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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

HIStalk Interviews Michelle Holmes, Principal, ECG Management Consultants

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

Tell me about yourself and the company.

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

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

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

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

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

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

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

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

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

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

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

What is worrying academic medical centers right now?

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

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

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

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

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

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

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

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

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

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

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

Do you have any final thoughts?

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

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

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

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

Morning Headlines 4/20/16

Theranos Is Subject of Criminal Probe by US

Federal prosecutors have launched a criminal investigation to determine whether Theranos misled investors about the state of its technology and operations.

Major Health Insurer Bailing On Most Obamacare Exchanges

UnitedHealth Group pulls its plans from ACA exchanges, citing $1 billion in losses from the markets over the past two years.

Health apps: Unlimited promise or ‘like having a really bad doctor’

The LA Times highlights the persistently poor clinical quality of consumer-focused medical apps, citing concerns over diabetes management apps that do not instruct users to call 911 when their sugar levels are dangerously low, or apps for people with depression that do not recommend calling a suicide hotline when users report feeling unsafe or suicidal.

Movie stars have their uses: medical science isn’t one of them

The Guardian discusses the role movie stars have in forming public health opinions after Robert De Niro lobbied to have a discredited movie about the risks associated with vaccinations included in the Tribeca Film Festival.

News 4/20/16

Top News

Federal prosecutors launch a criminal investigation of Theranos, seeking to determine whether the lab company misled regulators and investors about its technology. Founder Elizabeth Holmes said during her squirmy and somewhat creepy “Today” show appearance on Monday (sans her trademark black turtleneck, but sporting her equally common deer-in-the-headlights look) that she was “devastated” to learn of extensive company failings of which she was previously unaware.

Holmes confidently told “Today” that the company will survive because the world needs it, although I wouldn’t be so sure. She says Theranos will “rebuild this entire laboratory from scratch.” Maybe the show’s label of Holmes as “billionaire” (on paper, anyway) was correct before the hydrogen-filled Theranos zeppelin went down in flames, but I doubt anyone would buy the entire, permanently tarnished Theranos for anywhere close to $1 billion at this point.

The mistake Holmes made in starting Theranos as a rich, Stanford dropout (at 19) was proclaiming it to be a high-valuation, disruptive Silicon Valley tech startup rather than a tiny entrant into the boring back office lab system business that is dominated by Quest and LabCorp, failing to put reasonable clinical oversight in place and competing with them mainly on price (although the sustainability of even that business model has yet to be proven). It’s  OK and maybe even desirable to be quirky, obsessively focused, publicity-shy, and inexperienced when you’re starting a faddish website for easily amused 20-somethings, but less so when you’re running a federally regulated medical business with lives on the line.

Reader Comments

From CarrolltonObserver: “Re: Greenway Health. Tee Green is stepping away and another 100 employees were let go last week. My guess is that Tee is slowly stepping away to get into politics.” See  my mention in the People section below. The company says Tee “will remain in an active, full-time role as executive chairman, focusing on innovation and growth initiatives,” which sounds like work more appropriate to the position he left than the one he’s taking. 

From Blue Horseshoe MD: “Re: cholera in Haiti. This article that describes the US implications is mind-blowing, but it also demonstrates the power of data visualization in epidemiology and thus in medicine.” Haiti’s cholera epidemic, which has killed nearly 10,000 people and infected 775,000 others, was apparently caused by UN peacekeepers from Nepal who brought the disease with them and from whom it spread due to negligent sanitation practices. The article says the CDC and the US administration are trying to hide the outbreak’s source by using questionable public health tracking measures. No cases of cholera had ever been reported in Haiti until the peacekeepers arrived and geo-mapping of reported cases points directly to the UN facility, with a CDC official going on record in unscientifically characterizing its response as, “We’re going to be really cautious about the Nepal thing because it’s a politically sensitive issue for our partners in Haiti.”

Speaking of the value of data visualization, the Johns Hopkins Bloomberg School of Public Health launches a fully online, part-time masters in spatial analysis for public health.

From How EMRya?: “Re: the EMR replacement market. All the vendors thought the high EMR dissatisfaction rate would keep the market going with replacements. I don’t think it evolved that way. Physicians burned themselves out with their selection process within the past five years and don’t want to go through it again with vendors that seem about the same. Companies like NextGen and Greenway are retooling their business to an EBIDA strategy of just holding onto the base in running a profitable company in a saturated market.” I agree that it’s not likely that large numbers of physicians will want to go through choosing and implementing a new EHR no matter how unhappy they are with their current one. Even if they do eventually switch, it would be tough to build a stable business based on what they might do and when they might do it. I predicted early in the HITECH days that vendors would scale up to meet temporary demand, but then find it hard to shrink back down once they had blown through their share of the taxpayer billions. Maybe that’s why everybody from Allscripts to EClinicalWorks is trying to pivot into something fresh that’s outside their historic core competency, which usually ends up being population health management for lack of alternatives.

HIStalk Announcements and Requests

Welcome to new HIStalk Platinum Sponsor PokitDok. The San Mateo, CA-based company (its name is pronounced “pocket doc”) offers a healthcare API ecosystem that meets consumer-driven healthcare market demands. APIs include clearinghouse (enrollment, eligibility, authorizations, claims, claims status, referral – all of those X12 APIs are free); patient scheduling (across all major PM/EHR systems); identity management (EMPI queries); payment optimization (medical financing qualification tools); and a Private Label Marketplace for provider search (scheduling, eligibility, payments).  Customers use these APIs to connect doctors to patients, to help payers and providers develop new business functions, and to connect EHRs and other digital health services. PokitDok’s APIs allow startups to scale immediately with lower cost, encouraging innovation and connectivity. Thanks to PokitDok for supporting HIStalk.

Here’s an overview video of PokitDok that I found on YouTube.

My latest pet peeve: people who say “pop health,” apparently challenged to find time in their day to enunciate the three additional syllables. They probably mean “population health management technology” anyway, so maybe their 10-syllable avoidance is worth it. 

Mrs. Ulhaque from Texas is happy that we funded her DonorsChoose grant request for a single classroom iPad that is shared by her 24 students. She says they love playing educational games and she is rewarding students who show academic improvement with extra time on it.

Also checking in is Ms. Munoz, who teaches Grade 5-6 math and science for special education students (intellectual disabilities, Down syndrome, brain injury, autism, etc.) We provided four tablets and cases, which she says have helped the students complete lessons they couldn’t previously tackle before because of their disabilities and motor skills problems.  The students who can’t write or speak are using a communications app that allows them to interact with their teachers and fellow students. Just to give you an idea of how little it costs to fund such a significant classroom project, HIStalk readers paid for half of the $363 total and Google matched that amount.

Webinars

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

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

Acquisitions, Funding, Business, and Stock

A reader provided details on the lawsuit brought by the MetroChicago HIE against Sandlot Solutions. The HIE says Sandlot took away its data access one day after warning it that it would be shutting down but then provided a database copy. The HIE said that was unacceptable since any technical snags in restoring the information could cause the HIE itself to shut down. The lawsuit says Sandlot was insolvent and was closing following a failed merger attempt. Santa Rosa Consulting, listed in the lawsuit as Sandlot’s owner (which I’m not sure is exactly true – the parent of both is Santa Rosa Holdings), was a co-defendant in the lawsuit. Sandlot announced its only funding round ($23 million) about 18 months before it shut down (it’s always a red flag when a company fails to raise new money unless it’s doing so obviously well that it doesn’t need it). Interestingly, the HIE says Sandlot’s actions violated HIPAA since the company is a business associate of the HIE. Also interestingly, the lawsuit claims that Sandlot refused to provide the HIE with its data because the database would contain previously deleted data from other Sandlot customers.

UnitedHealth Group makes good on its earlier threat to stop offering policies on Affordable Care Act marketplaces as it loses $1 billion on those policies over the past two years. The company will offer exchange policies in only a handful of states in 2017, saying that the market isn’t growing and it’s being stuck with sicker patients as younger, healthier ones don’t see the value in buying health insurance. UHG’s policies are rarely the least expensive and it holds only a 6 percent market share.

People

Scott Zimmerman (TeleVox / West Interactive) joins Greenway Health as CEO, according to his LinkedIn profile. He apparently replaces Tee Green, who is now listed on the company’s site as executive chairman.

Voalte hires Adam McMullin (SFW Capital Partners) as chairman and CEO.

Government and Politics

A study finds that nearly 3 percent of physicians who provide Medicare Part B services billed CMS for work that would require more than 100 hours per week, with optometrists, dermatologists, and ophthalmologists leading the pack. Those same providers also submitted more high-intensity billing codes than average. The authors suggest using Medicare’s utilization and payments data to flag potential fraud, although they probably underestimate the complexity of how providers use their National Provider Identifier to bill Medicare for services they don’t necessarily provide personally.

Florida becomes the second state to prohibit hospitals from balance-billing patients treated in their network for services rendered by the hospital’s out-of-network practitioners — such as surgeons, ED doctors, and anesthesiologists — for which the patient can’t seek an in-network alternative. The patient will pay the in-network rate, leaving the insurance company and provider to negotiate any additional payments.

Privacy and Security

The computer systems of Newark, NJ’s police department are taken offline for four days following a ransomware attack.

Other

The board of Massena Memorial Hospital (NY) approves $1 million to upgrade its “ancient” Meditech system (or “metatech,” as the local paper spells it) in contracting with CloudWave for cloud-based hosting. The CEO warned the board that their current implementation runs on Windows Server 2003, which he describes as “a big garage door somebody could hack their way through and steal everything.”

A brilliant article in London’s “The Guardian” says unlearned movie stars should stick to pretending to be someone else on screen rather than taking positions on medical science, referencing “Vaxxed,” the new movie about Andrew Wakefield, the widely discredited anti-vaccine doctor who eventually lost his medical license. Robert DeNiro included the film in his film festival with a vague rationale that the documentary “is something people should see,” only to pull it when scientists complained. The Guardian notes:

If “Vaccinating With the Stars” looks a little inappropriate where public health is concerned, so too is the prospect of children falling ill because an actor clearly hasn’t read Wakefield’s Wikipedia entry. Unless, worse still, he has.

An LA Times article quotes University of Michigan’s Karandeep Singh, MD, MMSc, who says unregulated and sometimes poorly design healthcare-related apps can be “like having a really bad doctor.” It points out a recent study of Instant Blood Pressure, a $4.99 app marketed without FDA approval that correctly diagnosed hypertension only 25 percent of the time, with the company hiding behind the excuse that it isn’t intended for diagnosis and treatment, thus rendering its raison d’être questionable.

A New York jury awards $50 million to a woman who says she has become incontinent after her obstetrician performed an unnecessary episiotomy during the birth of her healthy child in 2008. The woman says she was forced to quit her job, has to wear panty liners, and can’t have sex with her husband. The doctor, who insists he did nothing wrong and that the woman never complained about any issues, says, “Someone can just make up a story, cry to the jury, and they will ignore all the records and give her a big award.”

Sparrow Health System (MI), bowing to pressure from the National Labor Relations Board and the state nurse’s union, rescinds its policies that prohibited employees from talking about health system policies on social media and to the press. NLRB says the health system’s policies related to social media, cell phone use, the wearing of unapproved buttons, and gossiping are overly broad and are discriminatory.

Minnesota hospitals report that their emergency departments are becoming “holding pens” for sometimes violent mental health patients, forcing other patients to wait for hours or to be sent elsewhere as up to half of their gurneys are occupied by patients who require levels of oversight and security that few hospitals can provide. One hospital psychiatrist reports, “This is supposed to be a place of peace and security. Instead, we have acute psychiatric patients banging on windows, throwing feces, and assaulting people. It’s deeply unsettling to other patients in the ER.”

In Canada, Alberta Health Services will spend $316 million over the next five years to replace 1,300 mostly non-interoperable clinical systems with a single system that can maintain a single medical record. It will issue an RFP shortly. The College of Physicians and Surgeons termed existing systems “woefully inadequate” in late 2014, with a government official adding that after spending nearly $300 million, Alberta “really got nothing more than electronic isolated file systems. Do we realize we need to have data exchange standards before we start adding systems? We need systems to talk. It blows my mind.”

A study of those Dyson Airblade hand dryers with which business replace paper towels (while claiming unconvincingly that their motivation is your health rather than reducing their restroom expenses) finds that they blast germs onto anyone within 10 feet of the bathroom wall, so you’d better hope the person using it washed their hands well first. Dyson disputes the study, claiming the paper towel cartel is behind it.

Sponsor Updates

• Aprima will exhibit at the Boulder Valley Individual Practice Association meeting April 26 in Lafayette, CO.
• Catalyze CEO Travis Good, MD will speak at the HITRUST Annual Summit April 25-28 in Grapevine, TX.
• Besler Consulting releases a podcast on “IME Shadow Billing.”
• Crossings Healthcare Solutions will exhibit at the Cerner RUG April 20-22 in Charlotte.
• Cumberland Consulting Group Managing Director Tom Evegan guest blogs for Revitas.
• EClinicalWorks will exhibit at the California MGMA 2016 Annual Conference April 22-23 in Sonoma.
• Isthmus Magazine features Healthfinch and its data partnership with Beekeeper.

Blog Posts

• Medical billing & EHR software tips for tackling 1,900 new ICD-10 codes (AdvancedMD)
• What in the Health IT (Arcadia Healthcare Solutions)
• Healthcare CIOs Share Their Interoperability Challenges (Iatric)
• Nurses deliver in the digital world: Real champions for change (CapsuleTech)
• How a Rare Disease Inspired the Creation of a Patient-Centric Healthcare Solution (CareSync)
• New York Temporarily Waives Legislative Requirements for Specific Prescription Types (CoverMyMeds)
• Clinical Communication: It’s about more than just the phone! (PatientSafe Solutions)
• Physician Quality Reporting (PQRS) (Culbert Healthcare Solutions)
• 3 Helpful Tips to Beginning Your IT Job Search (Direct Consulting Associates)
• Newly Proposed Bill to Delay CJR is Predictable and Pedestrian (ECG Management Consultants)
• The Do’s and Don’ts of Credentialing (E-MDs)
• Professional Services – the difference between your project’s success or failure (Extension Healthcare)
• Let the “Go Lives Roll” (FormFast)
• Success Story: CPSI to Epic Conversion (Galen Healthcare Solutions)
• Risk-Based Auditing: Why it May be the Right Choice for Your Organization (Hayes Management Consulting)
• Welcome to the New HCTec (HCTec)
• Costs Should Be Part of the Equation (Healthwise)

Contacts

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

Morning Headlines 4/19/16

Theranos Chief Elizabeth Holmes Is ‘Devastated’ Over Lab Deficiencies

Theranos CEO Elizabeth Holmes responds to federal calls for her ban from the blood testing industry, saying she is “devastated that we did not catch and fix these issues faster.”

CMS drops two-midnight rule’s inpatient payment cuts

CMS will stop imposing inpatient payment cuts to hospitals under the two-midnight rule.

Celebrating the Medicare Access and CHIP Reauthorization Act’s First Birthday

Acting CMS administrator Andy Slavitt discusses the impact MACRA is expected to have on healthcare reform on the one-year anniversary of its passage.

Why Medical Devices Aren’t Safer

The New York Times argues for more robust tracking of implantable medical devices.

Curbside Consult with Dr. Jayne 4/18/16

I recently concluded a long-term engagement with a client. Having started as a small private practice, they had grown to 20 or so physicians and wanted to get larger, but had been running in circles trying to figure out how to grow their business.

I was hired to do an analysis and conduct some strategic planning sessions. After my first call with them, it was clear that a multiple decisions had somewhat sabotaged their chances for success and that much work was needed before we could truly embark on strategic planning.

None of the physicians had really wanted to take the lead in managing the practice, so they hired an outside administrator. For lack of a better description, he was the Harold Hill of practice leadership. He had billed himself as an experienced administrator who could help them grow from 20+ physicians to over 100 in less than two years, so they hired him. I knew he was going to be an issue because he instantly opposed my involvement with the group, with some of his comments being red flags that he had something to hide.

It was clear early on that they had some serious issues with physician satisfaction and employee engagement that would make it difficult to grow at all, let alone quadruple in size. It’s hard to recruit physicians when the existing ones are disgruntled and when you’ve had turnover issues with staff.

When I tried to explore how their staffing ratios looked compared to various professional organization statistics, he couldn’t even cite his own ratios, falling back on the fact that, “Every one of our locations is a little different” over and over. The word “evasive” didn’t even begin to describe him at this point. He also kept going around and around about the fact that “we’re a family” and extolling the virtues of various team members.

In my experience, that’s a technique used to try to distract an observer from the fact that they are overstaffed, underproductive, or both. At many practices I’ve worked with, the sense of “family” often does not outweigh the fact that a staff member is dysfunctional or incapable, but it’s cited as a reason that the issue has not yet been dealt with. Family or longevity can also be a way to try to camouflage overcompensation of resources that haven’t been able to keep up with the evolution / revolution we’re seeing in healthcare delivery.

Once the administrator was hired, the physician partners gave him the reins and stopped checking in on management issues. There were some red flags on the revenue cycle side (lack of clean claims, increased denials, failure to track down slow-pay or no-pay accounts) and it was clear that some of the critical reports available in the practice management system had not been run recently.

The managing partners were shocked to hear that this was going on, although the audit trail data in the software was clear. If he wasn’t running the reports, he certainly wasn’t presenting the information to the practice. However, I had a hard time figuring out whether he was presenting bogus data or no data at all, because the physicians all just stared at each other around the table. When pressed about the lack of reports, he immediately threw the practice management vendor under the proverbial bus, but was unable to provide support tickets for the alleged problems.

In digging deeper into some of the employee satisfaction issues, it was clear that the new administrator had chosen his favorites and wasn’t doing anything to build relationships with the rest of the staff. He had given the favorites control of the other staffers and wasn’t monitoring the equity of shift assignments or the quality of work being performed. What I heard from the line staff didn’t match up with the inspirational posters he had placed around the office regarding the ability of employees to drive the success of the business.

Turnover was a significant issue with the clinical support staff. In working with the practice over several months, it was clear that they had no plan to engage the staff beyond just the day-to-day duties performed in a medical office. Those staffers that showed initiative and drive were quickly shut down by some of the favorite staff, who saw energetic young staffers as a threat. They quickly left.

Some of the remaining staff members were mediocre at best and were interested in punching the clock rather than making the practice great. While I was working with them, two staffers resigned. I asked if I could participate in the exit interviews and learned that they didn’t have them or see a need for them. I instituted them anyway and found that the employees didn’t feel like there was any room for them to grow in the practice, that they didn’t feel valued, and that they didn’t see it as a place they wanted to stay.

One mentioned that the administrator had done an employee survey which was supposed to be anonymous, but they suspected that their responses were identified and were shared with the middle managers who may have used the responses in a retaliatory manner. It’s a shame for an organization to fail to take advantage of employee feedback, but thinking that you can get away with creating a hostile / retaliatory workplace in this day and age is just shocking. Healthcare workers are in demand (particularly skilled ones who are energetic) and organizations should seek to cultivate them and empower them. This means really engaging with them and not just paying lip service to the concepts.

Apparently at least one of the partners had asked about turnover. The administrator’s idea was to put in place a bonus structure that was not clearly documented or well executed. Employees were told they would receive a bonus, and then it would be months before it was paid if it was paid at all (as was reported by two staffers). I’m not completely blaming the administrator for all of this, as the managing physician partners were also responsible for the situation. When hiring someone into a position of authority, organizations need to make sure the transition is carefully monitored and that outcomes are matching expectations. If they’re not, then there needs to be an intervention.

After receiving the results of my initial analysis, the practice decided to have me try to mentor the administrator to see if he could be salvaged. My gut instinct was that this was not going to be possible, but I was willing to give it a go. Working with him on a day-to-day basis, it was clear that he had no strategic plans for the practice and really had no idea what he was talking about in a lot of core areas. We tried to discuss managed care contracting as it relates to practice growth and he quickly became defensive, trying to cover the fact that he was lost in the discussion. We talked about physician incentive strategies and staff engagement and he had no concrete plans or goals. When asked to discuss the practice’s mission and culture, he popped out a canned response but could not elaborate.

After a couple of weeks, it was clear he wasn’t going to be part of their go-forward strategy, but the practice was on the fence about actually terminating him. Practices are often afraid of letting people go for fear of being sued. I explained to them that it’s really a fairly straightforward process, depending on whether you have an employment agreement or not and whether the job description is clearly documented. I suggested trying to document “non-performance of essential duties” strictly through the lack of diligence around the financial reporting requirements, which should have been a clean way to do things.

I was surprised that they didn’t want to go that way and instead wanted additional documentation. I explained that this would require some effort on the part of the managing partners as well as additional risk to the practice while the administrator was allowed to continue to alienate staff and fail to manage the practice. They disagreed, so we embarked on a four-week effort that ultimately did culminate in his departure, although not without a lot of angst among the partners and turmoil in the office.

My partner and I finally got them stabilized and spent quite a few additional weeks creating policies, procedures, and protocols to help take them forward. We took them through a search process and they’ve hired a new administrator who will be carefully supervised by one of the senior managing physicians, according to the steps we’ve laid out for them. My partner is going to continue to work with them on a weekly basis to make sure we can solidify their process and keep them moving forward. We’re planning to conduct the original strategic planning engagement down the road, but want them to show that they can at least keep 20 physicians and the accompanying support staff stable before they decide to try to grow again.

Given the changes in healthcare, I want to root for the independent practices and am happy that they are a large part of my consulting practice. It’s easy to throw up your hands and allow your practice to be purchased by a hospital or health system, but it doesn’t fix anything. Usually it creates more issues. I’m hopeful for this group, but we’ll have to see what the next six months bring.

Has your organization experienced their own Harold Hill moment? Email me.

Email Dr. Jayne.

HIStalk Interviews Ben Moore, CEO, TelmedIQ

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

Tell me about yourself and the company.

We’re a healthcare IT company focused on improving communication between clinicians to save time and increase patient safety. We do that by supplying HIPAA-compliant texting and voice solutions that integrate with the clinical systems in the hospital. We work with over 300 healthcare organizations to improve communication for close to 80,000 clinicians every day.

This company was started based on personal experiences within the healthcare industry. More specifically, my wife was in the hospital with a complicated pregnancy with the arrival of my daughter. I noticed a lot of issues in the communication between providers, specifically when patients were being handed off between doctors and nurses. That inspired me to start the company to fix that problem.

Into what groups would you categorize your competitors that offer pager replacement and secure messaging?

The first-generation, basic solutions take text messaging and secure that channel. The majority of the vendors fit into that space. There’s not really any efficiency gained by those solutions. There’s no clinical work flow. They don’t solve any of the fundamental problems. They just secure a channel that’s already being used. That’s the largest quadrant.

One step up from them are systems that attempt to do some integration with other systems, such as the call center and physician schedules.

The more strategic vendors are the ones that have robust, bi-directional integration with the medical record as well as work flow concepts.

The other component here is voice. Voice still drives between 30 percent and 50 percent of all communication between clinicians. You can also segment that out by which ones offer voice and which ones do not.

Sometimes technology vendors don’t understand that pagers offer value over telephones because they are asynchronous, which prevents busy clinicians from being interrupted. Are some vendors good with the technology but not all that aware of optimal clinician use?

Secure texting solutions give you that asynchronous approach, but it’s always been our belief that they’re not enough to replace pagers. We think it’s a dangerous context for an organization to try and replace pagers with texting. Some examples, such as who should get Dr. Smith’s messages when he’s unavailable? What happens if a page is not responded to in five minutes? Secure texting solutions don’t address those issues.

Pagers are more reliable than a smartphone in the sense that they are able to penetrate to the bowels of a hospital. It’s not enough just to say we’re going to replace pagers with secure texting. You need policy and rules behind how those messages get delivered.

The other thing that you need is voice capability, so you can call a pager number and leave a message. Secure texting platforms don’t do that.

How do you see the convergence of communications devices or services in healthcare?

There’s a few issues with respect to the secure texting solutions today. A lot of hospitals will buy them and layer them on top of other systems. It’s just one other mode of communication. Adding another secure texting platform to existing nurse mobility, house phones, and pager devices is not enough. It just adds to the clutter.

Our vision is of a single solution that coordinates all of those device end points. We’re calling that a healthcare communications hub.

As far as clinical integration, when you look at EMR platforms, when they’re used properly, they do a good job at clinical documentation. Some of them do an OK job at clinical work flow. But there’s a lot of things that need to be communicated between providers that should never go in the medical record, and some things that should. That’s one of the problems that we’ve tackled as a company.

For example, even a secure texting platform is not appropriate for the texting of orders if you haven’t thought through how those orders would make their way back into the medical record.

Are you taking situational awareness from the EHR and sending out alerts?

That’s one of our fundamental work flows. We have a deep level of integration with not just the EHRs, but also the lab systems.

We have a policy engine that allows the organization to set thresholds. For example, if a critical patient value comes back and it’s not read or accepted or reviewed by a clinician within a certain period of time, escalations can occur. That does two things. It improves your clinical efficiency by not requiring, for example, a physician to repeatedly log in to check for test results in the EMR. But it also fulfills the Joint Commission requirement to have escalations on critical lab value delivery back to the requesting provider.

What you said is exactly on point. That’s really where this industry is headed, which is situational awareness-based. Not just on the medical record, but also on the physician’s schedules, the time of day, and other policies that affect patient care.

What are the challenges in making the conversion from a hosted pager infrastructure to Wi-Fi or cellular?

It’s less of a problem now than when we started the company five years ago. You have corporate Wi-Fi that’s been put in place for the support of telemetry applications in healthcare. You can leverage a lot of those networks for the communications network.

What happens when the message does not get to the end point? That’s where you need a system that identifies that scenario and can respond on it through escalations or try an alternate delivery of a message. That’s an area that we were focused on from the beginning of our company. We productized that with our first launch called SmartPager. That’s exactly the issue that we addressed initially.

Is it now assumed that employees will use their own devices or are health systems buying devices for them?

What we’ve seen now as the norm is a mix of the two. It’s divided based on the type of clinician.

In the majority of our clients, the physicians are using “bring your own device” based on their preference. Some physicians are using corporate devices. But almost ubiquitously, all the nurses and other clinician staff that are on the communication network are using it from a corporate device.

It’s obviously important to have a solution that works nicely in that “bring your own device” environment, but that can also support a corporate device scenario. I believe that’s going to slowly evolve, where nurses will start to get more into the “bring your own device.” But right now, typically the policy for nurses would be corporate devices accessing through, for example, the nurse workstation. It’s not very common to see a “bring your device policy” for nurses. In fact, I haven’t seen that in my five years.

Are health systems interested having patients securely message into the health system with enough system intelligence to route their messages correctly, such as for population health management?

Yes. That is one of our initiatives, to allow patients to be a part of the communication platform.

Our experience when we tried to launch that initially was that it’s almost impossible to reliably get patients to install an app. Where we’ve taken the product — and where I believe the industry will go — is it will be a mobile Web experience that has a very similar experience to an installed app. That’s the best way to drive patient adoption, to not require them to install an app.

When the patient communication comes back in to the healthcare network, it has to be triaged based on who that message should go to and based on the call schedule and availability of the providers.

How does an answering service fit into the communications suite?

Our answering service essentially extends what is already being used as the texting platform and turns it into a converged solution. Clinicians can use one application to handle all of their texting and voice calls.

On my iPhone, if someone sends me a voice mail, I have no way to share that voice mail with a colleague. I’s the same thing for clinicians.Our solution allows voice mails to be passed around as they were text messages to allow for better communication. A lot of HIPAA audits overlook the fact that voice mail on personal devices is not secure and not being governed by the organization. By using a platform like ours, you can lock down not just texting, but also the voice mail communications between providers.

Where do you see the communications spectrum evolving over the next several years?

Things will be consolidating into single platform that involves all the stakeholders. Right now you have companies focusing on physician communication and others on patient-to-doctor communications, patient-to-practice communications, and nurse call communications. There’s no reason that can’t all happen on one platform, But in order to accomplish that, you need the clinical expertise, the integrations, and the experience of being in the market for a number of years.

Monday Morning Update 4/18/16

Top News

Epic’s trade secrets lawsuit against India-based Tata Group concludes with the Wisconsin jury awarding Epic $940 million in damages. The verdict calls for Tata to pay Epic $240 million for the benefits received by its subsidiary (Tata Consultancy Services) from stealing Epic’s trade secrets plus another $700 million in punitive damages. The lawsuit said employees of Tata posed as Kaiser Permanente employees to gain access to client-only Epic documentation that Tata planned to use to develop a competing product.

Tata says it will appeal, claiming it did not use Epic’s information in the development of its Med Mantra system. The company says its developers never saw Epic’s materials.

The $940 million judgment will certainly be reduced by the presiding judge, who chided Epic’s damage claims before the hometown jury’s verdict was announced. He observed:

• Epic didn’t provide the court with the method it used to calculate its damage claims until after the trial began, which could cause those claimed damages to be excluded.
• Epic hasn’t proved that it was damaged to the extent claimed or that Tata benefited to that degree, explaining, “The complete lack of evidence tying the costs of Epic’s research and development efforts to any commensurate benefit to TCS dooms its methodology.”
• Epic claims that the biggest benefit to Tata wasn’t stealing development secrets or source code, but rather then value of “what not to do” that is “spread throughout the enterprise.”
• The only evidence provided of how Tata used Epic’s information was a side-by-side marketing graphic comparing Epic’s products and Tata’s Med Mantra, with the claimed damages “based on Epic’s speculation that the confidential information is sitting on a shelf somewhere to be used immediately after this trial ends.”
• The judge says such “future use” assumptions are more appropriately addressed via injunction to prevent such use  rather than a speculative damage award. He also noted that Tata has mostly failed in its attempts to penetrate the US market and that an injunction would reduce its chances even further.

Reader Comments

From Verisimilitude: “Re: HealthTap access on Facebook Messenger. I’m not sure how much privacy protection people are given. I’m no HIPAA expert, but my guess is there’s a big fat release and arbitration clause buried in a EULA someplace.” Video visit vendor HealthTap offers a free chatbot Q&A service using Facebook Messenger rather than real-time access to actual human doctors. HealthTap’s terms of service are indeed voluminous and include an arbitration clause. I tried the Facebook service and it was worthless – all I received within several hours of asking a simple question was a list of previously answered similar questions (that weren’t similar at all) and a link to HealthTap’s site.

From Nasty Parts: “Re: NextGen. A major re-org was announced as Rusty Frantz continues the Pyxis-ization. It has dissolved its silos into ‘One NextGen,’ and as a result, multiple senior execs are transitioning out.” Unverified. Nasty Parts named several VPs who are leaving and says there’s “much more change to come.” I’m not sure that’s a bad thing. Frantz has been CEO at Quality Systems for almost a year, so he’s had time to think through what needs to be done.

From Maury Garner: “Re: Sandlot Solutions. You reported their closing. I ran across this lawsuit filed by one of their customers to prevent Sandlot from destroyer their data immediately after copying it for them. The article describes Sandlot Solutions as insolvent and closing.” I don’t have a Law360 subscription to see the details, but your description of their article seems accurate.

From Rebuttal: “Re: IT departments. In the last 5-6 years, I’ve noticed that organizations I’ve interviewed with seem to care more about what I can bring rather than having a balanced interest in our mutual needs. It seems that complex vendor systems have turned IT departments into sweatshops.” It may well be that the high cost of vendor systems has raised provider expectations that new hires will immediately pay off in task-specific, product-specific ways with implementation and optimization. It’s also probably true that for-profit companies in particular aren’t as interested in investing in mutually satisfying long-term relationships with new hires who might bolt once they’ve built their resumes. Lastly, I would speculate that the rise of the 1099 economy has redefined the work environment on both sides to a “what have you done for me lately” mindset. I’ll invite readers to weigh in.

From Vince Ciotti: “Re: Bill Childs. Just to make sure readers appreciate how progressive Bill and the pioneering team at Lockheed were, they also came up with:

• CRTs (cathode ray tubes). They called them VMTs (Video Matrix Terminals) in an era when most systems relied on keypunch cards and green bar paper reports for input and output.
• Light pens. The precursor (punny?) to today’s mice, an idea Jobs and Wozniak copied from Xerox PARC. Clinicians using MIS only had to click on the VMT screen instead of trying to learn touch typing.
• Screen building. Lockheed (later TDS) called it matrix coding, but teams of clinicians designed their own order screens rather than implementing a model designed by programmers who never saw a patient.

Feeling nostalgic? You can read more in Vince’s HIS-tory series that ran on HIStalk for several years. I immersed myself back into them over the weekend as a guilty pleasure.

From Rocket J. Squirrel: “Re: Erlanger. A rocky start to the Epic project. The consultant evaluation ignored the lowest-cost option and the CTO who made the decision is gone after eight months. Totally behind on project staffing and already six months delayed.” Unverified.

From Alpha Surfer Dude: “Re: Dr. Brink’s article on radiology benefits managers. See what’s going on in Hawaii if you want to learn why this is so topical.” A Readers Write article by James A. Brink, MD, vice chair of the American College of Radiology and Mass General radiologist in chief, criticized plans to require pre-authorization of advanced imaging. He says electronic guidelines can help ensure the appropriateness of such orders in real time. Insurer Hawaii Medical Service Association (HMSA) made outpatient imaging pre-authorization mandatory in December 2015, leading doctors to complain that care is delayed and that tests are often denied. Newly proposed legislation would hold insurance companies rather than providers liable for any civil damages resulting from pre-authorization delays. HMSA requires doctors to contact Arizona-based radiology benefits management company National Imaging Associates (a subsidiary of publicly traded Magellan Health), leading one Hawaii doctor to complain, “Do you want those decisions to be made by offshore non-experts?” Taking the counterpoint, it was widespread ordering of medically questionable imaging studies – sometimes by doctors with a financial interest in the machines used to perform them — that created the need for such restrictions in the first place. As they say, one person’s excess cost is another’s livelihood.

HIStalk Announcements and Requests

Only 12 percent of poll respondents have had a virtual visit in the past year, although 81 percent of those who did were satisfied. New poll to your right or here: would you be worried about your privacy if you were being treated for depression by an EHR-using provider? Please explain after voting.

Mrs. May, a first-year teacher from Florida, says her special education classes are using the STEM and engineering kits we provided in funding her DonorsChoose grant request not only to learn about science, but also “how important communication is to get to the finish line.”

Also checking in is Mrs. Johnson from Oklahoma, who says her elementary school students “are loving the hands-on materials that you have provided for us. I no longer hear any complaints when I ask them to go to their math stations because they are not only enjoying them, but they are practicing their skills.”

Last Week’s Most Interesting News

• CMS threatens to ban Theranos CEO Elizabeth Holmes from the blood testing business for failing to correct problems that CMS had previously called to the company’s attention.
• Kaiser Permanente launches a database of data contributed by its members that researchers will use to study how genetic and environmental factors affect health.
• CMS announces a five-year pilot of CPC+, a medical home model that requires the use of a certified EHR, and for one of the two tracks, a signed agreement from the practice’s EHR vendor that it will support the capabilities needed.
• Kaiser Permanente releases a summary of what it has learned from having a large number of its patients use a portal, disclosing that one-third of its PCP encounters are now conducted by secure email with expectations that the percentage will increase significantly.

Webinars

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

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

Acquisitions, Funding, Business, and Stock

Cardinal Health-owned NaviHealth, which offers post-acute care utilization management services, will acquire care transition software vendor Curaspan Health Group.

Behavioral health software vendor Quartet Health raises $40 million in a Series B funding round led by GV (the former Google Ventures), increasing its total to $47 million.

People

Mark Cesa, whose long healthcare IT sales career included stints with Baxter Healthcare, GTE Health Systems, Eclipsys, Tamtron, QuadraMed, Allscripts, and Napier Healthcare, died of cancer April 1. He was 61.

Announcements and Implementations

Voalte announces that it signed 125 hospitals in its fiscal year ending March 2016, increasing its customer base by 83 percent.

Imaging IT expert Herman Oosterwijk posts the Digital Imaging Adoption Model that was announced a few weeks ago by the European Society of Radiology and HIMSS Analytics.

Government and Politics

VA CIO LaVerne Council says in Congressional testimony that the VA needs “a new digital health platform” and seems to suggest it will pursue a custom-developed system rather than buy a commercially available product or upgrade VistA. Council says a working prototype will be available in a few months that “is aligned with the world-class technology everyone’s seen today and using in things like Facebook and Google and other capabilities. But it also is agile and it leverages what is called FHIR capability, which means we can bring things in, we can use them, we can change them, we can respond.” Lawmakers are justifiably concerned that the history of the VA specifically and government agencies in general suggests a high likelihood of expensive failure and lack of interoperability with the DoD, but Council says the cost-benefit analysis is solid. She also reiterated previous statements that the VA is putting its $624 million Epic patient scheduling system rollout on hold while it tests its own self-developed system that will cost just $6.4 million. The VA and Congress, anxious to deflect bad publicity about the VA’s wait time scandal, quickly threw IT money at the patient scheduling problem last year despite scant evidence implicating technology as the problem.

CMS Administrator Andy reiterates that EHR certification will require vendors to provide open APIs for interoperability.

Privacy and Security

The Department of Homeland Security’s US-CERT urges Windows PC users who have Apple’s QuickTime installed to de-install it immediately after a security firm finds major vulnerabilities and Apple quickly drops QuickTime for Windows support. It’s fine on Apple devices.

A federal appeals court rules that a healthcare company’s general liability insurer must defend it against security breach claims even when the policy doesn’t specifically include cyberbreach wording. .

Other

Jenn covered for me Thursday and mentioned the JAMIA-published study that found missing information about patients with diagnoses of depression or bipolar disorder, about which I will opine further. The authors try to make the case that primary care EHRs suffer from “data missingness” that indicates that “federal policies to date have tilted too far in accommodating EHR vendors’ desire for flexible, voluntary standards” that “can lock providers in to proprietary systems that cannot easily share data.” Underneath that big (and preachy) conclusion is a little study with a lot of problems:

• It analyzed data from 2009 only, eons ago in HITECH years (in fact, that was the same year that HITECH was passed, well before it had significant EHR impact).
• It covered patients from a single insurance plan’s patients, treated by a single medical practice, using a single EHR (Epic).
• The “data missingness” it claims involves only two behavioral health diagnoses that were likely treated by specialty providers (LCSW, PhD, psychiatrists) who weren’t HITECH-bribed to adopt EHRs and who often don’t use them because of privacy concerns and lack of benefit.
• The study matched EHR information to claims data in finding that 90 percent of acute psychiatric services were not captured in the EHR. The authors should have noted that many patients seeking behavioral health services pay cash to avoid creating a claims history, seek help from public services, or travel out of their own area for them to maintain privacy, all of which could impact their conclusions.
• It’s likely that some or even most of the patients with missing information would have opted out of automatic sharing of their behavioral health information given the chance.
• The authors blame EHR vendors for the lack of interoperability, but give the organization they studied a free ride in assuming that it freely exchanges information with any other provider who expresses interest.
• The study seems to state an expectation that every primary care provider’s EHR have a complete patient record from all sources of care, which is a nice dream, but as they correctly conclude is not today’s reality for many reasons, most of them unrelated to EHR vendors. That doesn’t necessarily mean the information isn’t available (via an HIE, records request, patient history, etc.) but only that it isn’t updated in real time across EHRs everywhere.
• Lack of information doesn’t necessarily change the treatment plan or outcome. Doctors have never had that information, electronic or otherwise, so it’s not like EHRs caused a new problem.
• The best conclusion is this: if you want the most nearly complete patient information available, use both EHR information and individual patient claims data across all commercial and governmental payers and present it from within the patient’s EHR record. That’s not how the system works for most PCPs, however.

Kansas City tax authorities approve reimbursing Cerner for $1.75 billion of the $4.45 billion construction cost of the company’s new The Trails campus. Cerner says the new space will allow it to add 16,000 jobs within 10 years and  the increased post-construction assessment should generate $2.6 million of additional property taxes per year.

In Canada, Nova Scotia has spent $30 million on incentives for practices to use EHRs, but faxing is still the most common way for practices to communicate with each other because the government-approved systems aren’t interoperable.

Lee Memorial Health System (FL) comes up with creative excuses for earning a one-star quality rating from CMS: (a) the hospital converted to Epic just three years ago; (b) incomplete EHR coding caused the health system to be compared unfairly; (c) CMS doesn’t take into account tourist-driven seasonality; and (d) CMS doesn’t take socioeconomic factors into account and therefore penalizes hospitals that treat poor patients who are sicker (a minor variant of the “our patients are sicker” explanation). The hospital didn’t suggest that it will actually treat patients any differently even though its largest customer gave it the lowest possible quality score.

Weird News Andy notes that “even junkies are logical” as evidenced by this story, in which drug abusers are injecting themselves in the bathrooms and parking garages of Massachusetts General Hospital so they can get medical help quickly if they overdose. MGH says people are even tying themselves to the emergency pull cords in its bathrooms so the alarm will go off if they keel over in a narcotic stupor.

Sponsor Updates

• A Spok case study describes the 50 percent of University of Utah Health Care’s incoming residents and medical students who choose to communicate using Spok Mobile for secure text messaging.
• Medecision President and CEO Deborah M. Gage is named as one of the most powerful women in healthcare IT.
• T-System will exhibit at the UCAOA National Urgent Care Convention April 17-20 in Orlando.
• Huron Consulting Group is named by Forbes as one of America’s Best Employers for the second consecutive year.
• Wellsoft will exhibit at TCEP Connect 2016 April 21-24 in Galveston, TX.
• ZirMed will exhibit at the California MGMA Conference April 21-23 in Sonoma.
• Zynx Health will exhibit at the ANIA 2016 Conference April 21-23 in San Francisco.
• PatientPay shows commitment to rid paper from healthcare billing in support of The Nature Conservancy.
• QPID Health CMO Mike Zalis will speak at the North Carolina Association for Healthcare Quality Annual Conference April 21-22 in Durham.
• Huffington Post interviews Red Hat CEO Jim Whitehurst.
• The SSI Group will exhibit at the Healthcare Finance Institute April 17-19 in Tysons Corner, VA.
• Streamline Health will exhibit at the 2016 California MGMA Annual Conference April 21-23 in Sonoma.

Blog Posts

• Three Lessons for Online Insurance Marketplaces (TransUnion Healthcare)
• 8 Tips for Supporting Your Population Health Management Programs (Verisk Health)
• Radiology Still Has Work to Do (Visage Imaging)
• Armed for Proper Data Security and Compliance (West Corp.)
• Radiology Still Has Work to Do (Visage Imaging)
• Meet the Artist Who Draws Healthcare (Xerox)
• Life in the Fast Lane (CloudWave)
• Why aren’t Patient Payments Reconciled Automatically? (Patientco)
• Large EHR implementations: two critical success factors (Nordic)
• A Patient’s Advocate: Nurses and Technology (PerfectServe)
• Beware: Ransomware Attacks are on the Rise and the Importance of ISO 27001 (Phynd Technologies)
• The People Make the Difference (PMD)
• Top Ten Trends at HIMSS16 (Point-of-Care Partners)
• The Interoperability Evolution (Relay Health)
• The Data Governance Foundation to Your Self-Service Initiatives (Sagacious Consultants)
• Key Industry Conferences in Q2-Q4 2016: Digital Health, Healthcare, and Pharmacy Event List (Surescripts)

Contacts

Mr. H, Lorre, Jennifer, Dr. Jayne, Lt. Dan.
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Morning Headlines 4/18/16

Epic Systems wins $940 mln U.S. jury verdict in Tata trade secret case

Epic wins its trade secret lawsuit against Indian IT firm Tata Consultancies. A judge awarded Epic $240 million in compensatory damages and $700 million in punitive damages after concluding that Tata employees illegally accessed Epic’s customer website and accessed proprietary information.

VA teases plans for new ‘state-of-the-art’ digital health platform

VA CIO LaVerne Council says she will unveil plans for a “new digital health platform” to replace VistA.

Nova Scotia spends $39M on electronic medical records push

After spending $39 million in incentive payments to encourage EHR adoption, Nova Scotia continues to rely on faxes to communicate between facilities.

Kansas City TIF Commission approves financing agreement for huge Cerner redevelopment

Kansas City approves a reimbursement plan to repay Cerner $1.75 billion of the $4.45 billion it is spending to build its new campus.

EPtalk by Dr. Jayne 4/15/16

In follow up to my recent discussion of faxing as a primary mechanism of data sharing, a reader sent this piece with data from a January provider survey. Traditional communication methods (letter, fax, phone) are still in use by the majority of providers. The graphic only tells part of the story, however. In order to have a better understanding of the situation, we’d need to see data from the same providers that shows what percentage of communications falls into each of the buckets. For example, 89 percent of providers are receiving using paper-based methods. Is that one letter or a hundred? The same goes for electronic exchange. Maybe only 40 percent of providers are doing it, but they’re doing it 90 percent of the time. I wanted to dig deeper into the data, but it was behind one of those “enter your email address to access this resource” pages. Those drive me crazy – it seems like it’s always a multi-step process to get the download. I’d look much more favorably on an organization that presented its content up front and asked you to sign up if you wanted to learn more, compared to organizations that require your address and then clutter your inbox.

Midmark’s announcement that it is acquiring RTLS vendor Versus Technology caught my attention. I’ve always been a fan of Midmark –  its sales team impresses me with their relatively-subdued, knowledge-driven approach as compared to the bluster of some of their competitors. They’ve been innovative in providing solutions that just work, which is always appreciated when you have hundreds of devices to bring online. Midmark is also interesting as a company. Starting more than 100 years ago as an industrial equipment company, they entered healthcare in the 1960s and diversified to veterinary and technology segments. It seems to be a company that works at its own pace and ignores the industry hype. We’ll have to see whether the acquisition changes that.

From Direct Doc: “Thanks for the Curbside Consult on the state of primary care training programs. What do you think about the fact that Harvard doesn’t even bother to train students in family practice?” He didn’t mention that the article he cited clarifies that it’s not just Harvard. There are actually 10 medical schools (many of which are regarded as the nation’s top schools) that don’t have a department of family medicine. Some of them do offer optional family medicine courses, but I can say from first-hand experience that it’s not the same as taking a course in a school with a full-fledged department. I was barraged with comments during my training that I was “too smart for primary care” and our administrators were saddened that my class had more students match into family med than into general surgery. They also allowed some financial aid shenanigans that actually put primary care grads at a disadvantage. Needless to say, I’m not on the alumni donation list.

Wearable tech vendor Ringly announced the bracelet version of its customizable notification jewelry. Their ring offering was a bit too chunky for my taste but I really like the bracelet concept. I’m not a fan of gold accessories, but I’ve been watching their products for a long time. They have a non-gold option for ring designs, and once they offer one in a bracelet, I will be sold. The idea of being able to receive notifications when messages arrive from a specific sender is an attractive one. I don’t routinely use audio notifications on my phone and turn off the notifications on Outlook and other apps, but I’d like to know if a high-priority client is trying to reach me outside of my normal email-checking periods.

Mr. H mentioned the CMS announcement regarding the Comprehensive Primary Care Plus (CPC+) initiative. It’s designed as a new medical home model that allows practices to choose one of two tracks for value-based reimbursements. One track will provide a smaller, monthly per-patient payment plus bonuses. The second provides a larger payment but has more requirements. It’s slated to run for five years and they want to include 5,000 practices. The launch is scheduled for January 2017, which doesn’t give practices much time to get their acts together unless they’re already doing a medical home model or have started the extensive change management and process work that is needed to make it viable. I have worked with a couple of practices that participated in the original Comprehensive Primary Care (CPC) program that started in 2012 and runs through the end of this year. The ones I worked with were already recognized by NCQA for their Patient Centered Medical Home efforts, and were looking for assistance with reporting and other EHR needs to meet the CPC requirements.

The key Comprehensive Primary Care Functions involved include: access and continuity; care management; comprehensiveness and coordination; patient and caregiver engagement; and planned care and population health. The higher-paying track definitely has more extensive healthcare IT requirements including the ability to manage the payments on the revenue cycle side. Although track 1 maintains regular fee-for-service payments, track 2 delivers hybrid payments with reduction in E&M payments for a percentage of claims. Bonus payments are also tiered, at $2.50 per patient per month on track 1 and $4 on track 2. Interestingly, incentives are prepaid at the beginning of a performance year, but must be refunded if the practice doesn’t meet quality and utilization performance thresholds.

Track 2 partners must submit a letter from their EHR vendor that outlines the vendor’ commitment to “supporting practices with advanced health IT capabilities.” I found it interesting that this wasn’t required for Track 1, because I’m not sure what difference it really makes. Of course vendors are going to say that they’re supportive. What else are they going to do? The devil will be in the details though, and I’d be surprised if this doesn’t lead to a host of de facto requirements that vendors may struggle to meet.

From The Ghillie: “I know that working with clients during their EHR transitions can be frustrating. You seem like an outdoorsy person, so I’d like to suggest an additional benefit to the paperless office transition.” I have to say, I’m smitten, especially since I’m a big fan of reduce/reuse/recycle. Most of my cast-off file cabinets were only two drawers, but I’m going to keep an eye out for a four-drawer on the yard sale circuit.

Do you have a novel use for cast-off equipment? Email me.

Email Dr. Jayne.

Morning Headlines 4/15/16

Missing clinical and behavioral health data in a large electronic health record (EHR) system

A JAMIA study comparing clinical data from an EHR with data from insurance claims finds that EHR data is incomplete, missing information on care delivered outside of the organization.

athenahealth Announces Acquisition of Arsenal Health, formerly known as Smart Scheduling, Inc

Athenahealth acquires former More Disruption Please startup Arsenal Health, a company building schedule optimization solutions.

Economic Outlook: Spring 2016 C-Suite Survey

A small survey of health executives finds that only 38 percent of organizations are successfully accessing ambulatory data from non-employed physicians, while 84 percent of respondents report that health IT will continue to be the area where most significant capital investments are made.

News 4/15/16

Top News

Yet another scathing letter from CMS to Theranos comes to light. Federal regulators propose banning company founder and CEO Elizabeth Holmes from the blood-testing business for two years after her company failed to correct serious problems discovered at its California lab. The news surfaces a week after Theranos bolstered its Scientific and Medical Advisory Board (perhaps in a last-ditch attempt to rescue what’s left of its reputation) with representatives from CDC, American Association For Clinical Chemistry, and several academic medical centers and hospitals across the country.

HIStalk Announcements and Requests

This week on HIStalk Practice: Western New York’s HealtheLink welcomes new physician practices. GA-HITEC reaches MU goals with Georgia-based physicians. HealthTap offers free consults via Facebook’s Messenger app. Spotify highlights the favorite tunes of healthcare IT legislators. ("The Ties That Bind" never seemed more apropos.) ONC highlights the successes of the REC program – in 124 pages. Buffalo Cardiology & Pulmonary Associates closes its doors after 40 years, citing a "new era of health care." Bill Moreau, MD details the impact healthcare technology will have on Team USA during the 2016 Summer Games in Rio.

Webinars

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

Acquisitions, Funding, Business, and Stock

Athenahealth acquires physician scheduling startup and More Disruption Please accelerator program graduate Arsenal Health (fka Smart Scheduling) for an undisclosed sum.

OSF Healthcare (IL) formally launches OSF Ventures, a $75 million venture fund that will invest in four to six businesses a year focused on reducing healthcare costs or improving patient experiences and outcomes. OSF clinicians will serve as willing guinea pigs for the fund’s companies, which already include Health Catalyst and Pieces Technologies.

GSI Healthcare relocates its headquarters to the BNY Mellon Center in Philadelphia’s City Center. The company, which offers care coordination technologies for ACOs and Medicaid Health Home programs, plans on growing its employee base by 60 percent this year, largely in technical positions like software engineering.

Sales

Orion Health signs contracts with two hospitals in London for its EHR and patient engagement software, and one with NHS Fife in Scotland for an integrated health and social care record for adult services.

MultiCare Health System (WA) expands its relationship with Health Catalyst, signing an enterprise-wide technology subscription agreement and professional services agreement. Health Catalyst will tie a portion of the professional services contract to achieving MultiCare’s annual $25 million improvement goal. The health system participated in the company’s $70 million Series E round of financing in February.

People

Specialists On Call names Sean Banerjee (Evolent Health) CTO and Ann Kessinger (The Advisory Board) executive vice president of sales and marketing.

California-based Stanford Health Care’s Board of Directors appoints David Entwistle (University of Utah Hospitals & Clinics) president and CEO.

Announcements and Implementations

Ensocare offers Dell Services customers access to its discharge management and care transition technology.

CVS MinuteClinic partners with American Well to offer its Ohio-based patients access to Cleveland Clinic physicians via a new Express Care Online program.

Mobile podiatry provider KG Health Partners teams with VAR ClinicAnywhere to implement HealthFusion’s MediTouch EHR and PM software for long-term care.

Technology

Navicure develops Navicure Perform, an analytics solution that helps providers identify and rectify cash-flow bottlenecks from within the company’s claims management software.

Panacea Healthcare Solutions incorporates a Web-based charge management solution from Holliday & Associates into its CDMauditing coding and compliance technology.

Government and Politics

California announces a $179 million settlement with Xerox stemming from a failed computer modernization of its Med-Cal claims processing system.

Louisiana’s Administration for Community Living awards nonprofit population health management company EQ Health Solutions a three-year grant to help Medicare beneficiaries recognize and prevent healthcare fraud.

Reports surface that the VA is looking to implement its own scheduling software rather than spend the $624 million promised to Lockheed Martin and Epic as part of last year’s highly sought after, seven-year-contract win. The agency is reportedly testing a homegrown solution at 10 pilot sites.

Privacy and Security

Intermountain Healthcare VP/CIO Marc Probst announces during a World Health Care Congress presentation that the health system will partner with the University of Utah and several other organizations to create a joint security center focused on thwarting cybersecurity attacks. Probst noted in a HIStalk interview earlier this year that security would be top of mind for him while strolling the show floor at HIMSS. You can read the interview here.

Innovation and Research

A study published in Nature describes a neuroprosthetic breakthrough called electronic “neural bypass” that has restored a quadriplegic man’s ability to move his hand.

A JAMIA study comparing patient data recorded in a typical EHR with corresponding data from insurance claims finds the EHR data to be fragmented and incomplete a majority of the time. Researchers looked specifically at mental healthcare and found outpatient care records for patients with bipolar disorder and depression missing an average of 57 percent of the time, and record of acute psychiatric services missing 89 percent of the time. The findings prompted researchers to suggest that “priorities for further investment in health IT will need thoughtful consideration.”

A survey of 82 health system executives shows that healthcare IT is still a top area for capital spend, and the need for interoperability is greater than ever. Nearly 70 percent of respondents feel their organizations successfully access ambulatory data from employed physician networks, while just 38 percent feel as successful with affiliated or non-affiliated networks.

Other

NY Jets wide receiver Brandon Marshall visits Silicon Valley to test the tech waters for the mental healthcare nonprofit he co-founded with his wife, Michi. Project 375 has partnered with Chicago Public Schools to offer behavioral health services to students, and has committed to investing $1 million to McLean Hospital, where Marshall received treatment for borderline personality disorder. He sees great potential in artificial intelligence like X2AI’s Tess bot and the impact it could have on psychotherapy.

Sponsor Updates

• The Black Book 2016 Research Report recognizes Medicity as the top vendor in public/government and agency HIE systems.
• The local paper highlights the success UK Healthcare (KY) has had with GetWellNetwork’s patient engagement technology.
• Health Catalyst receives the 2016 Gallup Great Workplace Award.
• Iatric Systems will exhibit at the HCCA 2016 Compliance Institute April 17-20 in Las Vegas.
• Influence Health will host its Influence Client Congress April 24-27 in Phoenix.
• InterSystems will exhibit at the Healthcare Payers Transformation Assembly April 19-21 in Houston.
• Intelligent Medical Objects and Navicure will exhibit at the EClinicalWorks 2016 Enterprise Summit April 19-21 in Boston.
• PDR will exhibit at Direct to Consumer National April 19-21 in Boston.
• LifePoint Informatics releases a white paper, “Why Access to Lab & Diagnostic Data is Important to Providers, Payers and Patients.”
• LiveProcess will exhibit at the 2016 Preparedness Summit April 19-22 in Dallas.
• Netsmart will exhibit at the New York State Public Health Association annual conference April 21 in Cooperstown.
• Nordic posts a new video, “Large EHR Implementations: Two critical success factors.”
• Obix Perinatal Data System will exhibit at the AWHONN Virginia Conference April 23 in Virginia Beach.

Blog Posts

• Why You Should Embrace an OCR Audit (Iatric Systems)
• Alphabet Soup of Value-Based Care (Impact Advisors)
• From the Armed Forces to Human Resources: Data is Key to Knowing Your People (Liaison Technologies)
• Trust Me, I’m a Doctor (MedAptus)
• The Rise of Messaging as a Platform (Spok)

Contacts

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

Morning Headlines 4/14/16

Intermountain, U. Utah to open cybersecurity center with 3 others

Intermountain Healthcare will partner with the University of Utah and several other organizations to create a joint security center focused on thwarting cybersecurity attacks.

Regulators Propose Banning Theranos Founder Elizabeth Holmes for at Least Two Years

Federal regulators have proposed banning Elizabeth Holmes from the blood-testing business for two years after her company failed to correct serious problems discovered at its California lab.

Restoring cortical control of functional movement in a human with quadriplegia

A study published in Nature describes a neuroprosthetic breakthrough called electronic “neural bypass” that has restored a quadriplegic man’s ability to move his hand.

State Junks $179 Million Medi-Cal IT System, Will Start From Scratch

California announces a $179 million settlement with Xerox stemming from a failed computer modernization of its Med-Cal claims processing system.

Readers Write: Radiology Benefits Managers: An Inelegant Method for Managing the Use of Medical Imaging

Radiology Benefits Managers: An Inelegant Method for Managing the Use of Medical Imaging
By James A. Brink, MD, FACR

Doctors, lawmakers, and regulators are supposed to work together to make healthcare better. So why put a process in place that takes medical decisions out of the hands of doctors and patients, may delay or deny care, and often results in longer wait times to get care?

That is what insurance companies do by requiring preauthorization of advanced medical imaging (such as MRIs or CT scans) ordered for beneficiaries. A better way to ensure appropriate imaging is widely available and already in use.

In most cases, if your doctor thinks an imaging scan can improve your health, he or she has to ask a radiology benefits management company (RBM) whether the scan will be covered or not. This process can take days or even weeks. You may not be able to get the scan at all if the RBM says no, which happens a lot.      

In fact, a Patient Advocate Foundation (PAF) study found that in people who challenged coverage denial for scans, 81 percent were denied by RBMs and 90 percent of reversed denials were in fact covered by the patient’s health plan. The U.S. Department of Health and Human Services (HHS) says there are no independent or peer-reviewed data that prove radiology benefit managers’ effectiveness. HHS also warned against the non-transparent coverage protocols that RBMs use. 

What’s more, ensuring appropriate imaging is already being done in a more modern and efficient way. Clinical decision support (CDS) systems, embedded in electronic health records systems, allow providers to consult appropriate use criteria prior to ordering scans. American College of Radiology (ACR) Appropriateness Criteria, for instance, are transparent, evidence-based guidelines continuously updated by more than 300 doctors from more than 20 radiology and non-radiology specialty societies.

CDS systems — easily incorporated into a doctor’s normal workflow — reduce use of low-value scans, unnecessary radiation exposure, and associated costs. The systems educate ordering healthcare providers in choosing the most appropriate exam and suggesting when no scan is needed at all.

An Institute for Clinical Systems Improvement study across Minnesota found that such ordering systems saved more than $160 million in advanced imaging costs vs. RBMs and other management methods over the course of the study. A major study by Massachusetts General Hospital and the University of Florida showed that these systems significantly reduced advanced imaging use and associated costs. This was done without delaying care or taking decisions out of the hands of patients and doctors.

In fact, the Protecting Access to Medicare Act — passed by Congress with the backing of the ACR and multiple medical specialty societies — will require providers to consult CDS systems prior to ordering advanced imaging scans for Medicare patients starting as soon as next year. This makes image ordering more transparent and evidence-based than any other medical service. The law would require preauthorization only if a provider’s ordering pattern consistently fails to meet appropriate use criteria.

In short, preauthorization is an antiquated approach to utilization management that disconnects doctors and patients from learning systems designed to improve patient care. Patients. together with the providers and legislators who serve them, should be demanding a more modern approach to prior authorization through the delivery of EMR-integrated imaging CDS.

James A. Brink, MD, FACR is vice chair of the American College of Radiology, radiologist-in-chief of Massachusetts General Hospital, and Juan M. Taveras Professor of Radiology at Harvard Medical School.

Readers Write: Why Can’t I Be Both Patient and Customer?

Why Can’t I Be Both Patient and Customer?
By Peter Longo

I love the clinicians at my local health system. However, I hate the bills from my local health system.

When the clinic staff helped last month with my knee, they were the best — rock stars. When I got their confusing bill, they were the worst. Is there any other industry where you love the service, but 30 days later, they go out of their way to take away all of your happy thoughts?

Yes, I did something stupid again. Over the holidays, I took some time off to go skiing with the family. Time with the family was not stupid; skiing in the trees was stupid. (note to self; you are not in your 20s any more and need to take it easy). The ensuing tumble, spin, twist, and crash resulted in an injured knee.

I entered the local university health system in search of a cure. In total amazement, I walked into the office and the entire staff greeted me. Just like in the Gap, the entire front staff looked up and said “hello” loudly.

Over the next month, the medical group and hospital went out of their way to make me feel at home … until the bill came. Or should I say “bills” (plural). They should have stamped on the envelopes, “Screw you” in an effort to be more honest.

Most of the bills appeared to be for my knee, based on the dates of service. But for the record, they decided to add some of my wife’s medical charges into the mix on one statement.

Having spent 25 years working in the healthcare tech world plus having two graduate degrees, it still did not give me the skills to make any sense of the bills. I decided to call them at 4:50 one afternoon. The very nice recording said, “The billing office closes at 4 p.m. Monday through Friday.” Seriously? What about people who work and don’t have time to call until after work, or on the weekend? The Gap has greeters, but they are open nights and weekends. Seems my health system copied the Gap only on the greeters.

A few days later, I was able to talk to someone. I started the call by saying, “I want to pay all that I owe, so please provide a summary and explain the charges so I can pay you.” Surprisingly, they did not understand half the statements. They indicated they could not access the “other system that has more information,” so they would need to call me back.

A few days later, someone from the billing office called. Together we figured out where there were some discrepancies and determined the correct amount owed. She indicated she would clean everything up and send me a new statement. Thirty days later, I got the statement and paid right away. As I was writing that check, I had already forgotten about how they “cured” me, as it seemed so long ago.

The cost for the billing staff involved in my bill was probably more that what I owed, so I did feel bad for them. That sympathetic feeling only lasted a short time. Last night I got a call at the house. My 15-year-old handed the phone to me. I owe $25 and they sent it off to their collection agency.

Is it too much to ask that my health system treat me both as a patient and as a customer?

Peter Longo is SVP/chief revenue officer of Sirono of Berkeley, CA.

Readers Write: Three Reasons EHRs Need to Treat Biosimilars Differently from Generics

Three Reasons EHRs Need to Treat Biosimilars Differently from Generics
By Tony Schueth

Biosimilars are being introduced in the United States and are expected to quickly become more mainstream in the near future. In response, stakeholders are beginning to work on how to make them safe and useful within the parameters of today’s healthcare system.

The reason is that biosimilars, like biologics, are made from living organisms, which makes them very different from today’s conventional drugs. These differences will create challenges and opportunities in how they are integrated in electronic health records (EHRs) and user workflows as well as how patient safety may be improved.

Normally, there is a lot of lead time before EHR vendors must address such issues. Things are different with biosimilars. Here are some reasons.

There are powerful drivers

Several drivers will stimulate demand for EHRs to address biosimilars sooner rather than later. This is because of central role EHRs play in value-based care coordination and patient safety.

New biologics will be bursting on the healthcare scene. Although biosimilars have recently been approved for use in the US, they have been in use extensively in Europe and Asia for many years. More than 80 biosimilars are in development worldwide, and the global biosimilars market is expected to reach $3.7 billion. This will stimulate rapid adoption by payers and physicians in the US, which, in turn, will create the need for EHRs to capture and share a variety of information about biologics and biosimilars. It is easy to envision the availability of four biosimilars for 10 reference products in 2020, given projected market expansions.

Next, uptake in the US is expected to take off because biosimilars are lower-cost alternatives that will be used to treat the growing number of patients with such chronic diseases as arthritis, diabetes, and cancer. Rand has estimated savings from using biosimilars at $44.2 billion over 10 years. Money talks and payers will create demand for EHRs to fold biosimilars and biologics into EHR functionalities and workflows.

Payers and regulators also will demand enhanced tracking of biologics and biosimilars because they are key pieces of the move toward value-based reimbursement and are a focus of public and private payers. Identifying, tracking, and reporting adverse events that might be associated with biologics and biosimilars are expected to become key metrics for assessing care quality and pay-for-performance incentives.

Biosimilars are not generics

It would be a mistake to think of biosimilars as being synonymous with generics, which have been around for years and use mature substitution methodology. The reason begins with the fact that biologics and biosimilars are medications that are made from living organisms. Unlike generics, which have simple chemical structures, biosimilars are complex, “large molecule” drugs that are not necessarily identical to their reference products, thus the term “biosimilar,” not “bioequivalent.” In addition, biosimilars made by different manufacturers will differ from the reference product and from each other, making each biosimilar a unique therapeutic option for patients.

Furthermore, biologics and biosimilars have varying locations where they are administered, most commonly infused in physician offices, hospitals, or special ambulatory centers, or by patients at home. Given that administration location and type can vary, such information — along with the particulars of the drug that was administered — must get back to the physician and incorporated into the patient’s EHR record.

Getting this information into the patient’s record in the EHR also is important for improving patient safety. That is because it will help in identifying and distinguishing the source of the adverse drug events and patient outcomes from a biosimilar, its reference biologic, and other biosimilars.

Substitution laws are expanding and evolving

Developers of EHR systems will need to keep abreast of evolving state laws concerning substitution. In fact, many states already are considering substitution legislation or have enacted it. According to the National Conference of State Legislatures, as of early January 2016, bills or resolutions related to biologics and/or biosimilars were filed in 31 states. Keeping pace with these new laws is likely to be a challenge to ensure that EHRs are compliant, especially since requirements are apt to vary considerably from state to state. Given the rapid changes in the regulatory landscape, latency of updates to EHR systems is a problem that needs to be addressed.

Not only that, the drug that is dispensed may be very different than what was prescribed. As a result, it is important for physicians to know whether a substitution has been made and capture information about the drug that was administered in the patient’s EHR record. Because of the differences from conventional medications, different, more granular information such as lot number, will also be required. This is important for treatment and follow-up care as well as in cases where an adverse drug event or patient outcome occurs later on.

All in all, EHRs will face a brave new world when it comes to adapting to biologics and biosimilars.

Tony Schueth is CEO and managing partner of Point-of-Care Partners of Coral Springs, FL.

Morning Headlines 4/13/16

Vermont first to coordinate health care delivery with disruptive information sharing technology

Vermont will implement PatientPing state-wide, a care coordination service that alerts providers when their patient is being treated at any other facility in the state.

Kaiser Permanente launches ‘research bank’

Kaiser Permanente has launched a new research tool that will allow its 675,000 members to submit their genetic, environmental, and general health data to a database that will be used by researchers to study how genetic and environmental factors affect health.

Lawsuit: TGH nurses told woman’s family that she is HIV positive

A woman is suing Tampa General Hospital (FL) after a nurse inadvertently disclosed her HIV status in front of family members. The nurse was coordinating with transplant team personnel over a Vocera speakerphone.

GE Ventures and Mayo Clinic Launch Company to Scale and Digitize Cell and Gene Therapies

GE Ventures and Mayo Clinic launch Vitruvian Networks, a company that will market software and manufacturing services to cell and gene therapy producers.