiving, which is historically one of the top three busiest days of the year at our practice and probably not the best choice for a preventive medicine visit unless you want to catch influenza or an upper respiratory infection in the waiting room.

I picked him up rather than one of the ED docs, so he did receive a full age-appropriate preventive medicine visit with preventive health counseling and notes on what screenings he should start having and when. I’m not sure how much he actually absorbed, though, and since we’re a walk-in urgent care, there’s not likely to be much continuity.

Another spin on this is the employer-owned health practice, where employees actually see on-site physicians for wellness visits, chronic disease management, and associated services. A friend of mine started working in one of these practices last year and found it to be much harder than she anticipated. She finds a tremendous conflict of interest with patients tending to want to conceal certain information that they wouldn’t want their employers to know. Although there are supposed to be safeguards in place, patients don’t always trust them.

Another negative aspect of open enrollment is the annual churn of patients having to change physicians when their coverage changes. Often this means starting over in the middle of treatment or having delays in care due to the need to obtain new referrals and authorizations. When I was in a traditional primary care practice, January always brought a flood of requests to transfer medical records, often with notes from the patient apologizing for leaving and asking us to let them know if we ever decide to start taking XYZ insurance plan.

For someone who became a family physician because I hoped to care for people longer than a year or two at a time, it was just sad. I’m personally averaging five primary care physicians in the last 15 years, which isn’t ideal as a patient.

I’m not sure what the answer is, but I hope it involves the ability of patients to choose physicians based on quality and cost and without network restrictions or burdensome processes. Somehow I think that’s just too much to ask, though.

What do you think the answer might be? Email me.

Email Dr. Jayne.

HIStalk Interviews Clay Johnston, MD, PhD, Dean, Dell Medical School

November 30, 2015 Interviews 1 Comment

S. Claiborne “Clay” Johnston, MD, PhD is dean of Dell Medical School at the University of Texas at Austin. Campus construction will be completed in May 2016 and the first medical school class will begin studies in June 2016.

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How have medical schools have changed over the last 20 years and how will the Dell Medical School will be even more different?

Medical schools are changing, and I think a little more rapidly now. They certainly haven’t changed as much as they should have.

The one realization is that lectures don’t work so well. There’s a lot more emphasis on flipped classroom type approaches to teaching, small group learning, that kind of thing.

More recently, too, there’s a greater appreciation of the fact that –  the way I learned was memorization focused, just cram all this knowledge. The reality is that information is cheap today. The resources available to physicians are much more accessible and are generally more accurate than memory for things that aren’t used frequently. Therefore, the need to memorize so much stuff is really not there.

There’s been some de-emphasis of that memorization task and more about how we find the data that we need, how we integrate that data, and how we use it solve problems. Those are some of the broader trends that are going on.

Obviously we want to take advantage of those, but also we’re coming without an existing curriculum. We have a lot more freedom than existing schools, where you always have people who defend the status quo and created that beautiful lecture set on the Krebs cycle and they’re just not going to let it go. We don’t have that, so that gives us a different perspective. 

For us, it’s more about, what is it that we want from health and from healthcare as a society? Then, what is the appropriate role of the physician in that ideal vision of what the health system should look like?  Then, how do we provide the best training to meet those needs, particularly given the problems in the health system? That completely opens your eyes in terms of thinking about, what is the skill set?

From our perspective, physician leadership is a big problem. Being able to look at system-level problems, work in teams, and use technologies and other new approaches to solving these system problems creatively. Those are some of the key things that physicians ought to be involved in. Not just to not resist them, which is a common problem now, but to actually help to lead them.

That’s what we’re doing. We’ve got a curriculum that’s very much designed around training these physician leaders of the future.

A significant percentage of medical school graduates either don’t follow with a residency or they take a non-patient care role after using up a class spot and the educational subsidy. How do you set reasonable expectations, especially as prospective students hear about burnout among practicing physicians?

We need to focus on why those physicians are burned out and look at the systems that have been put in place that have led to that burnout. One of the dysfunctions of the fee-for-service system is that it does not compensate people well for things like office visits or the cognitive aspects of medicine. It  does compensate well for procedures. Over time, the cognitive aspect reimbursements have been ratcheted down for physicians, so they’ve had to see more and more patients.

Then electronic health records were introduced. Their primary function today is billing. They have eroded even further the meaningful time that doctors spend with their patients. 

Those are just a couple of examples, but important ones for how we’ve made jobs like primary care really unpleasant. There’s very short visits — the average office is now 12 minutes. Up to half of that could be spent just documenting the visit in a very dysfunctional electronic health record.

The reasons that docs go into medicine have been lost. Having those meaningful, important discussions and time with patients is much more difficult today. 

How, then, do we change the system so that docs can spend more time with patients and maybe work with patients in whole new ways, you know, like email? It’s used in every industry. Why not allow patients to email their docs and make that part of the job of a physician to manage patients by whatever technologies make the most sense?

What do we tell our students? Well we tell our students, it’s your job to keep people healthy and to get them healthy again when they’re not. In the traditional approach, that was to be done in clinic visits and in ORs and emergency rooms. Now, open your eyes up and think about how you could do that best. If I gave you a panel of 3,000 patients to take care of, what would you put in place to make sure that they’re as absolutely healthy as they could possibly be and that you have meaningful discussions with them? 

You probably build a team around yourself. You would use technologies. OK, show me what that looks like. Tell me how we can build that and that there are ways to get paid for it. 

Medicine needs to evolve that way. Then the physician burnout also can go away because that perspective is just as important to fixing the health system.

Texas makes a lot of headlines related to telemedicine. Will telemedicine and other non-face-to-face technologies be part of your curriculum?

Yes. They need to be. To say that those technologies shouldn’t be important in the delivery of healthcare is just so short-sighted.

So many of the things that are currently addressed in office visits could be addressed much more readily by email. That opens up the possibility of more frequent interactions that can help patients who wonder, for example, whether a side effect they’re having is related to a new medicine they started. If we do that, then the office visits can be much more meaningful because you don’t need as many. 

There are definitely ways to easily imagine to push things forward, including telemedicine. Yes, we need to then engage our students in that.

Do you think the low-pay, high-workload model of medical residency that’s funded by federal taxpayers still makes sense?

It’s a strange model, but the reality is that the residents have two functions. They provide real work and help, which is why we feel like they deserve some salary, but they are primarily learners. They’re there to finish up their training. That’s in the best interest of society, to have that. 

Who should pay and how? It ends up the federal government actually pays for the minority of residents. Most are paid for through the hospital system. So it’s really, truly a strange, hybrid system. Could there be a better system? Probably. We do need to pay them something, but they don’t justify getting paid at the same level as physicians who have finished their residency.

Where in a physician’s career are the majority of concepts and treatment methods developed? How can a physician who has been out of school for 20 years remain as current as one who graduated five years ago?

I think that’s a learned behavior, not a deterministic one. I don’t think there is a point at which physicians are more difficult to teach. 

Physicians in general love their independence and love to be the final say in whatever it is that they work in. Traditionally, they’ve not been so comfortable changing over time. But honestly, if you look at systems, there have been some systems that have changed dramatically and pushed more to evidence-based medicine quite comfortably, where the physicians — a whole variety of different types within that system — move forward in lock step with the evidence. A good example is Kaiser Permanente.

I think there are processes and ways of working together and teaching each other and continuing to focus on education that can encourage those behaviors.

How much of medical practice is based on evidence and whose job is it to incorporate it ongoing?

Most of what we do in medicine, there’s not solid, high-quality evidence to support. It’s done because it seems reasonable, or it’s done because it’s always been done, that way or it’s done because the science underneath it seems to probably make sense, or it’s done because another patient was treated that way and did fine so it’s probably fine to continue. High-quality evidence — where you’ve got, for example, randomized trial data — that’s a minority of the decisions and weighty decisions that physicians make.

Currently it isn’t clear whose responsibility that is. I would say that physicians ultimately have the responsibility to practice based on the evidence, to stay current and to stay true to the evidence. But it is extremely difficult to do that in standard independent practice because things move so quickly and because it requires more adjudication than just reading papers. You have to really look at the papers in light of other evidence. You have to read the papers deeply. You have to think of the alternatives. 

That works better when groups of physicians and others come together to decide what standards they will practice under. Then the system really does have some responsibility for making sure that this can happen better.

In our case, we do feel like this is a responsibility that we have back to this community — to work with the excellent physicians here, but help them to stay excellent forever. How will we do that? We’re looking at ways. They need incentives to stay current. How do we work in creating those and then create those educational opportunities and also those arenas in which they can review and judge and decide on evidence that they should all follow.

How will you teach students to respect both traditional, large-scale, well-developed studies –which are often published only if the for-profit company sponsoring them likes the results — versus self-interpreted smaller data sets that will be available almost everywhere?

Obviously you have to teach them a lot more about how you look at data and what the issues are with it. The spectrum that you just described — be suspicious about Phase 2 clinical trials. Phase 3 clinical trials, those are so expensive that you have to publish it results from a Phase 3 clinical trial. That’s less likely, but the early-phase clinical trials — that is an important source of bias, as you say.

The individualization of care is the thing that was implied by your second question, you know, "These 10 people who look like you did well" — you don’t get that information necessarily from a clinical trial. You get it from a broader spectrum of folks who are eligible. They might do some sub-group analysis, but they’re never powered to adequately show a difference by sub-group.

Then obviously the problem with that evidence is that it’s weak. Maybe it’s luck that they all did well. Maybe doing well is an expected outcome, so it would be rare to actually have something bad happen. Maybe they were selected in a certain way that made them all do well. You can’t know.

How do you teach that? Data is going to be all around us and that’s a wonderful thing, because it gives us all kinds of additional information that if we’re careful, can be extremely useful in improving care, improving outcomes for our patients, keeping people healthier. 

We have to expose our students to that throughout the curriculum and get them involved in projects in which they’re using data to solve critical health problems. That’s what we do. We take them out of their rotations and they work for nine months in innovation and leadership blocks. They solve real health problems.

If the goal is to make our overall population healthier, what’s the right blend of what you  teach doctors to do as physicians in practicing medicine versus the public health approach that might include areas such as housing, education, income, or personal behavior?

It’s important for physicians to understand the full spectrum. Healthcare only accounts for 20 percent of the potential to improve health. Eighty percent of it comes from all that other stuff that you mentioned. If the goal of the physician is to keep people healthy, they need to be aware of that 80 percent and also understand how to integrate that into their practice or into their broader, system-level solutions to health problems.

The question is, where you draw the line? Are physicians going to be proponents of income equality because income differences lead to health issues? No, probably not. It’s not about getting to the political and the governmental aspects of the predictors. 

What if it is about diet and exercise? Those behaviors, or taking your meds — those are important things in which physician interventions or system-level interventions that could include a physician on the team are important things for the health system to focus on. It makes sense for physicians to have roles in those areas.

That stuff becomes critical to our curriculum. It is far more effective and can be cost saving to keep people healthier than it is to treat them once they are sick. The highest paid health professionals are physicians. Why shouldn’t they be engaged in that? Why shouldn’t they be helping to guide it rather than just been focused on the patch-up work?

Being in Austin and being associated with Dell suggests a focus on drug and technology research, but the product of such research is usually commercialized expensively without necessarily improving overall outcomes. How do you balance the human need for research with the desire of medical companies to make big profits and raise healthcare costs even more?

That’s one of the key reasons I’m here. I was the associate vice-chancellor of research and responsible for the Clinical and Translational Science Institute at UCSF. Our job was to accelerate discoveries from the laboratory out into health improvement. 

The reality was just as you said. We could keep doing that, but they’re going to be always maximally priced. They never lower cost, but they always elevate cost of care. That’s true — they have control of the pricing, so they price it to the point that it’s somewhere between $50,000 and $200,000 per quality-adjusted life year. That makes sense from their perspective to do that, but it just contributes to the problem where you’ve got so much cost that you can’t really afford innovation any more. 

That to me suggested, gosh, we’ve got to find a new way. What we’re trying to do is set up the health system to embrace and look for solutions that drive down cost. I think that we’ve left a lot of fruit low hanging on the trees because we haven’t had that perspective.

One example is antipsychotics. We know, as we’re looking at expensive health problems in Austin, the homeless — some of whom are schizophrenic — are a huge burden. Their outcomes are just terrible. It’s hard to get them to take their meds. It’s part of their disease. But if we had long-acting drugs, that could dramatically reduce the cost compared to what we pay today, with drugs that have to be given daily and are probably taken weekly if you’re lucky. That is an example of how taking a different perspective opens up new approaches, also for research.

Our hope is to integrate those perspectives throughout the research channels that we’re developing . We know we’ll have discoveries that come out and cost $200,000 per quality-adjusted life year, but our focus is to really concentrate on those that actually can reduce cost and improve outcomes.

It’s easy in the medical trenches to become disillusioned with what physicians are being asked to do, what issues they face that are beyond their control, and how the US healthcare system compares to countries that structure things differently. What will you tell students they need to do to improve it?

This is the absolute best time to go into medicine. We’ve gotten a point where we’re at the precipice — where physicians are unhappy, patients are unhappy, and we’re still costing the country a huge amount, 40 percent  more than Switzerland and that’s the next closest country. We’re at this crisis point. That means this is the time at which we can really push forward the creative solutions to healthcare. 

What are those solutions? Some are  easy to imagine, and as soon as we change the payment schemes, they become obvious and we’ll catch on. The payment schemes are changing. Some are not so obvious. It’s early days in what will be a really exciting point in medicine. I don’t think practicing medicine will look like it does today even 10 years from now.  I think it will be much more technology enabled, much more data enabled. The physician will be a true partner in improving health. That transition will be wonderful for those in practice and for the population.

Morning Headlines 11/30/15

November 29, 2015 Headlines 2 Comments

Dr. Patrick Soon-Shiong is postponing IPO of healthcare data company NantHealth

Healthcare billionaire Patrick Soon-Shiong, MD, will delay the IPO of his digital health startup NantHealth until market conditions improve. Soon-Shiong explains, “We’re basically ready. The problem is, we don’t want to go out in the current market. There is no reason for us to go out there in a bear market.”

Partners enters a genetics market

The Boston Globe covers Partners Healthcare’s sale of GeneInsight, its home-grown gene analysis software, to Sunquest Information Systems.

Medical Company LabMD Sues FTC Lawyers Over Data-Privacy Case

LabMD sues three FTC lawyers after being driven out of business over the agency’s poorly-investigated data privacy accusations. The case against LabMD was eventually thrown out by a DC judge and the now-defunct business is suing the FTC’s lawyers for “bringing a case based on fictional evidence.”

Samaritan plans for huge bump in IT spending

47-bed Samaritan Healthcare (WA) will implement Epic at a cost of $12 million. CFO Paul Ishizuka notes that the total cost is “magnitudes higher” than the hospital had spent on previous systems, but explains that interoperability across inpatient, ambulatory, and other health systems was the ultimate objective.

Monday Morning Update 11/30/15

November 29, 2015 News 7 Comments

Top News

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Billionaire Patrick Soon-Shiong, burned by poor IPO and biotech markets that evaporated $1 billion of the value of his NantKwest following its July IPO, postpones his planned IPO of NantHealth. “There is no reason to go out in a bear market,” he says.


Reader Comments

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From Turkey Trotter: “Re: poll idea. How do readers pronounce HIStalk?” You can vote here. It’s always been H-I-S-talk for me, but I don’t know which is more common know since I rarely hear it spoken by anyone else as I write it in solitude. The name’s back story is that when I first started putting random thoughts online back in 2003, the old blogging tool I was using (Blog City) required entering a site name. The term for hospital IT back then was “hospital information systems,” and from that, I quickly (and not very creatively) came up with “HIStalk.” Not that it really mattered since literally nobody was reading other than me.

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From Publius: “Re: New York-Presbyterian. I predict they will go Epic in the next 1-2 years. They are the only major NYC healthcare organization not on Epic, new CIO Daniel Barchi was CIO at two Epic organizations, and a plethora of experienced Epic consultants will be available from NYC Health + Hospitals, NYU, HSS, Montefiore, etc.” I had the same thought as soon as I heard Daniel was going there, plus the Weill Cornell physician group is already on Epic while the rest of the organization is on Allscripts. A NYP contact tells me they aren’t planning to look elsewhere, but I would be surprise if they don’t at least consider it.

From Steeple People: “Re: clearinghouses. How many EMR/PM vendors own their own? And if they don’t, which one do they use?” Vendor folks are welcome to provide their answer by leaving a comment.

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From Vince Ciotti: “Re: CPSI acquiring Healthland. CPSI’s revenue had flattened out in the last couple of years. Healthland’s customer base is very small facilities such as Critical Access Hospitals that have little funding as the company struggles to convert its Classic users to Centriq. CPSI has a strong sales and marketing team and must be aiming to sell Healthland customers its Thrive system – like Cerner acquiring Siemens, each replacement of the Classic system that will be sunsetted in two years will mean several million in booked revenue, quite a windfall for CPSI if they can make the sales. Healthland has made few new sales in the past few years and the privately held company has revenue of only around $80 million with 500 employees. It was acquired by Francisco Partners in 2007.” Vince has offered to do a webinar on the acquisition, which I think might be fun. 

From Kaiser Cutter: “Re: programmer joke. A programmer’s wife asks him, ‘Can you pick up a loaf of bread, and if they have eggs, get a dozen?’ He returns home with 13 loaves of bread. She asks, ‘What happened?’ He said, ‘They had eggs.” I returned the favor with this one. Why do programmers always mix up Halloween and Christmas? Because Oct 31= Dec 25.


HIStalk Announcements and Requests

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Sixty percent of poll respondents think everybody — not just covered entities — should be regulated by federal patient privacy laws. Mak doesn’t want taxpayers footing the bill for the inevitable bureaucracy, but HIT Geek says we need a common, simple nationwide privacy standard that can be easily enforced by built-in mobile device security controls. New poll to your right or here: where will you get your 2016 medical insurance? Click the Comments link on the poll after voting and let me know whether you’re happy with your coverage and its cost.

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Our DonorsChoose project provided an iPad for the Nevada first grade class of Mrs. Sensibaugh, who says the students are using it daily to study math and language concepts. She adds, “My students have been motivated and truly excited to use this wonderful technology. They can’t believe that someone actually cares so much about their education that they would donate such a wonderful, thoughtful gift.” Mrs. Owen from Indiana says that only two students per class have their own calculators and rulers, with our donation of 25 of each allowing students to perform dimensional analysis, mole conversion, and density graphing. I like how she attached them to clipboards and labeled them.

One of my recurring off-topic rants is the ridiculous price of razor blades, whose non-interoperable cartridges are so expensive that many stores bizarrely lock them away with the electronics. I found a solution: a safety razor like my grandfather used and high-quality blades that cost $9 per hundred (all blades fit all razors). The blades are not only good for several shaves, but are also double-sided, so I figure the $9 worth will last me for at least 2-3 years. Now I just need to convince people of the absurdity of high-technology cars riding on expensive and dangerous rubber balloons.


Last Week’s Most Interesting News

  • CPSI announces that it will acquire small-hospital systems competitor Healthland for $250 million, also giving the company a presence in 3,300 skilled nursing facilities.
  • AcademyHealth takes over the Health Datapalooza conference.
  • A research firm predicts that ransomware will infect medical devices for the first time in 2016.
  • The DoD announces that its Joint Legacy Viewer, which allows users to view combined data from the VA’s systems and its own, meets the federal requirement that the two organizations deploy interoperable systems.
  • A court rules that Tata Consultancy employees who downloaded proprietary Epic material while posing as client consultants constitutes “inside hacking.”

Webinars

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 2 (Wednesday) 2:00 ET. “Creating HIPAA-Compliant Applications Without JCAPS/JavaMQ Architecture.” Sponsored by Red Hat. Presenters: Ashwin Karpe, lead of enterprise integration practice, Red Hat Consulting; Christian Posta, principle middleware architect, Red Hat. Oracle JCAPS is reaching its end of life and customers will need a migration solution for creating HIPAA-compliant applications, one that optimizes data flow internally and externally on premise, on mobile devices, and in the cloud. Explore replacing legacy healthcare applications with modern Red Hat JBoss Fuse architectures that are cloud-aware, location-transparent, and highly scalable and are hosted in a container-agnostic manner.

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) 12 noon ET. “Population Health in 2016: Know How to Move Forward.” Sponsored by Athenahealth. Presenter: Michael Maus, VP of enterprise solutions, Athenahealth. ACOs need a population health solution that helps them manage costs, improve outcomes, and elevate the care experience. Athenahealth’s in-house expert will explain why relying on software along isn’t enough, how to tap into data from multiple vendors, and how providers can manage patient populations.

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.

December 16 (Wednesday) 1:00 ET. “A Sepsis Solution: Reducing Mortality by 50 Percent Using Advanced Decision Support.” Sponsored by Wolters Kluwer Health. Presenter: Stephen Claypool, MD, medical director of innovation lab and VP of clinical development and informatics for clinical software solutions, Wolters Kluwer Health. Sepsis claims 258,000 lives and costs $20 billion annually in the US, but early identification and treatment remains elusive, emphasizing the need for intelligent, prompt, and patient-specific clinical decision support. Huntsville Hospital reduced sepsis mortality by 53 percent and related readmissions by 30 percent using real-time surveillance of EHR data and evidence-based decision support to generate highly sensitive and specific alerts.

December 16 (Wednesday) 1:00 ET. “Need for Integrated Data Enhancement and Analytics – Unifying Management of Healthcare Business Processes.” Sponsored by CitiusTech. Presenters: Jeffrey Springer, VP of product management, CitiusTech; John Gonsalves, VP of healthcare provider market, CitiusTech. Providers are driving consumer-centric care with guided analytic solutions that answer specific questions, but each new tool adds complexity. It’s also important to tap real-time data from sources such as social platforms, mobile apps, and wearables to support delivery of personalized and proactive care. This webinar will discuss key use cases that drive patient outcomes, the need for consolidated analytics to realize value-based care, scenarios to maximize efficiency, and an overview of CitiusTech’s integrated healthcare data enhancement and analytics platform.

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


Acquisitions, Funding, Business, and Stock

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The Boston newspaper covers the previously announced sale of Partners HealthCare’s GeneInsight genetic testing  software to Sunquest, which will pay Partners sales royalties. The article mentions similar software deals between Partners and Health Catalyst and Beth Israel Deaconess Medical Center and Athenahealth.

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India-based healthcare software vendor Indegene Lifesystems expects to hit $250 million in annual revenue by 2020 and plans to go public within 2-4 years. The company says it will announce an acquisition in the next few days and is also in acquisition talks with an unnamed population health management analytics company.

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Georgia-based Brightee, which offers durable medical equipment and hospice software,  will expand R&D headcount at its Scotland offices to 150-200 employees. President and CEO Dave Cormack, who is from Scotland and was a director of Aberdeen Football Club, hopes to double annual sales to $240 million within 3-4 years.


People

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Culbert Healthcare Solutions promotes Jaffer Traish to VP of its Epic practice.


Announcements and Implementations

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Peer60 releases Trends in Medical Imaging Technology just in time for RSNA. It finds that radiology providers are most excited about breast tomosynthesis and cloud-based imagine sharing. VNA vendor preference is fragmented but Merge holds the lead, ACR Select enjoys a 60 percent mindshare in clinical decision support, and Nuance leads the “favorite imaging IT leaders overall” category. 

GE announces the GE Health Cloud for its imaging devices. The company also announces Centricity radiology apps: Cloud Advanced Visualization, Multi-Disciplinary Team Virtual Meeting, Case Exchange, and Image Access Portal.


Government and Politics

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Medical testing firm LabMD, which says it was driven out of business after seven years of fighting Federal Trade Commission charges of lax data security, fires back by suing three of the FTC’s lawyers for illegal and unethical prosecution. The FTC’s case, which was dismissed last week by a federal judge who found that no consumer harm occurred, was based on information from security vendor Tiversa. LabMD claims that Tiversa illegally hacked its systems and then threatened to expose the breach unless LabMD signed up as a Tiversa customer. LabMD CEO Michael Daugherty says the FTC should focus on real data breaches instead of potential ones and should be more transparent in conveying its expectations to companies, especially healthcare ones. He adds that FTC is made up of enforcement lawyers rather than technology experts and spent millions of taxpayer dollars pursuing his case, observing that HHS is a lot more willing to work with providers in trying to improve data security.


Other

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In Western Australia, a government committee finds that 783-bed Fiona Stanley Hospital is still riddled with IT problems a year after an opening that was marked by delays and cost overruns. Employees report that  a patient admission requires 15 minutes, the incompatible ICU system requires staff to print and scan a transferred patient’s record, and a poorly designed Wi-Fi system with limited coverage forces nurses to communicate via walkie-talkie. The report adds, “No hospital in the North Metropolitan Health Service is able to electronically access a medical record created at FSH,” although it concedes that given limited IT budget and skills, limited interoperability is reasonable and the new system is still better than paper records. The committee expressed concerns that no system in Australia can issue a delivery receipt for discharge summaries, leaving the sender unaware of whether it was received and acted upon appropriately.

In Australia, a cancer patient is given an incorrect chemotherapy dose due do a typo on a printed protocol form. Royal Adelaide Hospital’s hematology service noticed its error after six months and sent a group email with the subject line, “Updated AML … protocol uploaded.” Flinders Medical Center didn’t update its forms and gave the man half the desired dose. He’s one of 10 leukemia patients who were underdosed, of which two have relapsed and died. An independent review questions why Royal Adelaide sent a bland email that didn’t highlight the urgency of the required change and to alert clinicians that they likely underdosed their patients if they didn’t double-check the form’s incorrect dose calculations.

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Samaritan Healthcare (WA) will spend $12 million to implement Epic, increasing its annual system maintenance cost from $500,000 to $2 million. According to the CFO, “It is a much, much more expensive system than we are using right now, so our whole trick is, how do we maximize the investment in the system? Because it will give us so much more and better information. Can we extract the information to reduce cost and improve care? That’s really what our task is as management.”

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PatientKeeper offers a Thanksgiving-specific ICD-10 infographic.

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Hospitals in England urge consumers to avoid their EDs on Tuesday as 40,000 junior doctors and their British Medical Association labor union plan a 24-hour strike on Tuesday during which they will treat only emergency patients. The doctors will strike again on December 8 and 16, but on those days they won’t treat any patients at all, even those with urgent conditions. BMA expects the government to send Army medical staff to cover the EDs. The residents are protesting a change proposed by Secretary of State for Health Jeremy Hunt that would expand hospital services to seven days per week following reports that patients are 15 percent more likely to die if admitted on Sunday instead of Wednesday. Junior doctors already work weekends and nights, but worry the proposed changes will cut their overall pay.

The Columbus, OH newspaper finds that Ohio’s medical records copying costs are among the highest in the country, as providers can charge $3.07 per page for the first 10, $0.64 for pages 11-50, and $0.26 for additional pages. Neighboring Kentucky, in contrast, mandates that providers give patients the first copy of their records at no charge. Actual charges for a 10-page record range from $3.60 at OhioHealth to $30.70 at Mount Carmel and Ohio State.

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The New York Post reports that North Shore-LIJ Health System paid its president and CEO $10 million last year, much of it as a retirement payout even though he’s not retiring. New York-Presbyterian paid its CEO $4.6 million and gave several of its “honchos” housing allowances and chauffeurs, while Montefiore Medical Center paid its head $4.8 million. The state hospital association gave the standard checklist of excuses: it’s a tough job and the market is so competitive that hospitals would lose their executives if they didn’t pay them millions.

Vince Ciotti provides a tongue-in-cheek overview of system longevity.

Weird News Andy titles this story “To Womb It May Concern.” in which a not very convincing article (“it blew our minds,” reports the gushy writer) predicts that surgeons will within 5-10 years successfully transplant a uterus into a former male (transgender woman). WNA quotes Homer Simpson addressing Marge in bed: “But it’s uterus, not uter-you.”


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.

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EHR Design Talk with Dr. Rick 11/25/15

November 25, 2015 Rick Weinhaus 4 Comments

Designing a New EHR User Interface: The Paper Chart is the Wrong Metaphor

“New technology demands new representations.” Alan Cooper, Robert Reimann, and David Cronin, About Face 3.

When we are presented with a radically new technology, at first we can’t take advantage of its potential.

Instead, we apply old ways of thinking – old metaphors – to the new technology. Most of the time, the old metaphors don’t work.

In the early days of the automobile, many flawed designs resulted from the fact that at first people could only conceive of the auto as a “horseless carriage.” As a result, many early autos looked and rode a lot like their horse-drawn precursors.

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It took a long time for people to stop using the metaphor of horse and carriage when thinking about the automobile. Designers and drivers had to realize that the auto was fundamentally different from its horse-powered predecessor, with its own set of strengths, which eventually included speed, comfort, and reliability. It was only then (and only after we made the commitment to develop an infrastructure of better roads and highways) that innovative auto technology could fully blossom.

Similarly, before the era of EHRs, the paper chart was the predominant tool for organizing and making sense of a patient’s medical record. The paper chart is a powerful cognitive tool, but its strengths are very different from those of the electronic health record. Just as the metaphor of the horseless carriage constrained auto design, the metaphor of the paper chart constrained EHR design, limiting its potential.

The paper chart came in two basic types.

One type of chart, often used in doctor’s offices and other ambulatory settings, was a manila binder where documents of whatever category (notes, labs, orders, imaging studies, reports, procedures, and so forth) were simply added in chronological order to the documents already in the chart.

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The other type of paper chart, used in some ambulatory settings and for almost all inpatient care, was a ring binder, with multiple divider tabs which organized documents by category.

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New documents were added to the chart first by tab – that is, by category – and then by date.

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Both these filing strategies were different solutions to an inherent limitation of the paper chart – a piece of paper can physically only be in one place at a time. Although this physical constraint limited how data in the paper chart could be organized and reviewed, the tangible, physical aspects of the paper chart partly compensated for this filing limitation. For instance:

  • Different paper colors and textures were often used to designate different kinds of documents.
  • You could easily flip back and forth between two or more parts of the chart without getting lost.
  • When reviewing the chart, the documents were right there. You didn’t have to first click on a tab, select a document from a list, and then open it.
  • You could flag important documents for future reference by using sticky notes or paper clips.

Unfortunately, when EHRs were first being designed, instead of taking advantage of the potential strengths of digital technology, it was natural to adopt the metaphor of the paper chart. Many of the major EHR vendors adopted one or the other of the filing strategies described above, usually some variant of the latter, tab-based system, where documents are organized by category, and only then by date.

Surprising as it sounds, what this means is that if you are using Epic or Cerner or many other EHRs (at least the way they are usually configured), you can’t do something as simple as get a single date-sorted list of all clinically relevant documents.

In the era of paper charts, if you were using the tab-based system, this was just a fact of life. A physical document could only be filed first by category or first by date.

There is no such limitation, however, with digital documents. From the user’s point of view, a digital document can, in fact, be filed in two places at the same time. To retain the old paper chart metaphor when designing the EHR user interface makes absolutely no sense. The antiquated metaphor constrains and limits the design.

Now you may figure that this is not really a major issue – that it shouldn’t make that much difference whether an EHR organizes a patient’s documents first by date or first by category. But remember that if you are a doctor, nurse, or other care team member, as part of each visit, you are going to need to review the patient’s history, especially the interval history – what occurred since the last visit.

Consider the workflow below, recommended in a training video for a major ambulatory EHR which, like Epic and Cerner, uses a tab-based design to organize the patient’s documents by category.

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Much has been written about the time involved and the number of clicks required by most EHRs to accomplish this kind of task. I believe, however, that an even bigger problem is the cognitive burden a tab-based design imposes.

First of all, most tab-based EHR user interfaces violate a basic principle of interaction design – that of visibility. Specifically, until you click on a tab, you can’t see which documents are present or even if any exist.

Second, working with lists of dates in numeric format is cognitively challenging.

Third, when switching back and forth between documents stored in multiple tabs, you expend working memory keeping track both of the chronological order of the documents you’ve reviewed as well as their subject matter. There’s not much left for interpretation.

Unless you have experienced first-hand what it is like to review chart after chart, day after day in this manner, it’s hard to fathom how this kind of needless cognitive effort interferes with patient care.

The point is that EHR user interfaces do not need to be constrained by the old paper chart metaphor. The digital nature of EHR technology allows us to design better, albeit different user interfaces.

For instance, in addition to simply being able to switch back and forth at will between displaying documents by date or by category, digital technology can support:

  • Graphically displaying both the chronological order and the subject matter of documents by using an interactive timeline.
  • Using color, shape, size, and location to encode information visually, allowing us to use our high-bandwidth visual processing system to perceive much of the data.
  • Acquiring detail with a simple mouse hover or comparable touchscreen gesture.
  • Animating navigation to help the user stay oriented in information space.
  • Displaying detail plus context on the same screen.

I have long proposed that most doctors use a chronological mental model in thinking about the patient – the patient’s history should unfold like a compelling story. Furthermore, displaying information graphically shifts the balance of mental effort from cognition to perception, sparing cognitive resources for patient care issues.

If this is the case, compared to using current tab-based designs, a timeline-based, graphical user interface for the EHR should make it easier for doctors and nurses to review, explore, navigate, and select EHR documents.

In my previous post, I proposed an EHR user interface design of this nature, The EHR TimeBar. For those readers who have not yet seen the design or who would like to review it in connection with today’s post, it is described in the document below. Although the TimeBar design displays documents in chronological order, it also supports both searching and filtering by category (see pages 19-22).

The document above describes the EHR TimeBar. Click the two-headed arrow bar icon to display it full screen since it will be hard to see otherwise. It can also be downloaded as a PDF file here.

Next Post: Telling a Story on a Timeline

Rick Weinhaus, MD practices clinical ophthalmology in the Boston area. He trained at Harvard Medical School, The Massachusetts Eye and Ear Infirmary, and the Neuroscience Unit of the Schepens Eye Research Institute. He writes on how to design simple, powerful, elegant user interfaces for electronic health records (EHRs) by applying our understanding of human perception and cognition. He welcomes your comments and thoughts on this post and on EHR usability issues. E-mail Dr. Rick.

Readers Write: Eight IT Talent Trends to Watch for 2016

November 25, 2015 Readers Write 1 Comment

Eight IT Talent Trends to Watch for 2016
By Frank Myeroff

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What’s in store for the New Year when it comes to IT talent? Here are eight talent trends that are shaping the IT workforce in 2016.

  1. Internet of Things (IOT). Talk about a technology revolution! IOT is emerging as the next technology mega-trend across the business spectrum. This means a job boom for developers, coders, and hardware professionals. However, to land a job in IOT, organizations want candidates with specific technology skill sets and experience. Consequently, an IOT talent shortage is expected.
  2. New C-level title. Chief privacy officer (CPO) is a senior-level executive title and position that was created as a result of consumer concerns over the use of personal information, including medical data and financial information. Organizations have had to rethink IT security due to recent breaches. According to InfoWorld, while most organizations already have a CSO (chief security officer) and/or a CISO (chief information security officer), there’s a need for a CPO, a dedicated privacy advocate responsible for keeping personal information safe.
  3. Gen Z will enter the workforce in greater numbers in May. Generation Z, those born between 1994 and 2004 (although there’s been no general agreement on exact years), are the most digitally connected generation yet. They have no concept about life before the Internet, mobile devices, digital games, or iTunes. Therefore, they are tech savvy and even more entrepreneurial than Millennials. They will choose career opportunities that provide quick advancement and work-life balance over salary and want mentors to help them achieve their goals.
  4. Big data becomes even bigger data. Big data is increasing the need for a new breed of engineers who specialize in massive databases. While the skills required aren’t necessarily new, there is a significant amount of knowledge needed in the areas of math and scientific analysis. Typical high-level skills expected for a position in this field include data analysis, data warehousing, data transformation, and data collection.
  5. Longer hiring process continues. According to the Wall Street Journal, in the US, the time it takes to fill a job is lengthening. In April 2015, the average job was vacant for 27.3 days before being filled. This nearly doubles the 15.3 days it took prior to 2009. The long hiring process can be attributed to having fewer qualified candidates for job openings as well as the increased number of background screening and drug tests ordered. WSJ also cites that the many portals and databases used to source and find candidates have become more entailed. While better hires are coming out of the process, it’s moving slowly.
  6. Hybrid IT talent in demand. The IT hybrid employee is on the rise. They are considered a generalist and a specialist all in one. A generalist tends to be someone who knows quite a few technologies, but only at an average level. A specialist knows only one or two, but at an expert level. A hybrid knows about a great many things at an advanced level and can adapt to any type of project. With a hybrid employee, employers are basically getting two people in one.
  7. Project work and consultant roles are abundant. Project work and consulting roles are most likely to remain abundant through 2016 and beyond. Increasing business demands are prompting many companies to invest in new technologies, along with upgrades and migration projects around tools such as enterprise resource planning (ERP) systems. Candidates who have knowledge of both new and legacy business systems are highly sought after by employers.
  8. Hottest industries hiring IT. The following industries are the top industries that will be hiring more IT professionals in 2016: healthcare, financial services, managed services, mobile technologies, telecommunications, and hospitality.

Frank Myeroff is president of Direct Consulting Associates of Cleveland, OH.

Readers Write: Sitting In the Shopping Cart: IT Tips for RSNA 2015

November 25, 2015 Readers Write Comments Off on Readers Write: Sitting In the Shopping Cart: IT Tips for RSNA 2015

Sitting in the Shopping Cart: IT Tips for RSNA 2015
By Michael J. Cannavo

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Most IT and C-suite people are about as excited about going to the RSNA as a child is going to the grocery store with their mom. They hope mom buys them some candy to make the trip worthwhile, but often have no choice but to sit in the cart and watch as items are piled in.

That doesn’t need to be the case at RSNA and shouldn’t be, either. IT folks and C-suites have a responsibility to make sure the products and services being purchase make sense from a technical, operational, and financial standpoint. Following these tips should help the trip be more productive and provide a better overall solution for the facility.

  1. Ask pointed, directed questions. Don’t be shy. Have questions ready that you will ask of all vendors that require more than a simple yes or no answer. How do you do it, not just do you it.
  2. Be consistent. Apples to apples is key, with each vendor getting asked the same questions. If you uncover something that may require further elaboration, go back and ask the others the same question.
  3. Lead, don’t follow. It is very easy for a vendor to take you down the path that best projects their products, but that may not necessarily be one that best meet your needs. The Yellow Brick Road was good for Dorothy, but isn’t for you. Take control of the discussion..
  4. Interoperability. One of the biggest buzzwords in IT today is interoperability. Don’t just ask where a vendor has connected to an EHR. Find out where and how they have done it and who you can talk to there about it. What resources were required (internal and external as well as financial)? How much time did it take?
  5. Support. Does the vendor provide a data dashboard or allow you to integrate to one? How much support can you provide internally and what can and can you not have access to? These are crucial questions.
  6. Facts, not fiction. Where have you done it with an EHR like we have in place? Don’t fall for a simple “yes, we can.” Pretend you are from Missouri, the Show Me state. Who can I talk to who has done it?
  7. Talk to engineers. If you want the unfiltered truth, talk with a systems engineer. They are easy to spot — the wrinkled shirt that just came out of the Walmart bag and the loose 1980s vintage tie they borrowed from their dad. They are also the ones who also talk nonstop about anything and everything <laugh>.
  8. Bail on the demo. RSNA is the absolute worst place to get a full product demo unless you just want a quick and dirty overview. Do the demo at your facility, where you can examine the product in detail, walk it through its paces, and ask the questions to get the answers you want and need.
  9. Get contacts. Your IT counterparts are the best source of information. Get names, phone numbers, and e-mails of those who are similar to you.
  10. Relax. Consider this a first date, not an “I do” situation. Don’t hesitate to cut your losses early Trust your gut. If it doesn’t feel right, it usually isn’t.

Michael J. Cannavo, aka The PACSMan, is owner of Image Management Consultants of Winter Springs, FL.

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CPSI Will Acquire Healthland for $250 Million

November 25, 2015 News Comments Off on CPSI Will Acquire Healthland for $250 Million

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Computer Programs and Systems, Inc. (CPSI) announced this morning that it will acquire its main small-hospital technology competitor Healthland Holding Inc., which includes Healthland Inc., American HealthTech, and Rycan Technologies. Healthland has 350 hospital customers, while American HealthTech serves 3,300 skilled nursing facilities. Rycan has 290 hospital customers of its revenue cycle management system and was acquired earlier this year by Healthland.

CPSI will pay $250 million, 65 percent in cash and 35 percent in stock. The company will also take on $150 million in funded debt to complete the transition.

CPSI Board Chair David Dye will take the role of chief growth officer, TruBridge President Chris Fowler will become COO, and Matt Chambless will be promoted to CFO. Healthland President Chris Bauleke will remain in that role.

CPSI shares rose sharply on the news Wednesday, but are still 26 percent off their 52-week high. 

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Morning Headlines 11/25/15

November 24, 2015 Headlines Comments Off on Morning Headlines 11/25/15

AcademyHealth Becomes Host Organization for 2016 Health Datapalooza

Washington DC-based non-profit AcademyHealth takes over hosting responsibilities for this year’s Health Datapalooza conference.

El Camino Hospital launches new online services

After a two-year implementation, 395-bed El Camino Hospital (CA) goes live with its $150 million Epic system.

Paging Dr. Pigeon; You’re Needed in Radiology

Researchers find that pigeons can be trained to find tumors in medical images as well as radiologists or pathologists.

Man Receives $1 Million Hospital Charge For 5-Day Stay With No Surgery

An uninsured 24-year-old man from Pittsburgh is receiving national media attention after a five-day hospital stay at UPMC results in $1.1 million in hospital charges.

Comments Off on Morning Headlines 11/25/15

News 11/25/15

November 24, 2015 News 3 Comments

Top News

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Health Data Consortium turns over the spring Health Datapalooza conference to the non-profit AcademyHealth, saying it’s time to shift its theme from data liberation to data application. I attended one event and didn’t find it all that interesting, but it seems to have developed a following, particularly among people who seem to spend most of their working lives traveling conspicuously to conferences of questionable value to their doting employers. I’m not really clear about what else the membership-supported Health Data Consortium does beyond writing lofty vision and mission statements. It was created by an advertising agency working for the federal government and some non-profits.


Reader Comments

From Parse Person: “Re: ACA deductibles. The ACA passed over five years ago after years of debate. How is it only now, in its second active year, are we realizing that the average American doesn’t have the savings to pay a multi-thousand dollar deductible? The US savings rate has been at or below zero for quite a long time and mountains of actuaries and accountants studied the ACA details since the debate first began.” The ACA was a reasonably good idea that was hacked to pieces by high-powered insurance and pharma lobbyists whose own actuarial prowess is legendary. Insurance companies realized they could jack up prices as much as they wanted or needed in the supposedly competitive Healthcare.gov marketplace, while drug companies enjoyed a big sales uptick without any additional pricing pressure. The biggest flaw in the ACA is that it addressed health insurance, not healthcare and its cost, and had to compromise nearly everything to draw enough political support to pass. I don’t think anyone expected premiums and deductibles to jump so quickly or for inexpensive, high-deductible catastrophic plans to morph into expensive, high-deductible regular plans. However, I’m optimistic that ACA’s dramatic setbacks will either be reversed within a year or two as risk pools become more predictable or its spectacularly expensive failure will convince more people that the system we’ve allowed to happen is unsustainable without paying more attention to the high cost of everything related to healthcare, ranging from million-dollar hospital CEO salaries to drug companies worth hundreds of billion dollars to insurance companies that always seem to emerge from the scrum with our wallets in their hands. Our US problem isn’t overutilization, it’s cost, and one person’s high medical costs is the high income of another person who won’t give it up without a fight.


HIStalk Announcements and Requests

HIStalkapalooza (and thus, by inference, the HIMSS conference) is just three months away. We’ve booked the venue and band, we will have a fun cast of industry characters involved as always, and I’ll be ordering beauty queen sashes before you know it. I have capacity for another sponsor or two if your company would like to join an impressive list of those that have already signed up. Contact Lorre. She can also help if your company is planning next year’s budget and wants to sponsor HIStalk, which quite a few vendors have done recently (thanks!)

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Mrs. Gamache from Florida sent photos of her gifted students, saying they are excited to be working with the LEGO Mindstorms robot we provided via DonorsChoose, using its drag-and-drop programming to make it move and perform tasks. Also checking in was Mrs. McKnight of South Carolina, who says she immediately started using the copy paper and ink we provided to replace that which was lost in flooding there, allowing her to prepare materials for students to take home for self-study. She added, “I gathered my students during our morning meeting and told them that someone donated the supplies to our class. They were so thrilled. My students began cheering!”


Webinars

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 2 (Wednesday) 2:00 ET. “Creating HIPAA-Compliant Applications Without JCAPS/JavaMQ Architecture.” Sponsored by Red Hat. Presenters: Ashwin Karpe, lead of enterprise integration practice, Red Hat Consulting; Christian Posta, principle middleware architect, Red Hat. Oracle JCAPS is reaching its end of life and customers will need a migration solution for creating HIPAA-compliant applications, one that optimizes data flow internally and externally on premise, on mobile devices, and in the cloud. Explore replacing legacy healthcare applications with modern Red Hat JBoss Fuse architectures that are cloud-aware, location-transparent, and highly scalable and are hosted in a container-agnostic manner.

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) 12 noon ET. “Population Health in 2016: Know How to Move Forward.” Sponsored by Athenahealth. Presenter: Michael Maus, VP of enterprise solutions, Athenahealth. ACOs need a population health solution that helps them manage costs, improve outcomes, and elevate the care experience. Athenahealth’s in-house expert will explain why relying on software along isn’t enough, how to tap into data from multiple vendors, and how providers can manage patient populations.

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.

December 16 (Wednesday) 1:00 ET. “A Sepsis Solution: Reducing Mortality by 50 Percent Using Advanced Decision Support.” Sponsored by Wolters Kluwer Health. Presenter: Stephen Claypool, MD, medical director of innovation lab and VP of clinical development and informatics for clinical software solutions, Wolters Kluwer Health. Sepsis claims 258,000 lives and costs $20 billion annually in the US, but early identification and treatment remains elusive, emphasizing the need for intelligent, prompt, and patient-specific clinical decision support. Huntsville Hospital reduced sepsis mortality by 53 percent and related readmissions by 30 percent using real-time surveillance of EHR data and evidence-based decision support to generate highly sensitive and specific alerts.

December 16 (Wednesday) 1:00 ET. “Need for Integrated Data Enhancement and Analytics – Unifying Management of Healthcare Business Processes.” Sponsored by CitiusTech. Presenters: Jeffrey Springer, VP of product management, CitiusTech; John Gonsalves, VP of healthcare provider market, CitiusTech. Providers are driving consumer-centric care with guided analytic solutions that answer specific questions, but each new tool adds complexity. It’s also important to tap real-time data from sources such as social platforms, mobile apps, and wearables to support delivery of personalized and proactive care. This webinar will discuss key use cases that drive patient outcomes, the need for consolidated analytics to realize value-based care, scenarios to maximize efficiency, and an overview of CitiusTech’s integrated healthcare data enhancement and analytics platform.

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


Acquisitions, Funding, Business, and Stock

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Payer mobile messaging platform vendor HealthCrowd raises $2.1 million. Co-founder Neng Bing Doh is a UW-Madison computer science graduate who started out as software engineer at InstallShield and HP, while co-founder Bern Shen, MD, MPhil is a double-boarded physician who ran a VA ED and served as a South Pole doctor, later becoming chief healthcare strategist for Intel. 

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Drug company Pfizer will buy Allergan for $160 billion, with one of Allergan’s prized jewels being that it is headquartered in Ireland, where Pfizer will move its headquarters to reduce its US tax bill. Crafty lawyers structured the deal as the smaller Allergan buying Pfizer, which blocks some US interference even though the merged company will be called Pfizer and will keep Pfizer’s CEO. Merging companies always talk synergy and increased consumer value to wriggle the deal through FTC and SEC concerns, but somehow prices always increase as service falls apart.


People

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Patrick Anderson (Ochsner Health System) is named SVP/CIO of Hoag Memorial Hospital Presbyterian (CA).

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New York-Presbyterian names Daniel Barchi (Yale New Haven Health System and Yale School of Medicine) as CIO, as he confirmed on HIStalk last week. He replaces the retiring Aurelia Boyer.


Announcements and Implementations

Medical benefits manager EviCore Healthcare will use Merge Healthcare’s iConnect Network Services to manage imaging study prior authorizations.

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El Camino Hospital (CA) goes live on Epic with a project cost of $150 million.


Privacy and Security

A Forrester Research report predicts that 2016 will see the first infection of a medical device or wearable by ransomware.

Dell acknowledges a customer-reported security flaw in which the company shipped PCs with a certificate that inadvertently uses the same private key on every device, making it easy for hackers to impersonate that device. Dell has provided instructions for fixing the problem and says its just-released update will remove the certificate entirely.


Technology

The Robert Wood Johnson Foundation funds a project to develop a framework that will allow researchers to port their iOS ResearchKit apps to Android with minimal effort.


Other

KQED discusses biometric patient ID with a mixed level of credibility. It leads off with an overly provocative headline (“Would You Trust a Hospital to Scan Your Fingerprint?”); erroneously declares biometric ID to be “an alternative to a national patient identifier;” and fails to comfort fingerprint-nervous readers that the scanners don’t save the actual fingerprint or look it up in other databases – it simply records a mathematical model of the fingerprint to confirm a match. It does bring up the good point that it’s a big problem if someone were to hack a biometric database because users can change their password but not their fingerprint.

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I will extend the premise of MIT Technology Review’s predictable article “Your Doctor Doesn’t Want to Hear About Your Fitness Tracker Data” to posit that “Nobody Gives a Crap About Your Workouts, So Stop Yapping About Them.” There’s no reason other than navel-gazing narcissism to tell a breathlessly anxious world – whether in the break room or on Facebook — about your latest Runkeeper-recorded run or your just-completed kettlebell swing count. The fact that you use a fitness tracker means you’re probably pleased with yourself – it’s the people who don’t use wearables who might elicit a doctor’s exercise question or suggestion that would be worth the time required. Today’s medical model is that you tell your doctor what you’re experiencing in maybe 60 seconds, you get back 2-3 minutes of questions at best based on the doctor’s aggregated experience with other patients, and then the wrap-up is one or more of these options: (a) let me know if it gets worse; (b) get this test performed; (c) take this drug; or (d) go see this other doctor. Nobody is going to turn every encounter into a detailed probe into your health status in return for the small payment they’re getting as the waiting room backs up, so the last thing they want to see is patients waving around their irrelevant Fitbit step counts.

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The BBC quotes the founder of a telemedicine company who says, not surprisingly, that the mobile phone will change the face of healthcare. Babylon Health actually looks pretty good, offering online physician consultations via text message or video, appointment scheduling, answering medical questions via text message, and maintaining health records. It’s available only in the UK and Ireland, with UK customers paying $7.50 per month for unlimited consultations between 8 a.m. and 8 p.m with no contract required.

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I’m getting hooked on the blog of Chad Hayes, MD, a PGY-3 pediatrics resident at Greenville Health System (SC) and US Naval Academy graduate who describes himself medically as “a skeptic and a minimalist.” He’s a really good writer, to which I submit as evidence “The Presidential Candidates’ Brief Guide to Vaccines” and “On The Seventh Day, The Devil Created Gluten.” I almost never read blogs because those who write them are usually deficient in insight, writing skill, and often both, but this one’s a keeper.

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The Internet seems fascinated with the story of a 24-year-old uninsured man who was about to start his first job out of college in Pittsburgh, only to be rushed to an UPMC ED with a subdural hematoma. His uneventful treatment and recovery required only administration of an anti-hemophilia drug and a five-day inpatient stay. UPMC charged him over $1 million while warning him that the total could increase as it adds up the time spent by specialists (he says they spent only 40 seconds per visit each day asking him how he was doing and he said OK). The patient is likely to need the hemophilia drug for life at $200,000 per year, but the medical insurance he finally obtained from his new employer carries such a high co-pay and deductible that he can still barely afford it. The article includes comments from ZDoggMD (Zubin Damania, MD), who adds, “Our electronic health records are not designed for patient care at all—they are designed to be cash registers so the hospital can effectively bill for every little widget.” The patient concludes, “The US healthcare system is corrupt … the fact that it’s there for the sake of profit makes me sick.” UPMC, which pays its CEO $6 million per year, clarifies that the document isn’t actually a bill but rather a total of hospital charges, with the fact that they aren’t the same thing neatly encapsulating much of what’s wrong with the US healthcare non-system.

A study finds that requiring fast food restaurants to include calorie counts on their menu boards did not change consumer behavior a bit in five years – people just ignored the alarmingly high values and kept on choosing unhealthy food. McDonald’s admirably posted its calorie counts early, but I still see most people drinking milkshakes posing as coffee for breakfast and scarfing down piles of greasy fried foods in carefully avoiding the dreaded salads, apple wedges, and bottled water. The Affordable Care Act requires such menu labeling nationwide by 2016. Meanwhile, an investigative report finds that Coke heavily funded an anti-obesity group that promised to help the company avoid the wrath of what Coke calls “public health extremists” who want to use taxes or distribution restrictions to try to convince people to stop sucking down vast quantities of its sugar water like crazed hummingbirds attacking a feeder.

China Southern Airlines apologizes after a passenger with abdominal pain tweeted out that he wasn’t taken to the hospital until 15 hours after the flight’s emergency landing on his behalf. The plane’s captain didn’t open the door until 50 minutes after landing and then crew members argued with with ambulance workers over whose job it was to carry him to the ambulance. He ended up climbing down by himself and having emergency surgery at the hospital. The airline said it will work better with airport medical workers.

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Just in time for some spirited RSNA discussion: researchers find that trained pigeons rewarded with food pellets can analyze mammograms and biopsy slides for signs of breast tumors just as well as radiologists and pathologists. One bird, hopefully without a real-world radiologist counterpart, was never able to perform better than just picking randomly.


Sponsor Updates

  • Wellcentive is named #172 on the Deloitte Fast 500, also winding up at #2 in Georgia and #6 in healthcare IT overall.
  • Visage Imaging will demonstrate Visage 7 multimedia reporting and XML-based reporting integrated with Nuance PowerScribe 360 at Nuance’s booth at RSNA.
  • Voalte deploys its 11,000th Zebra mobile hand-held computer.

Blog Posts


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.

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Morning Headlines 11/24/15

November 23, 2015 Headlines Comments Off on Morning Headlines 11/24/15

Pfizer to buy Allergan in $160 billion deal

Pfizer will acquire Dublin-based Allergan in a $160 billion tax inversion deal that will move Pfizer’s headquarters to Ireland and create the world’s largest pharmaceutical company.

Moody’s warns of cybersecurity risks affecting credit ratings

Moody’s reports that while it does not look at cyberattacks as a principal driver of ratings, the attacks “will become more pervasive and begin to take a higher priority within our credit assessments and analysis.” The report lists healthcare providers, along with financial institutions and credit card companies, as the most vulnerable to attacks.

Ratings of U.S. Healthcare Quality No Better After ACA

Since 2001, Gallop opinion polls have shown little change in consumer satisfaction scores measuring healthcare quality and healthcare coverage in the US, while consumer satisfaction with healthcare costs has decreased during the same timeframe.

Ransomware could infiltrate medical devices, wearables

Forrester Research expects hackers to begin launching ransomware attacks targeting medical devices in 2016.

Comments Off on Morning Headlines 11/24/15

Curbside Consult with Dr. Jayne 11/23/15

November 23, 2015 Dr. Jayne 3 Comments

I’m still tunneling out after having been at the AMIA conference and then on site with a client who scheduled an emergency board meeting to discuss pulling the plug on their EHR. They’re a mid-sized multispecialty group that is physician-owned, so the entire board is made of physicians. The board meetings can be extremely contentious.

Apparently this one was in response to some agitation among doctors who recently joined the group and are not happy with having to give up their previous EHR, so they’ve united with some other unhappy doctors to push the idea that the entire group should change platforms.

My role was largely to support the IT department and the rational members of the physician leadership who don’t want to throw the baby out with the bath water. They’ve had some bumpy upgrades in the last year, but the group is also experiencing growing pains courtesy of some physician acquisitions as well as general growth in their geographic market. They’re also experiencing some Meaningful Use-related challenges with workflow (which is how they came to be my client). 

With all of that swirling around, it’s hard to lay blame on the vendor. Unfortunately, the vendor hasn’t had good communication through all of this and hasn’t been as participatory in troubleshooting some of the issues, so they already have a black eye.

Although the board meeting ran nearly three hours, we were able to achieve a reasonable resolution. I’m going back in a few weeks to do not only a workflow assessment, but also some stakeholder interviews to try to get to the root of what is going on as well as to try to uncover any other factors that haven’t fully bubbled up yet. Once we have the full picture from all the physicians (including those who are happy and therefore weren’t at the meeting screaming), we’ll be able to put together an action plan and make some interventions to improve things.

I did a follow-up call with the vendor on Friday. I don’t think they know what to make of a consultant who is not only a physician, but also knows her way around infrastructure. I left them with a to-do list of troubleshooting that they hadn’t even looked at yet, so I’m sure we have additional amusing (for me) and/or uncomfortable (for them) conversations in our collective future.

Also on Friday I listened to the Athenahealth Leadership Institute webinar, “An Interview with Dr. John Halamka and Jonathan Bush.” Although they had some audio troubles at the beginning, it was a good interview. I enjoyed John Halamka’s comments on information blocking and the perception that vendors, hospitals, and health systems are charging too much for interfaces. Halamka cited one survey that said physicians would be willing to pay $5 per month for information exchange, which is a far cry from the hundreds to thousands it may cost to implement an interface. Having seen it from both sides myself, it’s a great topic that needs further exploration.

They also discussed Halamka’s genome since it’s been sequenced and available, and how knowing his genetic status makes a difference in the screening services he should receive. I’m not sure if it’s recorded or available, but if it is, it might be worth a look.

I spent most of Saturday doing a community service project, which was a great way to reset after being gone for the week. I’m a mentor for a local youth organization and it’s particularly nice to see teenagers out serving the community, even if it means being in the snow and slush when they could be home watching TV and texting each other. This is my tenth year doing this particular project and some of the kids I started with are now old enough to drive, which is a bit of a scary thought. It does give me hope for the future, though.

As most of you know, I left my CMIO position some time ago. My hospital, however, still has not removed me from the email distribution lists, a fact which continues to provide ongoing entertainment. This week’s email gem (sent on November 19) outlined all the changes that took place in the system on November 17. I know I wasn’t perfect, but at least I got the change notices out before they happened. I know they’re in the middle of a system replacement and whoever is responsible for the communications now is probably distracted, but I still feel for the physicians and end users.

I also feel for all the employees who are going through open enrollment right now. Several of my friends have been cursing the rising premiums and shrinking benefits even with self-insured employers. I’m eligible for benefits through my clinical position, which thank goodness has no change in medical premiums and only 1 percent change in dental with the same level of benefits for both. I don’t know what kind of good karma we’re riding, but I know it’s making our employees very happy.

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Looking at the open enrollment statistics for the federal marketplace, the happiest callers might be the Spanish speakers, who averaged an 11-second wait for a representative vs. the average four and a half minute call center wait time. That’s still a lot better than I get with either my Internet provider or my cellular carrier. Looking at the data, there are a lot of window shoppers out there as well.

In other CMS news, I’ve seen several headlines about the Affordable Care Act leading to $2.4 billion in consumer rebates on health insurance premiums. This sounds like a lot of money until you realize how many patients it is divided among. My clinical employer was a recipient of one of those rebate checks, which ended up dividing out to $0.48 per employee – not even enough to cover a stamp. I’m sure our administrative staff spent a lot more than $0.48 per person dealing with questions and helping people understand how tiny it was. Personally I was in favor of taking the refund and donating it to a local food pantry, but they did go ahead and post the amount to each person’s paycheck. The CMS press release claimed $470 million in rebates for 2014 alone, averaging to $129 per family. Based on the math, some people might have gotten some nice rebate checks.

How’s your open enrollment process going? Email me.

Email Dr. Jayne.

HIStalk Interviews John Halamka, MD, CIO, BIDMC

November 23, 2015 Interviews 8 Comments

John D. Halamka, MD, MS, is chief information officer of Beth Israel Deaconess Medical Center and chief information officer and dean of technology at Harvard Medical School.

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What responses are you getting from your suggestion that Meaningful Use be dissolved and rolled into other CMS programs?

I would say 95 percent of the responses that I’m getting are very favorable. They say that the last five years has been like running a marathon every day. There’s a point at which you’re tired. You have to step back and say, "We’ve run a long distance." Now, how do we take that next step?

People of course say there’s some subtlety to moving forward, such as the Medicaid program was really about taking those without resources and funding them, as opposed to the Medicare program, which was initial funding followed by penalty. So when you say, “eliminate the program,” do you really mean no longer pay Medicaid providers to finish their implementations? 

That’s not at all what I meant. Which is to say, let’s get away from the idea of penalties on the Medicare side. Keep our Medicaid program still going, because if you’ve not finished your implementation, we’ve got to get that done. Instead of being highly prescriptive about the Medicare must-dos and the penalties resulting if you don’t, let’s offer some outcomes and let’s offer some variability. People have made that subtle comment.

One of the things they’ve also made a comment about is that I have recommended this FHIR standard. It’s something that is seemingly forward-looking. It’s the sort of thing Google and Amazon and Facebook would do. Some in the industry have said, yes, but there are some existent standards that are widely deployed. So maybe instead of just saying it must be FHIR and only FHIR, can you tolerate a transition period where some of the incumbent standards are used where they’re appropriate?

Of course. Being a reasonable person, I recognize change doesn’t happen overnight. You can’t go from a skateboard to a flying car. You might have some intermediate states. That’s recognized.

People have also commented, "Did you really mean to be negative about ONC?" What I tried to say … you write a lot, so you know it’s hard … I absolutely am not critical of any person. All I’m asking is, is the set of ideas, of getting very prescriptive and elaborative about the certification process, really a good idea? I think the answer with the certification rule is, it’s just too expansive in scope. It’s just  going to be too hard for stakeholders and especially developers to hit all the details that are in that rule.

The problem is that every time you give a developer an “or,” it means “and.” They’re going to say, "You could do it this way, or you could do it this way, or you could do it this way." There are customers who are going to ask for each of the variations. Really what it does is it takes our healthcare IT developers out of commission for a couple of years.

That’s really what I was getting at. People at ONC are very hard working and very well meaning, just probably as you pointed out early in the conversation have been so heads down in the details that they didn’t really look at the forest — they were looking at the bark. So, let’s step back.

Another thing that people have said is, "Did you really mean to eliminate all kinds of certification?" What I was getting at by saying let’s focus — if there were just three goals, maybe the right answer there is there’s still some kind of certification process, but it really is very narrow.

An example I can give you is if you went out to Best Buy today and you bought a DVD player, it will have a little Blu-ray symbol on it. You can expect that when you get it home and you plug in a Blu-ray disc, it will play. What I was saying is that we should focus on three things, such as can you use FHIR to do a push of data or a pull of data or get a patient to pull their data? You could imagine — of course I’m making this up as we go — that there are three little labels that you could be putting on the EHR package analogous to the Blu-ray label, so that you know when you got the package home, I will be able to push a payload to a trading partner or pull data from a foreign EHR.

Certification today is a multi-man year exercise where you are asked to enter a ZIP code and come back the next day and prove the ZIP code is still there. It’s just onerous, as opposed to a very narrowed set of, “When you take this home, it will do this.” Two or three things, not a thousand.

That’s the feedback. That’s the summary of what I’ve heard back.

You seem to be frustrated lately that the government is more involved in everything: HITECH, HIPAA, and  ICD-10, all enforced through Medicare. Do you think CMS has too much influence on what happens in the exam room between a provider and a patient?

I do. I’m not partisan in any way. It’s not that I have a Republican agenda or a Democratic agenda. I just try to have a multi-stakeholder agenda.

Here is an example. If Meaningful Use said, "We’re going to count the number of transactions you did,” but yet those transactions which I counted were actually not helpful to coordinate patient care or respectful of the patient’s wishes, was it really meaningful to count transactions? Here’s an example. You must, for a transition of care summary 5 percent of the time, ensure that from Provider A to Provider B, a package of stuff is sent. It turns out that package of stuff may be a bag of smelly garbage. That is, it’s 1,094 pages of completely unhelpful information, but I can count it in my numerator.

Wouldn’t a better measure be as a doctor, nurse, social worker, or physical therapist were you actually able to coordinate the care of this patient because you received the information that you thought was helpful to do so, somehow? As you know, I don’t have stock in any company. I don’t endorse any organization, so this is an exemplar. KLAS gathered together Cerner, Epic, eCW. Meditech, Athena, Surescripts, and others. If we want to look at the experience of data sharing rather than transaction counting, what questions would you ask?

Here’s a perfect example where the private sector said, we are very willing, in a Consumer Reports-like fashion, to have an independent entity call up 100 of our customers and ask them all these experiential questions which then will reflect — almost like a Yelp review — on the experience of interoperability with our product. That to me is a far better approach than CMS counting the number of bags of garbage that you sent.

What KLAS is proposing presumes that providers really want to share data with their competitors, at least on some occasions. Do you think customers are really demanding interoperability?

The United States has global capitated risk, bundled payments, and valued-based purchasing that’s been going on for five years in Massachusetts. Yet you go to the Midwest and there’s still fee-for-service.

Let me reflect on New England. We today at Beth Israel Deaconess have 1 billion dollars per year of bundled payment, risk-based contracts. We have told every doctor in our community it is not possible to manage risk unless we have, at every transition of care, about 150 data elements to understand what care was delivered. What’s the care plan? Who’s the care team? What’s the next bit of care the patient needs? What are the diseases we’re monitoring?

What you find, at least in our area, it isn’t even a question of siloed data, information blocking, or competitive whatever. It is an existential question. If you do not share data, you can’t survive, because we are paid for wellness, not sickness. I think a much more potent motivator than Meaningful Use or stimulus or compliance or penalty is this idea of, I will pay you when the patient is healthy or give you a fixed amount to keep them healthy. That eliminates these competitive kinds of barriers in information exchange.

Health systems haven’t done a good job at managing wellness or overall health outside of their own facilities. Are they capable of making the change from episode-driven care to population health management?

I just looked at our Pioneer ACO experience. I recognize that the Pioneer ACO program has very mixed outcomes. But at least at Beth Israel Deaconess, where we have 450 locations of care, we have gone beyond what we would call the EHR and now focus on the care management medical record. 

At our ACO, we have a single, normalized database that receives all the Meaningful Use transactions from every one of our clinicians and hospitals and urgent cares and SNFs and all the rest. Then the care managers are looking for variation. They’re looking for gaps in care. They’re looking for opportunities. They’re looking at risk and these sorts of things. 

I’m told we’re the #3 ACO in the country and the #1 in New England because of our capacity to reduce cost and improve quality with this care management medical record approach. You’re correct that the off-the-shelf products that exist today don’t do that very well, but it is certainly possible to use technology to accomplish the goals of, as MACRA will suggest, value-based purchasing.

The mainstream press and politicians seem to be paying attention the reactive phrases “gag clauses” and “information blocking.” Are big health systems using their EHRs to reinforce their market power?

When I say I’ve never seen information blocking — this is like the Loch Ness Monster, often talked about, but never seen — people do comment that information blocking can take many forms. Like a hospital that is technically not capable of sending information or a hospital that is 200 miles away from a referring physician and hasn’t quite got to the data transmission to those in the periphery. Again, speaking from Massachusetts, I have not seen hospitals and doctors use information blocking as a competitive weapon, thinking that if it’s my data, I will retain the patient and I will make more money.

In fact, I’ve quite seen the opposite. That is, there is this sense that if I need data for managing care and you need data for managing care, we had better bilaterally exchange data because it is no longer a competitive advantage to maintain a data silo.

The only time I’ve seen sluggishness in the transmission of data are for the reasons that I mentioned. That is, technically maybe a vendor or an IT department isn’t quite familiar with the technology. Or that there’s a Pareto diagram of all the clinicians we interact with and we’re going to start with the ones that are close, while the ones that are 200 miles away, we’ll get to. It’s not volitional. It’s just a function of resource.

What do you think of ONC’s proposed health IT safety center?

I have to read more about that. As I’ve read the various presentations about it, the concern that we have is that as we introduce new processes and technology, sometimes we create new errors and that we don’t really discuss those new errors in an open way. In New England, we have a patient safety organization which comes together to openly discuss these in a what I call a blame-free environment. I think that’s the notion of what ONC is trying to do at a national level.

I’ll give you a silly example. It’s not true, but it would illustrate the problem. If you came to me with high blood pressure and I wrote you for atenolol, which begins with A-T, I would never on a piece of paper write anything other than atenolol. Of course you couldn’t read it, but it would say atenolol. Whereas if I had an EHR that had a Google-like look-ahead feature and I started typing A-T and the first thing that came up was Ativan and I clicked on it and I was giving you Ativan, I’m giving you now something that’s an antianxiety drug instead of an antihypertensive.

That is a an error of commission. That is an error of technology that would have never happened in a manual process. I think those are the sorts of things that we identify locally in Harvard that ONC wants to see at a national level and Congress wants to see at a national level, enumerated and fixed.

Are EHRs poorly designed or are doctors just unhappy with the information insurance companies and the government require before writing them a check?

Probably there are a couple of answers to that. This usability question … I’m sure you’ve heard many, many people quote Justice Potter: "I have no idea what usability is, but I know it when I see it." Having an objective metric of usability … NIST is trying, but it’s hard.

Why are there usability challenges? I could argue Meaningful Use itself creates usability challenges. If, for example, there is a quality measure that says I must, in my denominator, only include people that have had strokes less than two hours ago. "Mrs. Smith, did your husband start talking funny one hour and 59 minutes about or two hours and one minute ago?" I now need to literally build a pop-up in the middle of my EHR workflow with a question about the timing of the stroke. It would never be part of my normal clinical data workflow.

As we do all these quality measures, as we do more and more structured data capture, what you find is that these vendors are having to add on all of these fields outside of workflow. That creates enormous usability problems.

One of the members of the Standards Committee said that they had actually done a usability analysis of how many clicks a nurse must use to admit a new patient and to document that new patient admission. The answer was 523. That was really just a function of all the regulatory mandates that require all the structured data capture.

I think we would all agree that each of the federal mandates on its own is a noble thing. All of us think domestic violence should be identified and treated, but that is just one of 100 structured things you ask on admission, "Do you feel safe at home?" That just creates real usability burden. Of course, one asks, are there other ways one can do this, such as a natural language processing or ways in which a free text entry is parsed by a computer and the clicks are reduced?

One of the things that I have suggested to Karen DeSalvo — and I think she recognizes it as a good idea —is maybe a certification criterion for the future is, “Did you eliminate the number of clicks by 50 percent?” Part of that has to be that the regulations were simplified so that we could.

I always assume that if one EHR requires 523 clicks, others might be 518 or 591. It’s not as though one vendor approaches things so differently that only they have problem with the number of clicks.

I would agree with you. Although, I live in a Web-mobile world. If you look at the user possibilities in a Web-based or mobile-friendly framework versus one that was more based on a client-server framework, I think you can probably achieve a better user experience on the Web than client-server. Many, many people debate that and I have no objective evidence to back it up, so it’s purely my bias. 

First, reduce regulation. Secondly, as we move to different kinds of technologies on the client side, probably the user experience will be enhanced.

Direct messaging never seemed to get the traction people expected, maybe because nobody ever took the responsibility to publish and manage a Direct address directory. Does Direct still have relevance in interoperability?

Here was the problem with Direct. As you say, whatever we chose — it could have been FTP, it could have been REST, it could have been SMTP — it depends on an ecosystem, not a standard. Dave McCallie, I think, wrote a guest post on my blog saying, “Standards are necessary, but insufficient.” So to say, “We will mandate Direct" was a lot like saying, "We will mandate you to drive a car, but we won’t have any highways.” How come you aren’t driving? Well, let’s see. We don’t have road signs and we don’t have maps. We don’t have any laws or governance. It’s pretty hard to drive. 

What should have happened with Direct is it should not have been mandated as fast as it was. It should have been encouraged and an ecosystem developed first. You’ve seen what I’ve written about things like a provider directory. It’s pretty hard to have successful Direct messaging in a community unless somebody has a directory of places to message to. DirectTrust, of course, is trying to work on the directory and certificate bundles and that sort of thing. When the Meaningful Use Stage 2 requirement was launched, DirectTrust didn’t have all that stuff built. Surescripts is trying to do the same thing.

You’re starting to see private industry building the missing enablers. As I wrote in the blog piece, some enablers may be government based. Some may be private industry based. Or you might have both. But it’s pretty hard to mandate the Direct protocol before the enablers exist.

Healthcare IT always gets stuck with some mandate that moves us sideways instead of forward. Are you concerned that we’ll chase data security with nothing really different than it was before?

You might guess that I spend a vast amount of my time on information and security. The challenge is, I mean, sure, go invest $5 million in technology. That won’t help you so much. You are going to be as vulnerable as your most gullible employee. What we’ve found is that you must invest, sure, in detection, prevention, and all the good things like firewalls, antivirus, and malware prevention, that sort of thing. But you also must educate every member of your workforce and you really have to reinforce that education.

For example, we have an internal, self-created phishing campaign that we use to test our employees’ knowledge of, “I just emailed you a password reset message with a URL in China. Did you click on it or not?” Of course, beyond that, you need very good policies, policies that people can actually comprehend. When I tell you, "You had better not show up at work with an unencrypted device," what does that mean? What kind of encryption? How do I do it? Be very specific. It’s hard to hold employees accountable for doing the right thing unless you show them how to do the right thing.

I tell people security is a process that will never be done. It isn’t a discrete project that you do once and forget. It’s technology. It’s education and policy. We can do it, as you say. It’s certainly an effort. It takes a lot of resource, but done right — and I think we can do it right — it’s an enabler.

Some of your CIO peers have told me they don’t stand a chance in trying to defend against a nationally sponsored, sophisticated cyberattack. Does government have a role or can something else be done to help individual health systems protect themselves?

There’s probably a couple of answers to that. Threat notification — that’s certainly important. That’s where, yes, the government has now crossed multiple industries, tried to create enabling legislation to share cybersecurity threats and vulnerabilities and do that in a way that can protect us all. So yes, we probably need to do that.

Harvard was attacked by Anonymous in 2014 with a massive distributed denial of service attack. This was published in The Globe, so I’m not revealing anything that is a secret. Was Harvard ready for a massive denial of service attack by a hacktivist group? That wasn’t one of the threats that anyone had enumerated as likely. So sure, the government can help us with that. If there is a mechanism of using government to help with forensics when you’re getting these kinds of attacks that are virulent and new, probably the government has more resources than an individual hospital.

I suppose one thing I would say is enforcement by OCR and OIG and other folks has to be done with an eye to, what is the community standard? If I see you as a patient and I do everything per the community standard but you still die … I mean you could sue me, I suppose, but generally malpractice looks at, was the standard of care followed, regardless of outcome achieved? If I put in intrusion detection and prevention and malware this and that and mobile encryption but still a state-sponsored cyberterrorist penetrates me? Probably I did everything I should have and I couldn’t defend again this highly virulent attack. Not my fault. You sort of hope OIG and OCR and others recognize it’s a community standard question not a, “I avoided all breaches forever,” because we will never all avoid breaches.

Do HIPAA fines and regulatory action need to be changed in some way to be less punitive and more constructive?

I certainly think that government regulators have to enforce based on volitional, “I spilled data because I actually gave it to somebody that I shouldn’t have,” or what I’ll call egregious malpractice. "I bought a wireless access point at Best Buy and put it on my data center," as opposed to, “I’ve had two publicly reported breaches over the last two years, neither of which I could control.”

As an example, if a doctor goes out to the Apple store and buys a device and thinks that adding a password to the device is the same as encryption and then the device is stolen but it was a device I didn’t even know about. Of course today, I the CIO am accountable for this device purchased at the Apple store that wasn’t encrypted. Of course, we do everything we can to now educate and anything we buy we encrypt, and all the rest. We did our best.

So, guys, what should we do? Tackle every individual who enters our building carrying a non-encrypted technological device? It’s not technologically possible. Recognize that there are gradations of things we can do and can’t do. Hold us accountable for the things we can do and recognize that education is often the best we can do in many circumstances and decide that that’s OK.

You mentioned in your write-up about the Meaningful Use program that it may have stifled innovation. What kind of innovation do you think healthcare or healthcare IT needs and what’s the best way to achieve it?

I have 19 developers total at Beth Israel Deaconess. Remember, we still self-build our EHR. It isn’t that Epic and Cerner and Meditech and Athena and eClinicalWorks or whoever are doing a bad job. It’s just that the kind of things that our clinicians have demanded and the prices we can afford to pay mean that building still works for us.

Look at the Meaningful Use “Statement of Burden.” I’m sure you’ve read all those thousands of pages. You look at these burdens like, “It will only take you 30 man-years to certify your EHR.” You’re like, "I have 19 people, total." Instead of working on Apple Watch medication reconciliation for elders in their home, I am now doing certification scripts. That’s where it has truly paralyzed my development shop for the last three years.

The kinds of things that our patients are asking for are more mobile technologies, more patient and family engagement, more what I’ll call family decision support, better access to information. There’s all these things that you would think, “Oh, if we were a customer service-driven organization, we would naturally offer them.“ But we have a choice — customer demand or federal regulatory stimulus and penalty. For the moment, we’ve got to go with regulatory demands.

People will then criticize me and that’s OK, saying "See, you shouldn’t self-develop. You should just go buy Epic and Cerner or whatever.” That’s fine, but Beth Israel Deaconess for 30 years has had this idea that innovation happens in the trenches, and that probably it’s a good idea to have a doctor code and come up with something that is solving a problem they saw today rather than wait a few years for a vendor to include it as a feature. Wouldn’t you love to have doctors and pharmacists and nurses and social workers creating software that solves real-world problems? Isn’t that the kind of innovation that we want to support?

What patient-facing technologies are you using or considering?

Recently we launched a program in our ICUs called MyICU. You’re familiar with various patient portals and these sorts of things. If you’ve ever had a loved one in an ICU or been in an ICU yourself, you know there’s a dizzying amount of data, but not a whole lot of information and wisdom.

What we’ve done is create an iPad app that shows patients and families –we’ve just written a paper that you’ll see published in JAMIA shortly about how we decide, based on patient privacy preferences, to share information with what family members and how does that work if the patient is intubated debated and that sort of thing – but it’s essentially a real-time dashboard saying, here are the goals that you have for today in this hospitalization. Here are your preferences for care. Here’s how the patient is doing against those goals. Here are the events of today. You’ve built this closed-loop information system with messaging back and forth between care team and patient and real-time interpretation of data into wisdom. Suddenly patients and families are saying, wow, I’m really an equal partner in my care here.

My father died two years ago and was in an ICU. Of course they said, "You know, his ejection fraction is 20 percent and his O2 sat on a non-rebreather is 82 percent and his creatinine has gone from three to five." Of course my mother goes, "Uh, and?" This app wouldn’t show you that. It would say the goal was to get him off a ventilator and that’s now red, so things aren’t looking so great. Or, we want to make sure that his organs are doing well, but that’s red, so they’re not. The kind of thing we’re focused on is not just raw data, but wisdom.

Is it hard to reconcile the science of informatics that could be versus the reality of what has to be?

Doug Fridsma, who is now the CEO of AMIA, and I had this discussion during the conference. He said that AMIA is striving to pivot from being a research-oriented group — the sort of folks that are in a lab and they’re more or less trying to push the envelope of possible — to a gathering of applied informaticians who are asking, how do you take Epic and optimize the care plan? Or, how do you take Cerner and do population health?

It’s exactly the point you make, that it’s probably a great use of all the smart people in our country to optimize the things we are seeing in the trenches as opposed to just work in the laboratory. That’s really what they want to do.

Do you have any final thoughts?

You may glean from some of my writing that there’s a hint of pessimism. We have been overwhelmed with Meaningful Use, ICD-10, the HIPAA Omnibus rule, and the ACA. The government has co-opted our agenda. Many of those great people in government who we worked with early in the Obama administration when there was hope and change have left.

I want to make sure the readers know that I’m incredibly optimistic about the future. What I see is that we are going from an era where we’re following regulatory requirements to an era where we, in theory, will be incented to innovate based on new kinds of payment models. Therefore, we actually will see – not one top-down command and control, this is what you must do, enumerated list of prescriptive regulations – but if you want to give all the 80-year-olds Apple Watches and monitor their vital signs and have visiting nurses come to their homes and keep them out of the hospital, we’ll reward you for that. Oh, but you don’t like Apple Watch? That’s OK, you can do something else.

I really feel that we’re on this cusp of moving to a new kind of work where we’re going to run lots of pilots. We’re going to learn. That’s really, I think, what the Institute of Medicine ultimately wants us in the next 10 years to be, is this learning healthcare system that tried a lot of things. Many of them will fail, but when they succeed, we’ll share them broadly.

That’s why I maintain my optimism. That’s why I come to work every day. That’s why, after 20-some years, I’m still a CIO.

Morning Headlines 11/23/15

November 23, 2015 Headlines Comments Off on Morning Headlines 11/23/15

DoD Meets Interoperability Requirements for Electronic Health Records

The DoD unveils its Joint Legacy Viewer, a web-based portal that captures key health data items from DoD and VA clinical systems and presents them to end users in a consolidated format. This, the DoD says, satisfies its federally-mandated requirement to integrate records with the VA.

6 Tips for Reading Your Own Medical Records

Cleveland Clinic warns patients viewing their medical records that provider notes written about them are not necessarily written as letters to them, clarifying that these notes could contain inaccuracies, incomplete documentation, poor grammar, and comments about weight or tobacco and alcohol use that should not be interpreted as personal attacks.

Epocrates removes flawed Bugs + Drugs app from the App Store

Athenahealth pulls its Bugs + Drugs app from the app store. The app launched in 2013, combining geo-located bacteria data from Athena’s EHR database with antibiotics data from its then recently acquired Epocrates drug reference app. The app was found to have outright medical errors shortly after launching and has not been updated since January 2014.

Epic Systems Corporation v. Tata Consultancy Services Limited et al

Epic wins an early victory in its legal battles with India-based Tata Consultancy Services, after a Wisconsin court finds that Tata’s consultants accessed Epic’s UserWeb and downloaded proprietary information without authorization, meeting the legal definition of “inside hacking.”

Comments Off on Morning Headlines 11/23/15

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