News 6/17/15

Top News

An HHIS OIG report finds that the federal government has paid Healthcare.gov insurance subsidies since January 2014 even though CMS hasn’t finished the software module that verifies the payments owed. Insurers are still submitting estimated claims that the government pays even though it can’t verify their accuracy or whether the enrollees have paid their share of the premiums. CMS sent checks for $2.8 billion in just the first four months of 2014, the period OIG audited.  

Reader Comments

From Levi Kittycat: “Re: University of Virginia. Leaving Sunquest and going with Epic Beaker for lab over the next 2-3 years.” UVA posted a Beaker trainer job a few weeks back, so I assume they are indeed going in that direction. I did a quick search and found Beaker analyst positions recently listed at ThedaCare, Stanford, Duke, University of Colorado, PeaceHealth, Sanford Health, UTMB, Thomas Jefferson, OhioHealth, Wellmont, and others. The best-of-breed LIS vendors had better jump quickly onto genomics and personalized medicine before the customer demand for integrated systems shuts them out despite the complaints of the lab people who like having their own systems.

From Ed Hocken: “Re: MModal. Announced in an internal email that chief scientist and co-founder Juergen Fritsch will leave to pursue ‘personal interests.’” Unverified.

From Willow: “Re: Xerox Midas+. Developers have been ordered to work weekends for no extra pay to try to finish development of the in-house replacement for 3M’s APR-DRG coding, which has been dropped to save $3 million per year and must be finished by August.” Mandatory overtime indicates a management failure in overcommitting and underfunding resources assigned to unprofitable work (if it was profitable, they would happily bring in more help). My short stint with a failing vendor many years ago involved the occasional mandatory work weekends, with our clueless leadership exhibiting complete indifference to the family and religious activities they were disrupting through their ineptitude. However, the free market works – if the employees have better options, they are free to seek them (as did quite a few of the best folks at the vendor I worked for). You would hope that the work flexibility extends in both directions so that employees don’t have to burn PTO for occasionally leaving early or taking a long lunch for an appointment (such as a job interview with a better company). I wouldn’t be thrilled with working every Saturday for a few weeks, but it could be worse – at least it’s for a finite product delivery event rather than just offsetting ongoing inadequate staffing.

From NewHavenNighthawk: “Re: Yale New Haven. Big IT management shakeup – Ed Fisher is out and Jimmy Weeks is in.” Former YNHH VP/CTO Ed lists his current LinkedIn position as of May as being in that “between-jobs limbo” of freelance consultant.

From Ben Dover: “Re: Providence Health & Services IT. The former COO and chief of technology and service operations is leaving and his position eliminated after a number of failed projects and clinical system outages. IT has struggled to execute on the system’s affiliations and acquisitions, leading to rumors that it will revert back to the regional model.”

HIStalk Announcements and Requests

My latest gripe: sites that headline stories with Batman-like verbs (Kapow! Powie!) in describing companies that “snag” funding or hackers that “swipe” data. They probably get their coveted clicks for their low-expectation advertisers, although from readers who quickly abandon the story (and possibly the site) after realizing they’ve been baited one time too many by inexpertly written, non-clickworthy stories that were all sizzle and no steak.

Mr. S sent photos of his South Carolina classroom of profoundly mentally disabled K-5 students, for which we provided (via DonorsChoose and matching funds from Publix) baby wipes, diapers, a blender for preparing food (some of his students can’t eat otherwise), and insect repellent so the kids can participate safely in Special Olympics. 

Webinars

June 30 (Tuesday) 11:00 ET. “Value Based Reimbursement – Leveraging Data to Build a Successful Risk-based Strategy.” Sponsored by McKesson. Presenters: Michael Udwin, MD, executive director of physician engagement, McKesson; Jeb Dunkelberger, executive director of corporate partnerships, McKesson. Healthcare organizations are using empowered physician leadership and credible performance analysis to identify populations, stratify risk, drive physician engagement, and expose opportunities for optimized care. Attendees will learn best practices in laying a foundation for developing a successful risk-based strategy.

Acquisitions, Funding, Business, and Stock

CVS buys Target’s money-losing pharmacy business – which includes 1,660 drugstores and 80 in-store clinics – for $1.9 billion. CVS will rebrand the departments as CVS/pharmacy and MinuteClinic. CVS and Walgreens are pulling away from the drugstore chain pack in footprint, technology, and revenue as they diversify traditional drugstore offerings into providing extensive health services in convenient locations. I would expect grocery stores that operate in-store pharmacies (Kroger, Safeway, Publix, and possibly even Sam’s Club and Costco) to pay attention since running increasingly complicated pharmacy businesses isn’t their core competency. 

Forward Health Group moves to a new headquarters location in Madison, WI.

Big insurance companies take acquisition aim at their smaller competitors that are still worth dozens of billions of dollars, with UnitedHealth hoping to acquire Aetna, Aetna eyeing Humana, and Anthem and Cigna performing a mating ritual. Reasons: (a) declining employer-provided insurance in favor of exchange and government plans; (b) the need to improve bargaining position with big and expensive market-dominating health systems; and (c) the rise in value-based care.

Former National Coordinator Farzhad Mostshari, MD’s ACO startup Aledade raises $30 million in a Series B round. It will be interesting to watch as heavier investments and the mandatory outsider board seats they require set up a potential clash between idealism and capitalism and the ongoing need for the founder to keep investors and the board happy. The industry rags are covering the story like it’s breaking health IT news, but other than Farzhad’s former job and Aledade’s somewhat related need to assemble information from its physician EHRs, it’s not all that relevant to healthcare IT in general.

CTG will take a $0.09 Q2 earnings charge after failing to convince payers to buy its end-stage renal disease management system that cost over $1 million to develop. CTG will also lay off the non-billable employees working on the product and has revised its Q2 and full-year earnings guidance down sharply. CTG is also considering selling its Buffalo, NY headquarters building. CTG shares are down 48 percent in the past year, valuing the company at $147 million.

Sales

Millinocket Regional Hospital chooses Medhost’s emergency department information system.

Florida Hospital Physician Group (FL) chooses Smartlink Mobile for its Medicare Chronic Care Management services, billing for which at $40 per patient per month requires clinical information exchange, management of care transitions, creation of a patient-centered care plan, and patient access to electronic communication.

Westchester Medical Center Health Network (NY) signs a $500 million deal with Philips for consulting services and medical technologies that “gives us access to the latest in connected digital health technologies, it will be allow us to collaborate on proactive health management and co-create new patient-centered models of care for the Hudson Valley area.” It would be fascinating to see how the actual agreement matches up to the lofty statements in the announcement, and even more fascinating to look back in five years to see how much of the deal was hype.

Weill Cornell Medical College and New York-Presbyterian Hospital sign up for electronic informed consent from Mytrus for clinical trial enrollment in their oncology clinics.

People

Spok promotes COO Hemant Goel to president. He replaces Colin Balmforth, who will “pursue other opportunities.”

Boston Children’s Hospital (MA) promotes John Brownstein, PhD of the Children Hospital Informatics Program to the newly created role of chief innovation officer.

CTG names Alfred Hamilton, PhD (George Washington University) as VP/GM of CTG Healthcare and Life Sciences. He is retired lieutenant colonel in the US Army Medical Department, where he served as a military CMIO and CIO and was deployed to Iraq to support the IT needs of two mobile trauma units.

Don Kemper, who founded Healthwise in 1975 and still serves as its CEO 40 years later, will retire in 2016.

Announcements and Implementations

Imprivata joins App Configuration for Enterprise, which is developing open standards for managing and securing enterprise mobile apps.

Patientco announces the launch of a redesigned PatientWallet, which allows patients to pay bills from any device. The announcement says, without apparent irony, that the product uses “new-and-improved technology.”

Cerner and the Commission on Accreditation of Healthcare Management education announce an awards program and scholarships that will recognize graduate programs that focus on the use of information for healthcare performance improvement.

Incident training in Elgin, IL includes the use of a cellphone app by Augusta, GA-based Global Emergency Resources that allows first responders and hospital personnel to log patient information, including photos and driver license images, so that hospital employees and other emergency teams can monitor progress.

Government and Politics

HHS seeks software developers to become Entrepreneurs in Residence for two development projects: an FDA cancer and hematology data aggregation analysis platform and a CMS system that connects providers to their Medicare interactions.

In England, NHS alerts users that its newly live e-referral service, which replaces the problematic Choose and Book system, has 33 known problems, including system delays, search problems, and reporting capabilities.

The government’s top seven contractors are, in order, Lockheed Martin, Boeing, General Dynamics, Raytheon, Northrop Grumman, and McKesson, which slipped into the defense-heavy list with its $6 billion in drug contracts.

The Senate’s HELP committee convened its second hearing Tuesday, this time on EHR user experience. Vindell Washington, MD, CMIO of Franciscan Missionaries of Our Lady Health System (LA) testified that EHR workflow and documentation requirements are based on outdated paper models and providers should instead be rewarded for patient outcomes. Tim Pletcher, executive director of the Michigan Health Information Network Shared Services, said that health plans and payers have been conspicuously absent from Meaningful Use and patients are still forced to use their portals as are providers who are asked to submit additional documentation, suggesting that health plans be encouraged by HHS to use direct secure messaging. Meryl Moss, COO of the Coastal Medical ACO, urged the government to harmonize quality measures and add data analytics criteria to EHR certification. 

Privacy and Security

The FBI is investigating reports that the St. Louis Cardinals hacked into the player performance and scouting databases of the Houston Astros, which had hired the head of its “Moneyball”-type operation who apparently reused his Cardinals password on the network of the Astros, thereby inadvertently enabling the alleged unauthorized access.

Technology

A JAMIA article by Dean Sittig and Adam Wright proposes use cases of exactly what determines whether a given EHR is “open” or “interoperable,” which hopefully will squelch the bleating of robotic vendor CEOs who insist on abusing the term to mean “whatever we’re selling at the moment.” The authors also question whether a system is open if its vendor requires those who need access to its system to be certified, to sign a non-disclosure agreement, to pay a license fee, to pay the vendor for custom programming, or to buy documentation. The EXTREME (Extract, Transmit, Exchange, Move, Embed) use cases require the EHR to:

1. Export patient records in a format that can be discretely imported into another system that includes enough metadata to make the information usable, with a published dictionary describing how the information is stored and what it means.
2. Support the ability for users to send some or all of a patient’s information to another EHR or PHR system via a standard format, allowing the user to choose which information to send and maintaining a usable data structure.
3. Respond to data queries 24×7, use a record locator service, send information in a structured format, and send its data dictionary to the receiving EHR.
4. Allow a customer to move all of their patient information to a new EHR, preserving metadata and maintaining the existing transaction history.
5. Provide read and write API access to clinical and administrative information, such as by using SMART or FHIR services, and store new values provided by the external application.

For more information, see the summary Dean and Adam wrote as a HIStalk Readers Write article.

Here’s a challenge to EHR vendors: is your system open and interoperable based on the definition above?

An interesting article in Wired debates whether “apps” as we know them are obsolete, with both Google and Apple developing technologies that allow apps to be accessed more like services, so that users don’t even need to open one of many apps that reside in their “bag of hammers.” A developer says companies might be forced to sell “powers” rather than “things,” explaining, “There’s a lot of startups that are features masquerading as companies, and they’ll find a better home in this world. For some transactions, it’s ideal. If you can write a perfect API, there’s no longer a need to wrap it up in an app or UI.” The downside is that big companies like Google and Apple will control the entire user experience and compete to lure users into their competitive ecosystems. The author concludes that users may not care since they want results, not services.

Other

A Cerner spokesperson tells me that the Leidos tweet and infographic claiming that “40%+ of healthcare facilities worldwide use Cerner’s EHR system” was, as HIStalk readers pointed out, incorrect (which was pretty clear given that 40 percent of the world’s healthcare facilities don’t have an EHR at all, much less Cerner’s specifically). Cerner says someone probably misinterpreted an analyst’s “global” report title as indicating that it covers the entire world. They’ve asked Leidos to correct the statement. Cerner responded quickly and apologized for the misstatement, which was nice considering they didn’t make the claim in the first place.

Hartford Hospital (CT) says proposed state budget cuts will force it to cut jobs and eliminate programs, with the health system’s CEO calling on residents to demand that Medicaid funding be restored. The most recent tax return I found for the hospital (2012) showed that it earned a $110 million profit, paid the quoted CEO $2.1 million, and had at the top of its one-year compensation list a VP who took home nearly $4 million.

It’s all about perspective: a research article addresses how states are “protecting consumers from unexpected charges,” specifically when they are billed the balance not covered by insurance, such as when they are referred to an out-of-network specialist. That’s something the federal government could address – requiring providers who aren’t covered by a patient’s insurance to state that fact and to provide an estimate of their charges. It’s infuriating to be treated in an ED, where you have no choice in the hospital’s choice of contracted service providers, and to receive out-of-network bills weeks or months later that charge non-negotiated list prices from the ED doctor or even the lab. That’s much more egregious than predatory lending practices if you ask me, especially since the providers dump the responsibility on patients who are usually, by definition, not prepared to sort it all out on the spot.

Dilbert takes on wearables.

Weird News Andy says you have to pay extra for this service at some places. A 21-year-old home health nurse in Florida is arrested after she “decided to take off her clothes and not act normally” in stripping off her uniform and attacking the elderly patient under her care. The local TV station predictably made the non-news item its breathless lead, sending a reporter to report live from the jail’s driveway. Providing competitive snark to WNA this week is @JennHIStalk, who provided the heads-up that a neurosurgeon in Italy plans to lead a team of 100 technicians in transplanting a human head in 2017, with the ailing Russian patient saying, “I hope it will be OK.”

Sponsor Updates

• Culbert Healthcare Solutions becomes a CHIME Foundation Affiliate.
• Frost & Sullivan names Validic a “Healthcare Disruptor.”
• Ricky Caplin, CEO of The HCI Group, is named EY Entrepreneur of the Year in the Florida Health Care & Life Sciences category.
• ADP AdvancedMD offers “ICD-10 billing & coding help – just in the nick of time.”
• AirStrip will exhibit at Connected Healthcare 2015 June 18-19 in San Diego.
• AirWatch by VMware is recognized as a leader in the 2015 Gartner Magic Quadrant for Enterprise Mobility Management for the fifth consecutive year.
• Practice Unite offers “Is your mHealth app HIPAA compliant?”
• Besler Consulting offers an “Update regarding HIPAA Eligibility Transaction System (HETS).”
• Bottomline Technologies will exhibit at ACE June 17-19 in Austin, TX.
• XG Health outlines “XGlearn – Care Management Training.”
• Craneware kicks off a new “value cycle” initiative at HFMA ANI 2015 next week.
• Caradigm offers “The Cultural Shift to Population Health.”
• Commvault offers “Backup-as-a-Service (BaaS) Just Became Easier with Cisco and Commvault.”
• TechOhio discusses startup success with CoverMyMeds VP of Engineering Alan Gilbert.
• Divurgent team members race to support the Children’s Hospital of the King’s Daughters.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

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Readers Write: Defining Our Terms: Does Anyone Know What an "Open EHR" Really Is?

Defining Our Terms: Does Anyone Know What an "Open EHR" Really Is?
By Dean F. Sittig, PhD and Adam Wright, PhD

Adapted from “What makes an EHR “open” or interoperable?” J Amer Med Inform Assoc 2015. Available at: http://jamia.oxfordjournals.org/content/early/2015/06/13/jamia.ocv060.

There’s been a lot of talk lately about “open” EHRs, ranging from Congressional hearings to industry buzz. Last summer, Mr. H challenged his readers with, “What core set of published standards or capabilities must a given EHR support to be considered open?” We thought this was a great question, so we decided to give it a try.

First, “open” does not mean “open source.” Although open source software is of great value, an EHR can certainly be open without being open source.

We’ve also noticed that some commentators equate open with the platform software is built on, and specifically, that systems which use relational databases and support SQL (structured query language) are inherently more open than those that use hierarchical databases (e.g., Cache). We think this is a distraction, too – you can make closed systems on SQL or open systems on Cache.

Regardless of the database technology (relational, hierarchical, object-oriented), data exchange with another application requires significant effort to transform the data into an agreed-upon format with agreed-upon meaning. This transformation must take into account the data’s syntax (the format), semantics (the meaning), and pragmatics (the way the data are used in context to create a meaningful clinical application). The internal representation of the data, in either the sending or receiving EHR, is largely immaterial.

We decided to organize our definition of open around five use cases, which we refer to as the EXTREME criteria (short for EXtract, TRansmit, Exchange, Move, Embed):

EXTREME Use Cases

An organization can securely extract patient records while maintaining granularity of structured data.

• Secure login and role-based access controls.
• Structured data importable programmatically into another database (unstructured formats such as PDF, do not suffice).
• Audits of extracted records.
• Sufficient metadata included in the extract to ensure interpretability, e.g., units and normal ranges for lab results.
• Freely-available data dictionary indicates where data are stored and what they mean.

An authorized user can transmit all or a portion of a patient record to another clinician who uses a different EHR or to a personal health record of the patient’s choosing without losing the existing structured data.

• Data selection methods that allow users to identify which data to include or exclude.
• Standard method to structure data (e.g., C-CDA) or portions thereof (e.g., DICOM, e-prescribing).
• Standard methods used to describe the meaning of the data (i.e., controlled clinical vocabulary used) Note: conversion of structured data to an unstructured format such as PDF would not meet these requirements.

An organization in a distributed/decentralized health information exchange (HIE) can accept programmatic requests for copies of a patient record from an external EHR and return records in a standard format.

• EHR infrastructure capable of responding to queries 24 hr/day, 7 days/week.
• Record-locator service functionality available and in use.
• Standard method used to structure data (e.g., C-CDA).
• Sending EHR’s data dictionary available to receiving EHR.
• “Internet robustness principle” respected (be liberal in what you accept and conservative in what you send).

An organization can move all its patient records to a new EHR.

• Standard method in which to structure key clinical data (e.g., laboratory results, medications, problems, admission history) provided (e.g. HL7 v2.x or v3).
• Data dictionary used to define clinical and administrative data.
• Existing metadata (e.g., timestamps, source, and authors) exported to the new system.
• Transaction history of data items (e.g., renewals and dose changes for a medication) preserved.

An organization can embed encapsulated functionality within their EHR using an application programming interface (API). Goals: access specific data items, manipulate them, and then store a new value.

• External applications have “read” and “write” access to clinical and administrative data, including metadata from the EHR (e.g., using the SMART app platform or HL7’s Fast Healthcare Interoperability Resources (FHIR) services.
• Programmatic method to embed external applications (either code or presentation, i.e., an embedded web application, e.g., Cerner’s mPages) with which the user can interact via the EHR’s user interface without re-compiling the existing EHR’s codebase.
• Appropriate support and maintenance to ensure that encapsulated functionality will continue to work and meet user needs following system configuration changes or upgrades.
• HIPAA-compliant protection of newly created data item(s) (e.g., only accessible to authorized users and backed-up with all other patient data) like all other patient-related data.

These use cases were designed to address the needs of patients, so they can access their personal health information no matter where they receive their healthcare; clinicians, so they can provide safe and effective healthcare; researchers, so they can advance our understanding of disease and healthcare processes; administrators, so they can reduce their reliance on a single-source EHR developer; and software developers, so they can develop innovative solutions to address limitations of current EHR user interfaces and create new applications to improve the practice of medicine.

In addition to the specific features and functions required to implement these use cases, we also note that many developers limit access to their systems by requiring: special training and certification by the developer before users can extract data from the system or integrate an application; users to sign a non-disclosure agreement; users to pay an additional license fee to access data or integrate an application; customized programming that only the developer can do; or access to documentation that requires special permission or additional fees. While we understand that developers need to maintain a degree of control over access to their software for financial, security, intellectual property, and reliability reasons, we question whether a system subject to such constraints can be considered truly open.

In addition to these use cases, open EHRs should be subjected to stringent conformance testing to ensure that receiving systems are able to import and parse the structured data and store it in the appropriate location within the receiving EHR, while maintaining the metadata and transaction history from the sending system.

Widespread access to open EHRs that implement at least the five EXTREME use cases we propose is necessary if we are to realize the enormous potential of an EHR-enabled healthcare system. Healthcare delivery organizations must require these capabilities in their EHRs. EHR developers must commit to providing them. Healthcare organizations must commit to implementing and using them.

In addition to having all EHRs meet these technical requirements, we must also begin addressing the myriad socio-legal barriers (e.g., lack of a unique patient identifier, information blocking, high margin, fee-for-service clinical testing) to widespread health information exchange required to transform the modern EHR-enabled healthcare delivery system.

Dean Sittig, PhD is professor of biomedical informatics at the University of Texas Health Science Center at Houston. Adam Wright, PhD is senior scientist in the Division of General Medicine of Brigham and Women’s Hospital, a senior medical informatician with Partners HealthCare, and assistant professor of medicine at Harvard Medical School.

Morning Headlines 6/16/15

Anthem Talks to Cigna on Possible Takeover

Anthem pursues rival insurer Cigna in an acquisition deal that values Cigna at $45 billion.

FDA to Work With Online Patient Forum to Mine Safety Data

Online support group vendor PatientsLikeMe signs a research partnership with the FDA to supplement its post-market drug surveillance program with patient-generated adverse events reports.

Inside Obama’s Stealth Startup

Fast Company profiles Obama’s growing US Digital Services team, which was established in the days after Healthcare.gov’s failed launch. Todd Park, who is responsible for recruiting Silicon Valley’s best and brightest for the team, describes it as “DARPA meets the Peace Corps meets SEAL Team Six,” and tells stories of Obama’s hands on involvement in recruitment efforts.

White House Weighs Sanctions After Second Breach of a Computer System

The Office of Personnel Management reports that mental health data may have been compromised in its second confirmed security breach in the last two weeks.

Curbside Consult with Dr. Jayne 6/15/15

As a free-range CMIO, organizations often hire me to do work that they should be able to do themselves. Sometimes there are valid reasons why they can’t, such as the unexpected departure of a key employee. More often, though, it’s due to lack of organizational structure or even outright chaos.

I was working with a group in the latter position this week, putting together a plan to try to get them back on their feet. It’s a mid-sized group of employed physicians associated with a mid-sized hospital. They were initially referred to me by one of their physicians after we met at a conference.

I knew I would be in for an interesting time after the first discovery call. I usually set up a meeting or two to figure out who the key players are and why they think they need assistance. The calls usually reveal that why they think they need my help is not actually why they need my help. More often than not, they think there’s a problem with their software, or that they have problems with individual physicians refusing to get with the EHR program. When we start to talk about the specific concerns, it tends to show that they have problems with communication, resource allocation and prioritization, or perhaps strategic planning. If I’m lucky, it might be a project management issue.

This time it was all of the above. The first time we tried to do a discovery call, only one of five client attendees bothered to show up. The second time, we had several “leaders” (and I use that term loosely) attend, but two of them had no idea why they were on the call or why the organization was seeking outside help. We spent the first half of the call with one of their internal IT resources trying to explain to them who I was and why they had contacted me. Ideally that would be done before we all get on a call together, but then again if they had their act together, they wouldn’t need my help.

We talked about their key concern of “we’re not going to get Meaningful Use” money and did a quick exercise to determine root cause. I love techniques like the Five Whys for their simplicity. The premise is that you can get to the heart of an issue by asking why something occurred, then following each answer with another “why” question. Usually after three to five repetitions, it becomes clear what the real problem is. People are often astonished when you start identifying the real reasons behind their situation. Of course, there are a lot of other formal methodologies you can use to do a true root cause analysis, but when there are “soft” issues at play, the Five Whys is usually enough.

We quickly identified some major issues contributing to their lack of MU confidence. Their EHR is poorly configured and overly customized. When physicians complain about the workflow, there’s no routine analysis. Instead, the IT team just adds fields and checkboxes to the EHR because they perceive they’ve been given a mandate to “make them happy.”

The operations team, on the other hand, feels that IT coddles the physicians and that the customization interferes with their ability to control the providers. The finance team thinks the whole thing is too expensive and the consultants they’re using to customize the system are laughing all the way to the bank.

I’ve been working with them for a couple of months to put together a proposal and actually get them to approve it. Through that process, I was able to identify that they have some pathological corporate policies that certainly aren’t helping things. One major issue is their email retention policy – all emails delete after 45 days unless they’re manually archived. I don’t know about you, but I certainly don’t have time to go through my emails on a regular basis and manually archive things on that kind of cycle. My former employer had a six-month retention policy, which was reasonable – after six months, you know whether something is archive-worthy (and they actually had a class in how to best manage folders and filtering to make the retention policy easier). These folks just leave their employees hanging.

Inability to manage and retain emails led to a lot of requests to resend documents and repeat conversation threads that we thought were already resolved. It also was instructive in warning me that I needed to dramatically increase the block of time that I was planning to allocate to this client.

Once they accepted the proposal, I was able to do a fair amount of remote work with them while we waited for calendars to open up for our first onsite visit. I had requested documents related to their organizational structure, roles and responsibilities, contracts between the client and their EHR vendor, and service level agreements between IT and their internal customers. Although it took weeks to get some of the documentation, eventually most of it turned up.

What surprised me (but probably shouldn’t have) was the lack of awareness of some parties regarding their own documentation. Interestingly, no one could actually produce the policy about the 45-day email retention standard. Needless to say, unless they can validate why they want to allow that to contribute to their dysfunction, I’m going to push to lengthen it.

This week was my first time at their offices. I had scheduled a number of one-on-one interviews with identified members of their leadership. Usually I walk through an interviewee’s understanding of the EHR initiative and its purpose, what they think is in it for them, what they hope it will accomplish, etc. For the first few interviews, I felt like I should be charging behavioral health CPT codes because the leadership interviews turned into therapy sessions. I felt like I was in junior high school again, but instead of dealing with cliques and mean girls, I was dealing with organizational silos and power-hungry players with grossly inflated titles.

Of course, most of them want me to just jump right in and “fix the EHR.” Having been in this game for a fair length of time, I know that without putting the right leadership structures in place and making sure we have functional processes to sustain any changes to EHR content and workflow, we might just worsen the chaos and make the physicians even less happy. Once we identify who the decision-makers will be and what the strategic goals are (besides just “get that MU money”), we’ll be able to really figure out how to solve the problem.

I wasn’t able to finish all the interviews last week (of course, many “emergencies” prevented people from attending, but they wouldn’t tell me what those urgent problems were) so I do have some phone interviews to finish this week. At least I won’t have to hand out tissues since we won’t be in the same room. I also don’t have to worry as much about maintaining my poker face when the stories of one department slighting another get petty or silly. Once the interviews are complete, I’ll deliver a formal assessment and recommendation and we’ll see how it is received.

Having done this more than once, I know they’ll go through some of the stages of grief (particularly denial, anger, and bargaining) before we can arrive at a real plan to move forward. They have some strong physicians who seem to be buying what I’m trying to sell. They’re not ‘titled’ leaders, but rather informal ones, so I’m hoping they’ll be able to help drum up some grassroots support. The titled leaders will be a bit of a challenge, but I’m hopeful that the burning platform of MU will help move them in the right direction.

What is your current stage of grief? Email me.

Email Dr. Jayne.

HIStalk Interviews Jay Deady, CEO, Recondo Technology

Jay Deady is CEO of Recondo Technology of Greenwood Village, CO.

Tell me about yourself and the company.

Recondo has been in existence for about seven years. We have a SaaS-based single platform focused on revenue cycle and have built a series of modules or applications off that single platform. We commercialized the first product, Sure Pay Health — which does patient estimation — about five years ago. We’ve continued to add more functional modules since then.

I joined the organization as CEO in mid-November of this past year after originally being contacted around the HIMSS conference the prior year about becoming a board member. During the course of those discussions, it switched to both being on the board and an opportunity to run the company as well.

How would you differentiate Recondo’s offerings from those of its competitors?

When you say the words “revenue cycle” in the industry, it’s almost like saying “analytics” or “work flow” these days. It means a lot of different things to a lot of different people.

We take revenue cycle in three phases. The first is around patient access. The second is what I’ll describe as the mushy middle, where I’ve spent a lot of my prior experience and career in health IT — the ordering, the delivery of care, the documentation of that care, and the coding against that care. Then you have the back-office claims processing and the adjudication thereof. We have solutions in patient access and in the business office – we stay out of the middle for right now. 

We have a suite of products from patient access. We have a couple of competitors that have a suite. There’s a lot of niche players that might just do eligibility, payment estimation, or registration QA. We’re taking a broader suite approach versus a number of those more singular niche players in the market.

Do you see integration occurring between financial and clinical work flows that is tied together under the revenue cycle umbrella?

I do. In some of our more recent contracting efforts, it’s quite varied. Meaning, we have a really sophisticated back-end cloud engine where we have patented bot technology. We can go out to payer websites around what historically might have EDI transaction sets for eligibility and payment estimation, and then certainly on updating claim status. We can grab more information, create a superset between the EDI transactions and the additional information that we can grab with the bot technology, and run that through a rules engine and make it actionable. We can serve that information up in our own applications in work flow. That’s the way the majority of clients have contracted and deployed with Recondo.

But we also have multiple Epic clients. It has a fully-integrated patient payment estimator solution with their Cadence registration and scheduling products. We’re serving up the information I just described by enabling that product as a Web service.

In the past, there was certainly a lot of bi-directional HL7 integration. What we’re starting to see, in some cases, is API Web service enablement integration. For some of these applications, we might not be the front end, but we’re doing a great job with our back-end capability of enabling other solution front ends with more intelligent data.

Is revenue cycle management still a core competency for health systems?

The answer to that question varies by segments of the acute care market in the US, so I’ll answer it that way. I think we’ve seen in the past few years an increase in outsourcing in mid-sized singular institutions. They’ve increased their outsourcing. One, because of the competitive nature of getting resources. Two, are they really experts in that or should they focus on being experts in care delivery, and as it relates to coding and other aspects of revenue cycle such as claims and collections, can they outsource that to somebody who’s an expert at just doing that? We’ve seen an increase in that market segment.

Inversely, in the IDN and investor-owned market, we have a large relationship with Community Health Systems, CHS. They have consolidated 215 business offices out of their hospitals to six or seven regional centralized business offices. They have actually decreased outsourcing during that process. They are using some of our technology to help support more efficient automated processing versus what used to be more of a manual effort as it relates to claim status, processing, and adjudication.

I think outsourcing is alive and well in certain market segments, but as IDNs merge and try to consolidate their business offices, we’re seeing a trend to take some of that back.

Healthcare administrative overhead is high and yet revenue cycle is one of the hottest areas since hospitals have to jump through hoops to get paid. Will that become more streamlined with value-based care?

I think it will become more streamlined for two reasons. Historically, revenue cycle has been patient billing and HIS systems with some bolt-ons. But then a lot of personnel are required from the health system on the front end and the back end of the business office on what has historically been a lot of manual effort around some of that automation. As more tools from Recondo and some of our competitors continue to come to market, you’re seeing more aspects of the revenue cycle and work flow becoming less manual, more automated, with a higher percentage of claims going all the way through in a touchless fashion. That is contributing to a reduction in overhead.

Whether it’s under an ACO heading or some form of capitated at-risk bundle that takes many different forms, since they know how they’re going to get paid based on that value-based, at-risk package, it’s more about how they efficiently track, project, and manage costs against it versus the overhead of how do I get paid for the care I’m delivering. They understand what the denominator’s going to be. Now their question is, how are they going to maximize their efficiency in the health system against that denominator?

Are consumer expectations changing for the revenue side of healthcare and are ideas being brought in from other sectors that have more experience with deploying consumer-focused technology?

Absolutely. What has accelerated that more recently has been the Affordable Care Act, the exchanges, high-deductible plans, even private plans that are going to high-deductible plans. We have a high-deductible plan here at Recondo. The company contributes two-thirds of that based on people seeing primary care docs. It affects what our contribution is.

That type of plans, whether it’s through the exchange or through an employer insurance product, is causing people to not just take their healthcare coverage for granted. It is turning them into consumers, particularly in patient access. There’s a really interesting dynamic of understanding not so much the net price that will be paid for whatever the procedure might be, but the out-of-pocket price associated with it. It’s definitely now being viewed by the consumer differently.

There is a crossroads at the same time for availability or access. If I can save $50 to $200 by going to an imaging center versus having that scan done at an academic medical center, depending on whether I have a minor meniscus tear versus a blown-out ACL, how fast I can get in probably determines whether that $50 to $200 out-of-pocket savings matters to me.

There is an empowered consumerism that is accelerating. That’s going to change that whole upfront patient access, whether it’s through portals, but the convergence of scheduling availability with what it’s going to cost the consumer against those plans. It’s really driving some change in the industry.

Are health systems struggling with trying to get more intimately involved with their patients while at the same time pressing them harder for payment?

I think they are struggling a bit. Historically, they haven’t participated directly so much in it. Two, there’s been a number of companies in the industry and other players in the industry that have tried to disintermediate the actual providers. What I mean by that is there are pricing estimate tools, some of which have gone public with a lot of notoriety, and they have been targeting the major employers and in some cases the payers.

The larger IDNs, some of our clients that we do pricing estimations for now, are frustrated that the quality of the care they deliver as well as the pricing is being represented to the marketplace without their input. They’re taking action themselves so that they can start to present both a combination of quality and pricing on a direct basis versus allowing third parties in the health ecosystem to represent that information to the market under an apparent market fairness play, when in fact the pricing for a particular patient on a particular plan, looking at something that’s generically available from an employer or insurer website, could be off as much as 30  to 40 percent. That’s pretty frustrating to some of our largest clients, so we’re working with them so they can represent that on a consumer basis themselves.

For patients who have a provider choice, do they have enough information to make a decision based on value since there’s no published price that is the same for everyone?

The information is getting better. I believe you’re going to see providers provide a lot more of that information themselves. I’ve seen some third-party studies and we’re contracting some primary research ourselves. Depending on the economic situation of an individual, there appears to be somewhere between $300 and $500 from an out-of-pocket perspective that does start to impact location and care decision based on price. That seems to be the number where someone in Boston who typically go to Partners might go to CareGroup, for example.

I think it is based on the quality of the information. It’s based on a perceived confidence in a price that’s quoted upfront. It’s a lot easier, as we know, for a radiological imaging procedure than a major surgical situation, because once they’re in, what happens on the surgical table can vary quite a bit from what was originally scheduled. 

I think you’ll see a stepped in, service-by-service situation where the confidence of both the health system providing the price estimate and the confidence of the consumer receiving it passes what I call the Twizzlers test. If you go into the 7-Eleven to buy a package of Twizzlers and it’s $1.89, you don’t want to go to the register and then get hit with a 40 percent price change. There are certain service lines where the confidence can be high enough to pass that test. In others, for a while, it’s going to have a lot of variability to it.

I don’t think it’s going to all or nothing. I believe people from a service line perspective will step into this, both on the consumer and a provider side.

Hospitals have never been good at cost accounting and determining whether a given patient is profitable –they just know that if their market share and payer mix don’t change, that $5 aspirin will probably keep them in a financial surplus. How can hospitals quote a patient a competitive price for a given service when they don’t really know what it costs them?

I had with my team a lot of experience with that a number of years ago at Eclipsys when we bought EPSi. We did have clients who fully deployed that capability, and for certain service lines, got to a true cost accounting model.

As an industry, what accelerated that more recently with that tool and others and new ones that have come out –and some of those are going through IPO processes – is the whole bundling process. Whether it’s an ACO or other forms of capitation, in the beginning, they were probably bidding somewhat blind. If I don’t bid, I’m going to lose share, but I’m not quite sure if I’m going to make or lose money based on my bid. That’s accelerated a lot of analytics and cost accounting plays in the industry.

Compared to others, because of the longer-term historic nature of not deploying that, the industry is still a little bit behind. But in the last five years, based both on tools that are available as well as the changing market conditions, folks are making some pretty fast strides to close on that.

How will healthcare look different in five years?

Everything will continue to push as close to the patient’s home as possible. The furthest right on a graph of lowest patient satisfaction versus highest cost is an ICU bed. Advances that allow doing cardiac care and others laparoscopically and driving it into a clinic and ambulatory setting has been accelerating and I think that’s going to continue quite a bit. The trend of the percentage of physicians that are employed versus independent is going to push forward.

Consumerism, cost, and quality are becoming bigger decision makers that will force health systems and physician groups to market themselves and be accountable against. I see that rapidly accelerating, primarily because of the economic pressure from high-deductible plans as well as capitation bundles. That’s going to accelerate over the next three to five years as well.

Lastly, based on some of that, we’ve seen the historic ramp-up in annual cost to somewhat curtail. In general efficiency in healthcare, how the revenue cycle and care delivery gets more streamlined, I see that continuing to accelerate as well.

Do you have any final thoughts?

Recondo’s solutions are touching the consumer with our provider clients more directly. A fun aspect of my 26-year career is starting to work with clients on that consumer enablement, where historically I’ve been a bit more removed working with clients more internally focused from an EMR and revenue cycle perspective. Together with our clients, where they in the past may have been disintermediated by employers and insurers, putting some of these tools out faster, putting some of this information out. It’s going to be exciting in the next couple of years of helping our largest clients catch up and take control of that conversation with their patients and consumers.

Morning Headlines 6/15/15

VA app could change future of veteran care

The VA will pilot a new app that will give VA doctors a single view of a patient’s complete medical history, including allergies, prescriptions, and test results from both DoD and VA medical records.

Health Catalyst Is Keeping the Jobs At Home

Health Catalyst announces that it will add 300 jobs over the next five years, for which it will receive $700,000 in incentives from the Utah Governor’s Office.

Data Security in Healthcare 2015

A Peer60 survey on data security in healthcare finds that information security is the most important priority for 29 percent of organizations. The report finds that lack of funding and staff compliance with IT procedures are the largest issues preventing improvements.

Additional Actions and Oversight Urgently Needed to Reduce Waste and Improve Performance in Acquisitions and Operations

A GAO report on government IT projects finds that projects often result in “multimillion dollar cost overruns and years-long schedule delays,” with billions wasted on failed project cited. The government spends $80 billion on IT projects annually.

Monday Morning Update 6/15/15

Top News

The VA will launch a three-hospital pilot of its self-developed Enterprise Health Management Platform, which allows clinicians to view non-VA patient information such as that stored in the DoD’s systems. The VA says the new system uses coded, discrete data that can be used for clinical decision support across all systems and to provide a “veteran-specific” rather than “local-specific” view. The VA developed the product using open source programming and will release a software development kit that will allow others to create add-on applications. Rollout of eHMP to the entire VA will continue through December 2017.

Reader Comments

From LearnHealthTech: “Re: 50 hospitals gouging uninsured patients. Any surprise that so many are in Florida under Governor Rick ‘why isn’t he in jail’ Scott?” I’m not surprised a bit, but not because of Rick Scott, who seems to have turned his previous wildly capitalistic healthcare opportunism into a zeal for financial responsibility and transparency, at least among Florida’s non-profit health systems. Florida has always been ground zero for healthcare fraud, with international criminals, known hucksters, and immoral providers flocking there as predictably as snowbirds with harsh accents and pale skin. My theory is that everybody there is from somewhere else, lured by an implied lack of responsibility in a vacation-like lifestyle and no state income tax, so there’s little social stigma associated with scandalous behavior, which in addition to brazen healthcare fraud includes transplanted Midwesterners wearing black dress socks with sandals and aging Canadian expats hitting the beach in tiny Speedos obscured by pendulous, sun-leathered stomachs sprouting a scorched forest of gray hairs.

From Imelda Roxas: “Re: Medical Center Health System, Odessa, TX. I saw this article saying they are replacing their McKesson Horizon system. The selected vendor is not named. Any idea of who it is?” I asked CIO Gary Barnes, who says they will implement Cerner in a $55 million, three-year project.

HIStalk Announcements and Requests

Most poll respondents think overall health IT vendor revenue will grow over the next five years. New poll to your right or here: how many smartphone-based, non-fitness health apps do you use at least weekly other than those required by work? I’m curious what they are, of course, so click Comments after voting to tell me.

Mrs. D says her New York second graders are enjoying the STEM science kits we provided via DonorsChoose donations, giving them exposure to group communication and project planning. I have matching funds available (courtesy of an anonymous vendor executive) to companies willing to donate $1,000 or more, which I will acknowledge on HIStalk as well.

Last Week’s Most Interesting News

• The Senate’s HELP committee on Wednesday kicked off the first of a series of hearings that will review the Meaningful Use program, with the testimony of industry experts focusing mostly on interoperability.
• Walgreens announces that it will roll out MDLive-powered virtual doctor visits to users of its app in 25 states by the end of 2015.
• PHR vendor NoMoreClipboard announces that the information of its customers has been exposed to hackers.
• Epic CEO Judy Faulkner signs The Giving Pledge in which she will donate 99 percent of her estimated $2.3 billion in assets to a charitable foundation.
• Telemedicine provider American Well sues competitor Teladoc for patent infringement.
• CSC agrees to pay $190 million to settle SEC fraud charges over falsifying financial results to hide losses from shareholders related to its participation in the UK’s defunct NPfIT program.
• Hawaii announces that it will shut down its $130 million health insurance exchange because of low usage.

Webinars

June 30 (Tuesday) 11:00 ET. “Value Based Reimbursement – Leveraging Data to Build a Successful Risk-based Strategy.” Sponsored by McKesson. Presenters: Michael Udwin, MD, executive director of physician engagement, McKesson; Jeb Dunkelberger, executive director of corporate partnerships, McKesson. Healthcare organizations are using empowered physician leadership and credible performance analysis to identify populations, stratify risk, drive physician engagement, and expose opportunities for optimized care. Attendees will learn best practices in laying a foundation for developing a successful risk-based strategy.

Acquisitions, Funding, Business, and Stock

Health Catalyst will expand its Salt Lake City, UT headquarters, planning to add 300 jobs over the next five years. The Utah Governor’s Office of Economic Development is providing $700,000 in incentives.

Cerner will co-market a video analysis-powered musculoskeletal health screening tool from Kansas City-area startup DARI that Cerner is using in its Motion Health employee program to reduce the employer cost of mobility problems.

People

Nordic Consulting promotes Abby Polich to VP of affiliate solutions.

Announcements and Implementations

Aventura announces Sympatica, which will present clinicians with real-time, context-aware information from predictive analytics and performance management applications along with their EHR content. The application integration solution, which will be released in Q3 2015, has already been chosen by three healthcare organizations that includes Wise Regional Health System (TX), which will use it to present users with context-aware patient care checklists and reminders. The company will provide APIs for partner integration.

A Peer60 healthcare data security report finds that 95 percent of hospitals place data security as either their highest-priority project (29 percent) or as one of a few major priorities (66 percent). Budget limitations and lack of employee compliance are the biggest security barriers. The top provider priority is securing mobile devices, with smaller hospitals also focusing on intrusion protection.

Billian’s HealthData offers an Essentials licensing tier of its market intelligence database that includes key hospital and health system executives.

Children’s Healthcare of Atlanta goes live with Clockwise.MD in its urgent care centers, allowing patients to reserve their spot in line and receive wait time updates.

Government and Politics

GAO testimony criticizes high-risk federal IT project cost overruns, schedule delays, and questionable achievements, calling out ineffective management and lack of follow-up on the GAO’s recommendations. Among the massively expensive and ultimately cancelled projects mentioned are the DoD’s CoreFLS  and the VA’s scheduling system replacement, which cost at least $750 million. The GAO also notes that the VA and DoD have failed to modernize and integrate their EHRs over many year and questions the likelihood that their new focus on integrating their separate systems will succeed. The federal government spends $80 billion per year on IT.

Privacy and Security

The Texas Department of Aging and Disability Services announces that the medical information of 6,600 Medicaid recipients was exposed when data from an internal software application was accidentally opened up to the Internet.

Symantec reports that hackers are spreading malware by sending emails about MERS outbreaks in South Korea that contain an attachment named “MERS_List of hospital and infected patients.docx.exe.” that launches a Trojan. The company reports that malware creators often use current news headlines, including last year’s Ebola scare, to get email recipients to open attachments.

Other

Harvard Medical School’s Center for Biomedical Informatics will convene a free, two-day program titled “Precision Medicine 2015: Patient Driven” June 24-25 at the medical school’s campus in Boston. Presenters include the center’s Zak Kohane and Ken Mandl, 23andMe co-founder Linda Avey, and Cloudera founder Jeff Hammerbacher.

The American Medical Association passes a proposal from its resident and fellow members that calls for the AMA to create ethical and professional guidelines for media doctors such as Dr. Oz, whose evidence-lacking snake oil claims reach millions of TV viewers who aren’t aware of his paid endorser status and his wildly off-center positions on scientific topics. The AMA will also issue guidelines disciplining unethical media doctors through existing channels such as state licensing boards and medical societies.

Weird News Andy says it was, “Tats, not cancer.” Surgeons remove a woman’s uterus, cervix, Fallopian tubes, and pelvic lymph notes after a PET scan showed spreading of her cervical cancer, only to find that the bright spots on the image were caused by migration of ink from her many tattoos rather than the radioactive tracer that would have indicated lymphatic metastasis. The surgeons had planned to remove the organs anyway; the woman is recovering and cancer free.

Sponsor Updates

• Medicity recaps its HIStalk webinar, “Successful HIEs DO Exist: Best Practices for Care Coordination.”
• Brad Levine of Visage Imaging is interviewed about imaging industry trends during SIIM 2015, including the movement to make radiology processes and technologies more relevant to referring physicians.
• Versus Technology offers “How Your Hospital can Easily Track Nurse-to-Patient Ratios.”
• Cumberland Consulting Group reports that since its June 2014 acquisition of Cipe Consulting Group, 16 new and 10 existing clients have used the services of its specialist consultants, the company now supports the applications of all leading vendors, and its recruiters have expanded their network to 2,500 contacts for responding quickly to customer requests for specific skill sets.
• Summit Healthcare honors non-profit Hands on Nashville at the International Muse conference.
• SyTrue will exhibit at the Healthcare Innovation Conference on NexGen Data, Analytics, and Technology-Enabled Services June 16 in Palo Alto, CA.
• Verisk Health will offer analytics education to members of the Association for Community-Affiliated Plans.
• SyTrue publishes use cases for its Smart Data Platform including conversion of physician narrative into structured data, real-time transformation of clinical documentation into diagnosis and procedure codes, conversion of radiology information into evidence-based insight, and translating pathology terminology and codes to improve billing accuracy.
• T-System offers “Nurse Debate: The Value of Electronic Alerts in ED Documentation.”
• PMD blogs about “Hotel Room Hacking” to push client-requested updates through while on the road.
• Greenway Health chooses Talksoft as Partner of the Month for June 2015.
• VisionWare will exhibit at the Big Data & Healthcare Analytics Forum June 18-19 in New York City.
• TeleTracking will exhibit at the Digital Health and Care Congress 2015 June 16-17 in London.
• TransUnion offers “Uncompensated Care: Hospitals’ Billion-Dollar Challenge.”
• Validic will exhibit at Connected Healthcare USA June 18-19 in San Diego.
• Verisk Health offers “Improving Medical Cost Containment with Pre-Payment Claim Review.”
• Nearly 100 PatientKeeper employees donate time, goods, and money to Massachusetts charity Cradles to Crayons on the company’s volunteerism day.
• PerfectServe client Orange Coast Memorial Medical Center (CA) is featured on the American Medical Group Association’s premiere of online news program High Performing Health.
• VitalWare’s VitalCoder receives HFMA peer review designation.
• Voalte previews its Mobile Communication Strategy eBook.
• Huron Consulting sponsors Loyola University Medical Center’s Health, Hope, and Heroes 5K Run/Walk June 14 in Maywood, IL.
• Close to 450 WeiserMazars employees volunteer at over 30 community organizations in four states for its first annual “Days of Service.”
• Zynx Health offers “Let’s Keep Nurse Recognition Going!”
• Leidos Health VP/ Health Information Privacy and Security Officer Sean Murphy will speak on a panel cybersecurity at the iHT2 Summit June 16-17 in Washington, DC.
• MEA/NEA offers an article series taking a closer look at HIPAA.
• JAG Products will offer its ClinicTracker users revenue cycle products from Navicure.
• Sandlot Solutions will exhibit at the Minnesota e-Health Summit June 16-17 in St. Louis Park.
• Netsmart announces its support for the Helping Families in Mental Health Crisis Act, which aims to bring Meaningful Use parity for behavioral health and addiction treatment providers.
• The New York eHealth Collaborative will exhibit at the NY MiniHIMSS Conference June 17 in New York City.
• Nordic Consulting focuses on intervention in the latest episode of The HIT Breakdown podcast series.
• Oneview Healthcare recaps its experience at the Cleveland Clinic’s Patient Experience & Empathy Summit.
• Orion Health’s David Hay talks with Radio New Zealand about FHIR’s impact on population health.
• Patientco offers, “3 Reasons Why Insourcing the Patient Revenue Cycle is Easier Than Ever.”
• Phynd offers an “Introduction to Phynd’s Single Provider Profiles.”
• Qpid Health offers “Human-Digestible Documentation Tops AMIA EHR 2020 Task Force Recommendations.”

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
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Morning Headlines 6/12/15

Committee Working to Identify Immediate Solutions to Electronic Health Records Program that has Physicians “Terrified”

Senator Lamar Alexander (R-TN), chairman of the HELP committee charged with evaluating the Meaningful Use program, says at the committees first hearing this week, “Physicians and doctors have said to me that they are literally terrified of the next implementation stage of electronic health records, called Meaningful Use Stage 3, because of its complexity and because of the fines that will be levied. My goal is that before that phase is implemented, we can work with physicians and hospitals and the administration to get the system back on track and make it a tool that hospitals and physicians can look forward to using to help their patients instead of something they dread.”

E-health Progress Still Poor $2 Billion and 14 Years Later

The Canadian Medical Association Journal reports on the country’s largest annual e-health conference, saying that interoperability roadblocks are still hindering improvements. Mike Checkley, conference speaker and president of British Columbia-based QHR Technologies, quipped “Ten years ago, the big topic was interoperability. Ten years later, it’s not a lot different."

Study may help Department of Veteran’s Affairs find patients with high risk of suicide

The VA and NIH co-develop an algorithm that can scan the VA’s electronic medical records and identify patients that have a high suicide risk.

Judy Faulkner’s Giving Pledge

Epic Systems CEO Judy Faulkner signs the Giving Pledge, launched by Warren Buffet and Bill and Melinda Gates in 2010, promising to leave 99 percent of her estimated $2.3 billion fortune to charity upon her death or direction.

EPtalk by Dr. Jayne 6/11/15

Only a couple of days remain to submit comments to CMS on the proposed modifications to Meaningful Use. Comments are due on June 15. Be sure to have them in by 11:59 p.m. if you’re submitting electronically. If you opt for mail, courier, or hand delivery, they need to be there by 5 p.m. I wonder just how many people submit them by hand? I’ve been watching episodes of “The West Wing” on Netflix and recently viewed one where they put a campaign volunteer in a chicken suit to heckle the opponent. I think it would be great to hand deliver comments dressed in ironically themed costumes.

In other news, CMS released the Medicare Shared Savings Program Accountable Care Organization final rule last week. It addresses beneficiary assignment methodology as well as beneficiary protection during data sharing. The rule also looks at measurement benchmarking and adjustments based on an organization’s previous performance. I’m still torn on whether I am on board with the whole ACO concept. I understand that we need to generate savings for Medicare and deliver more quality care to patients, but it seems overly complex.

In my market, the ACOs are all over each other and it’s confusing for patients, who may not be motivated to seek care in the way that the ACO wants them to. Some may not even realize they’re part of an ACO. Many of us who have insurance through our employers receive premium discounts for healthy behaviors. How about something similar for the Medicare set? Let’s split the savings between Medicare and the patients when diseases are managed through lifestyle interventions rather than drugs or surgery. I bet that would drive the needle in the right direction.

With the tagline “It’s time to rebuild medical education from the ground up,” the AMA launches an initiative called Accelerating Change in Medical Education. They’re accepting proposals for the ChangeMedEd 2015 conference in October. Additionally, a new policy statement calls for medical students to experience hands-on use of EHRs during training. I like the idea of actually teaching future physicians how to use EHRs well rather than just throwing them out on the wards and hoping for the best as many programs still do. Using an EHR well in the patient exam room is a learnable skill. Not everyone takes to it easily, but being able to interact well with patients while documenting and accessing information is a key skill that many end users still lack.

I hope that while they’re “rebuilding medical education,” they push for courses in the other key areas that none of us realized were part of the practice of medicine:

• Quasi-Mandates 101: Managing participation in federal and payer programs while keeping your sanity. (Prerequisite is “Zen Breathing 101: Skills to avoid strangling people who say this isn’t mandatory and that physicians have choices.)
• Open Wallet 101: Understanding all the outlays required to practice medicine. Includes coverage of AMA’s stranglehold on CPT code licensing as well as discussion of state licensing, DEA, state controlled substance permits, medical staff dues, professional liability coverage, specialty board fees, maintenance of certification, and more.
• Administralian 200: Learn how to speak fluent buzzword and translate what you are hearing from administrators. (Co-enrollment in Hospital Administrator language lab required.)
• IT Support Practicum: Learn how to work through help desk blockades and the magic words to getting administrative privileges so that you can install useful medical apps on your personal device.
• Medical Review Practicum: Learn how to navigate payer phone trees and multi-level case reviews to ensure your patient receives the care he or she needs.

Most of my professional friends know I’m pretty happy in my new role as a free-range CMIO, but that doesn’t stop them from sending potential opportunities my way. Some are serious and some are hilarious. They also send clippings form sites like Glassdoor with reviews of potential employers. One I received today wins the prize. It was from a hospitality employee at a major teaching hospital. “Pros: great benefits, discounts on meals, yearly bonuses. Cons: you have to interact with a lot of sick people at work.”

I’ve always been a sucker for Vespa scooters. After today, though, I know that if I decide to move to fewer than four wheels, it will have to be in one of these. Thanks to the intrepid reader who sent it, making my day. I’m sure I can get a matching helmet to complete the ensemble.

Email Dr. Jayne.

News 6/12/15

Top News

Senator Lamar Alexander (R-TN), who chairs the Senate’s HELP committee that is reviewing the Meaningful Use program in a series of hearings this summer, says physicians are “terrified” of MU Stage 3 and he wants to change it before it is implemented so that “hospitals and physicians can look forward to using it to help their patients instead of something they dread.” Testimony from Wednesday’s first hearing was as follows (video of the hearing is here):

• AMIA Board Chair-Elect Tom Payne, MD says Congress should provide regulatory guidance on who is allowed to enter EHR information and should publish standards by which external data such as patient-provided information and medical devices can be incorporated into the EHR. He also suggests that Congress eventually consider revamping the Medicare payment system to focus on value-based purchasing rather than paying from code-driven documentation requirements. He adds that it is “unconscionable” that patients can’t get their full medical record in a standard, machine-readable format and says fixing that situation is the most important thing Congress can do.
• Cerner CEO Neal Patterson says health IT vendors must sell systems that are open (supporting externally built apps and extensions) and interoperable. He defines interoperability as being when a doctor seeing a patient for the first time can click an EHR button that immediately displays all relevant patient-approved information from the lifetime record from many sources, adding that we’re close to realizing that vision and the remaining problems don’t involve technology. He says a national patient identifier is essential. He admits that EHR vendors, including Cerner, “were out conquering the map” and competitive pressure led them to create technology silos, while full interoperability will require vendors to cooperate with the understanding that they will then need to compete based on innovation, quality, and cost. He talked up CommonWell and said Congress should act immediately to challenge behaviors that restrict patient choice, limit interoperability, or use captive data to increase market share.
• Consultant Christine Bechtel says consumers need to force the issue of having their data spread across multiple provider systems that can’t talk to each other so that none of them have a complete health picture. She reported her own experience on trying to get her electronic data from her PCP, who told her their portal was broken and they don’t plan to fix it. She then invoked the HITECH-HIPAA requirements that require providers to give her an electronic copy and the practice refused. She finally got them to provide an electronic copy (via a CD she had to pick up at the front desk) and found that the only way she could make sense of the CCR text file was to download an app that presented it more clearly. She recommends that the government provide consumer information and tools that make it easier for them to obtain and understand their medical information, require EHRs to incorporate consumer-generated data via the certification program, require EHRs to offer API access to earn certification, retain the Meaningful Use threshold for patients to view/download/transmit their information, publish privacy and security best practices for developers, and require providers to give patients their electronic data quickly and with a single, ongoing request.
• Carolinas HealthCare SVP/CIO Craig Richardville, representing the health system and Premier, says the market doesn’t reward information sharing, which is expensive. He wants Congress to encourage private-public interoperability governance, establish data and transport standards, and prohibit EHR vendors from charging fees for exporting information or accessing it via APIs.

Reader Comments

From Plyometric: “Re: Ministry Health Care. Eliminating positions due to its breakup with Marshfield Clinic and the loss of revenue that followed. Looks like a 5 percent RIF. At least they’re giving six months’ severance.” Unverified.  

From Flush the Money: “Re: Leidos. Is a renamed SAIC. Around 1994, Arlen Specter of PA – home of the then-owner of Sunquest — got funding passed to have a pilot program  for an anatomic pathology system for DoD hospitals. The privately owned CoPath system was chosen, to the surprise of the then-leading lab vendors Sunquest and Cerner. This was the first time a commercial system was integrated with CHCS. $10 million was allocated for the pilot, of which CoPath got $1.6 million and the rest went to and through SAIC for overseeing the process and interfacing CoPath to CHCS. One more reason I am rooting for Epic.” I took a trip down memory lane in reassembling cobwebby nuggets from anatomic pathology systems ancient history:

1. CoPath developer CoMed sold itself to Dynamic Healthcare Technologies (DHTI).
2. Sunquest wanted CoPath but couldn’t convince DHTI to sell the company so instead Sunquest signed a VAR agreement to resell it.
3. Publicly traded DHTI went down in flames and sold out to Cerner, meaning the two leading lab vendors (Sunquest and Cerner) were both selling the same CoPath product.
4. Legal disputes cut off Sunquest’s access to ongoing updates from Cerner (where the original CoPath developers remained), so then each company starting doing their own development in creating different products that were both called CoPath.
5. AP vendor Tamtron sold itself to Elekta, which eventually sold the PowerPath AP product to Sunquest, giving Sunquest two AP products that it still offers today.

You might correctly assume that all of these corporate gyrations and convoluted family trees have confused laboratory customers for years, while Epic’s Beaker genealogy (including anatomic pathology) is a short but straight line. 

HIStalk Announcements and Requests

From the jobs board: director of provider solutions, western region (VisionWare).

This week on HIStalk Practice: MyIdealDoctor partners with Zest Health. Physicians seem dead set against sharing data with patients. Mountain River Physical Therapy implements Clinicient tech. Kareo, Greenway Health, ADP AdvancedMD, and McKesson rank high for physician practice IT. Delaware and North Dakota adopt new HIE technologies. Cactus Clinic moves to Athenahealth.

This week on HIStalk Connect: an artificial intelligence-based algorithm developed at Tufts University solves a 120-year-old biological mystery with no human aid. The VA pilots a program that captures patient’s life story as told by them. Walgreens expands its telehealth platform to residents of Colorado, Illinois, and Washington. Google X Labs launches a ResearchKit-like app that it designed to support its Baseline Study project.

Webinars

None scheduled soon. Contact Lorre for information about webinar services.

Acquisitions, Funding, Business, and Stock

British medical equipment vendor Smith & Nephew acquires two orthopedics supply chain software applications developed by Memphis-based S2 Interactive, a visual OR preference app and a central processing management system.

Twitter, desperate to boost usage and revenue that have been constrained by new users who can’t figure out how it works, will increase the character count allowed in direct messages from 140 to 10,000 in hopes of making it a desirable messaging app.

Sales

Mount Sinai Medical Center (FL) chooses Phynd for creating and maintaining a single provider profile for its 10,000 referring and credentialed physicians across multiple systems that include Epic.

People

Care coordination software vendor TEAM of Care Solutions hires Thomas McCarter, MD (Executive Health Resources, An Optum company) as chief medical officer.

Announcements and Implementations

Ireland-based claims processing and procurement software vendor SoftCo reports several recent US hospital sales that include Providence Hospital (SC) and UPMC Cancer Center (PA).

National Billing Center will offer its customer nVoq’s SayIt Transcription Assist service to customers who want to dictate notes that are routed to US-based transcription company and that can then be sent to the EHR.

Software vendor Kolkin offers physicians a free download of its SOS real-time patient list and handoff tool through July 31.

Walgreens will expand its MDLive-powered $49 virtual doctor visit service to 25 states by the end of 2015 now that testing in California and Michigan has been completed.

Terebonne General Medical Center (LA) goes live on RightPatient biometric patient ID management throughout the hospital.

Meditech’s UK dealer, Centennial-MIT, is listed on the NHS Shared Business Services procurement framework.

Government and Politics

HHS warns physicians to carefully review the terms of medical directorship agreements they may sign, suggesting they make sure their compensation reflects the market value of their services to avoid any hint of being paid kickbacks for their Medicare referrals.

The VA and National Institute of Mental Health develop a suicide risk algorithm that, when applied to the VA’s EHR data, identifies high-risk suicide patients that have been missed by clinicians.

National Coordinator Karen DeSalvo, MD posts her #HealthySelfie and challenges her 6,180 Twitter followers to do the same.

Privacy and Security

PHR vendor NoMoreClipboard, operated by Indiana-based Medical Informatics Engineering, reports that the information of an undetermined number of its users was exposed in a breach discovered on May 26, 2015. It apparently collected and stored Social Security numbers that were contained in the breached information.

The South Korean government is enforcing the quarantine of citizens exposed to Middle East respiratory syndrome by tracking their cell phone locations.

The government of Ontario, Canada proposes to double the fines (to $100,000) for people who inappropriately access patient medical records and also eliminate the requirement that prosecution starts within six months of the breach.

Technology

Mayo Clinic launches its Periscope account to provide Twitter-owned, real-time video streaming from smartphones. As with most new technologies, they’re trying to figure out what to do with it, while also being careful of the possible patient privacy implications of streaming live, unedited video from one person’s mobile phone.

Other

A recap of Canada’s largest e-health conference by the Canadian Medical Association Journal says the country has seen limited progress after spending $2 billion on EHRs because each province developed their own technical standards and chose their own systems without considering interoperability. A researcher says Canada Health Infoway has spent $220 million on salaries and administrative costs in handing out $2 billion in federal grants, but doesn’t manage those investments with interoperability in mind. A physician who helped create Alberta’s EHR says the government should encourage provider interoperability by using pay-for-performance measures as the carrot and financial penalties as the stick.

Epic CEO Judy Faulkner signs The Giving Pledge, launched by Warren Buffet and Bill and Melinda Gates in 2010 to encourage the world’s wealthiest people to give most of their fortunes to philanthropy. Faulkner, who says in her pledge letter that she “never had any personal desire to be a wealthy billionaire living lavishly,” will direct 99 percent of her estimated $2.3 billion in assets to a charitable foundation upon her death or direction.

In a brilliant motivational and engagement practice, blood donors in Sweden receive a thank-you text message when their donated blood is administered to a patient.

Stanford University researchers discover a possible link between the use of proton pump inhibitor drugs like Prilosec and heart attacks by mining Stanford’s own EHR databases as well as those stored by free EHR vendor Practice Fusion. The authors acknowledge that their work is not definitive, suggesting that a large, prospective clinical study be performed to prove causality rather than correlation.

Here’s a fun sepsis awareness video from Kern Medical Center (CA).

Weird News Andy says, “He’s bean curd” in summarizing the removal of a patient’s 420 kidney stones that doctors blame on his excessive consumption of tofu.

Sponsor Updates

• Extension Healthcare offers a new blog on standardizing hospital sounds with alarm management middleware.
• Galen Healthcare asks, “Quality Incentive Programs Reporting – Which Opportunities are Right for You?”
• Hayes Management Consulting posts “Why Your Front Desk Needs to Understand Coding.”
• The HCI Group offers “5 Steps to Harness Healthcare Innovation.”
• SVP of Marketing Sarah Swidron of Healthcare Data Solutions is profiled in the Pharmaceutical Marketers Directory Refresh newsletter.
• Healthfinch offers “Physicians: Ready to Give up Your Lunch Time Now Too?”
• Healthwise offers “Decision aid reduced men’s interest in PSA screening and helped shape patient-clinician conversations.”
• Impact Advisors is named to The Channel Company’s 2015 CRN Solution Provider 500.
• Influence Health recaps its Annual Client Congress.
• Ingenious Med will exhibit at the 2015 National Health Leadership Conference June 15-16 in Charlottetown, PEI.
• InstaMed looks at “Trends in Consumer Healthcare Payments.”
• Holon Solutions will exhibit at the Indiana Rural Health Association meeting June 16-17 in French Lick.
• InterSystems will exhibit at the 2015 NYS Mini-HIMSS Conference June 17 in New York City.
• Ivenix releases a new white paper entitled, “Improving Intravenous Therapy: Opportunities for Designing the Next Generation Infusion System, Part 2: Infusion Pump Alarms Management.”
• PDR will exhibit at Pioneer Rx June 12-14 in Nashville, TN.
• HealthMedx will exhibit at the LeadingAge PA Annual Convention June 16-17 in Hershey, PA.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

Morning Headlines 6/11/15

Walgreens and MDLIVE Expand Telehealth Platform to Three New States, Add Desktop and Tablet Functionality

Walgreens expands its telehealth service to users in Colorado, Illinois and Washington, and promises to make the service available to 25 states by the end of the year.

Kentucky Physician Named AMA President-elect

AMA announces that its next president will be Steven Stack, MD, an emergency medicine physician from Kentucky. Stack served as the chair of the AMA’s Health Information Technology Advisory Group from 2007 to 2013 and has served on multiple ONC advisory groups.

Reducing Alert Fatigue Prevents Pharmacy Medication Errors

Hospital Sisters Health System (IL) reduces the number of alerts being presented to physicians by 40 percent, while improving its rate of catching preventable medication errors by analyzing and optimizing its alerts.

Growth Of New York Physician Participation In Meaningful Use Of Electronic Health Records Was Variable, 2011–12

Health Affairs publishes an analysis of the Meaningful Use program, finding that providers that had adopted EHR systems prior to MU were more likely to be “early and consistent participants” in the program.

Readers Write: The Learning Healthcare System Starts with the Vendor-Neutral Archive

The Learning Healthcare System Starts with the Vendor-Neutral Archive
By Larry Sitka

The Office of the National Coordinator for Health Information Technology, commonly referred to as ONC, recently released “Connecting Health and Care for the Nation, A Shared Nationwide Interoperability Roadmap (DRAFT Version 1.0).” Inside the 166-page framework description, ONC introduces the need for a platform called a Learning Health System, which it defines as “an environment that links the care delivery system with communities and societal supports in ‘closed loops’ of electronic health information flow, at many different levels, to enable continuous learning and improved health.”

The ONC document is designed to be a 10-year roadmap that describes barriers to interoperability across the current health IT landscape, including a description and proposal for a desired future state of healthcare IT. It introduces an architecture overview for a learning healthcare system and what is required of such a system.

In the report, ONC states that “by 2024, individuals, care providers, communities and researchers should have an array of interoperable health IT products and services that support continuous learning and improved health. This ‘learning health system’ should also result in lower health care costs (by identifying and reducing waste and preventable events), improved population health, empowered consumers and ongoing technological innovation” through coordinated care plans.

The report states that in the future, “all individuals, their families and health care providers should be able to send, receive, find and use electronic health information in a manner that is appropriate, secure, timely and reliable. Individuals should be able to securely share electronic health information with care providers and make use of the electronic health information to support their own health and wellness through informed, shared decision-making.”

While the vision and future state put forth by the ONC is sound, as healthcare professionals, we must ask ourselves, “Where do we begin?” and, “What can we do today to begin reaping some of the benefits of interoperability and providing the foundation for the next 10 years?”

As with any technology revolution, certain technologies mature faster than others and begin to provide a glimpse of the future landscape. In the case of interoperability, the vendor-neutral archive (VNA) is a mature technology that is already playing a leading role in evolving the current healthcare ecosystem toward a learning healthcare system and providing a means for real-time healthcare delivery.

The foundation for a learning healthcare system is the basis of what a VNA provides today. Leveraging and thinking of a VNA as merely an imaging storage tool is shortsighted. Why not envision the VNA as providing the pathway and functionality for a patient-centered healthcare discovery tool? The VNA already has the capability to provide an IT interoperability framework that enables many applications to work in unison to learn the context of a patient, inside or outside the current healthcare organization. By leveraging a VNA in this context, suggestive results can be provided to the healthcare organization’s clinicians, physicians, and, most importantly, the patient in a passive or real-time manner.

The VNA is an effective means for improving patient outcomes through interoperability and for moving healthcare organizations beyond the traditional product sell. The ONC report states, “Consumers are increasingly expecting their electronic health data to be available when and where it matters to them, just as their data is in other sectors. New technology is allowing for a more accessible, affordable and innovative approach. However, barriers remain remain to the seamless sharing and use of electronic health information.” The VNA has all the elements necessary to establish a learning health system foundation.

In the construction of a building, every project begins with the foundation. A solid and stable foundation is critical and must be carefully planned. It is the most difficult structural element to change. The foundation of a learning healthcare system is built around two key components—patient context and the healthcare delivery organization (HDO) context. Taking ownership of the data and focusing on HDO interoperability through standards are essential pillars that must be cemented into this foundation.

From an HDO perspective, ownership of clinical content on behalf of the patient is a mandatory requirement. An assumed role of the HDO, on behalf of the patient, is the holding of collected patient content for future use in the continuum of care. The HDO must define and build a foundation by which secure sharing of patient content is inherent. This environment must be capable of not just storing content but also dynamically finding, moving, and distributing content in real time.

This content is linked and possibly moved into a learning healthcare system independent of the organization’s affiliation. The content is either linked on demand or covertly as information is discovered, further extending the patient longitudinal record. The goal of content aggregation is to provide suggestive access to patient information for the healthcare worker who is responsible for delivering a better patient outcome. The patient outcome is the evidence by which the HDO shall be paid.

From the patient perspective, ownership of the data by the patient is now something we vendors must enable and that HDOs are legally bound to steward. HIPAA, for example, can appear to vendors as restricting and controlling. It attempts to define who and what content can be accessed along with the purpose of accessing that content. However, it is actually HIPAA that finally gives ownership of the content back to the patient. It is the first piece of legislation specifying to the HDO and its vendors that true ownership of results and supporting documentation belongs to the patient and not the healthcare organization, the insurance company, or the product vendors.

Once the foundation of a learning healthcare system is created, the framing comes next. Framing requires exact measurements and sizing using standards-based products. With the cutting and coercion of the materials comes a custom fit per the requirements in a blueprint. Such is the case of a learning healthcare system, where the HDO must begin by demanding standardization of not only structured content but also unstructured content. Standardization assures interoperability and a canonical data model that is based on industry standards and site-specific requirements, not proprietary vendor specifics. Standardization or canonicalization of the metadata to be used and exchanged in a learning healthcare system is exactly what a true VNA platform provides.

Simple problems come with very complex solutions in these cases. For example, patient names, IDs, and study descriptions have become as complex to the HDO as the Y2K problem. Can you imagine the chaos that would ensue from an IT infrastructure not based on wireless or Ethernet standards for physical connectivity? Simply put, what if we all drove on an Interstate without painted lines? What if the map we used for guidance did not include a legend?

Such is the case for the HDO when it comes to delivering a standards-based form of patient content. Of course, there are DICOM standards, HL7 standards, and the XDS framework, but HDOs must demand that vendors actually support and utilize these standards, participating in annual Connectathons to validate their ability to interoperate. More importantly, HDOs must contractually demand interoperability following those exact standards. In short, an HDO must stop purchasing solutions that are unique to its own internal, proprietary standards.

The deployment of the electronic medical record (EMR) to capture and attempt to hold unstructured content, at least inside a data warehouse application, is a step in the right direction. Unfortunately, the EMR only solves half of the problem by providing a collection point. To test this, try and share the unstructured content between EMRs and between organizations. This has become a next-to-impossible task. EMR providers that claim to be able to share unstructured content typically come up far short of expectations.

The idea of sharing an electronic record is what initially drove EMR adoption. But now we have a large volume of unstructured content that must feed the learning healthcare system. The VNA is a capable platform for achieving this goal. The chart above indicates where the VNA is already meeting three-year and six-year interoperability objectives set forth in the ONC report.

The final steps in a construction process are completed by selecting the best products, with the best look and feel, to meet the needs of the owner. Such is the case in creating a learning healthcare system, which demands the ability to select the best products and functionality to deliver the best patient outcomes. Different departments and healthcare settings, much like physicians, have different needs and requirements. Why be limited to only one selection? More importantly, don’t be forced into “one size fits all” in the selection of applications. Give HDO users the flexibility to select the applications that best suit their workflow and objectives. For example, a radiology-centric viewer will not work very efficiently for wound care or treatment planning.

When connecting the building to the outside world, each location typically has its own utility providers that are part of a grid. The same is true for a learning healthcare system, where existing healthcare information exchanges (HIEs) are the on-ramps. The HIE and image or content exchange, which are typically not profitable today, are expected to evolve into much more in the future. Difficulties often arise when seeking cooperation among different, unaffiliated organizations for patient informational access. Vendors, of course, find it difficult to build any product today around something that is not profitable, not to mention being a very difficult sell to HDO executive teams. Tomorrow’s HIE technology inside the learning healthcare system, however, will not only be a necessity but will be integral in making sure image and content exchange is included in the VNA as an embedded feature. Sharing patient content across the private sector, HIEs and government organizations will become commonplace within the next decade, all driven by patient outcomes.

But, more importantly, the business and legal perspective. The VNA selected should support an HIE inherently. An image/content exchange is a mandatory requirement of a VNA and is the basis of a learning healthcare system for moving released content in a secure manner. It is also critical that an image/content exchange within a learning healthcare system provide the business process and verification steps, including automation of steps that include BAA approval and appropriate patient release form access and approval.

The data demands of a learning healthcare system will far exceed anything an HDO has seen to date. Typically, the sizing of a VNA is done by traffic volumes requested by concurrent users, or study volumes. However, the oncoming big data analytics applications (a necessity inside a learning healthcare system) will far exceed any current traffic volumes requested by humans. A learning healthcare system will be in a continuous mode of finding, aggregating, and coercing information relevant to the patient in context. This is also a necessity to building out the patient record.

Once found, the information is persisted in the learning healthcare system whereby the analytics and other applications, including natural language processing (NLP), will access the information. NLP will give the data better context and perception around the patient, allowing the healthcare worker to have better informational access and decision processing through new clinical support applications. Support for these demanding applications will require an infrastructure that can scale on-demand, both horizontally and vertically. These applications will leverage your VNA for more than just “basement storage,” where content becomes cluttered and inefficient while never being used again.

The learning healthcare system will be an integral part of improving the way the healthcare ecosystem works and how patients, providers, and payers interact within that ecosystem. Achieving the complete vision of the learning healthcare system will be a gradual process and lessons will be learned throughout the journey. There are important actions we can initiate today, however, to begin building the necessary foundation for this vision. VNA technology is the foundational cornerstone mature enough to begin solving some of the greatest challenges and to remove some of the obstacles to a fully interoperable healthcare system.

Larry Sitka is principal solution architect with Lexmark Healthcare of Lexington, KY.

HIStalk Interviews Tony Schueth, CEO, Point-of-Care Partners

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

Tell me about yourself and the company.

Point-of-Care Partners is a health IT strategy and management consulting firm that I started 12 years ago when I left Merck-Medco, which is a pharmacy benefit management company that was owned by the pharmaceutical manufacturer Merck. We are unique because we focus on a subject matter and then work across stakeholders. For example, health plans, PBMs, integrated delivery networks, EHR vendors, and other technology companies and pharmaceutical manufacturers are all our clients.

The first subject matter that we focused on was electronic prescribing. Then we consulted and worked with all the different stakeholders in prescribing. The subject matter that we focus on now are some variations of e-prescribing, including e-prescribing of controlled substances, specialty e-prescribing, but also electronic prior authorization, population health, clinical decision support, clinical messaging, real-world evidence and outcomes, health information exchange, and patient engagement. We also have three new solutions and services built primarily for EHRs, a 50-state regulatory analysis of e-prescribing and e-prior authorization laws as well as a database of NPIs-to-EHR, including version numbers.

I got my start in electronic prescribing in the mid 1990s when I was a product manager for an early-generation e-prescribing solution and have been working in electronic prescribing ever since then. We have created a transaction standard that supports the process. We also have intermediaries that specialize in e-prescribing. Prescriptions are flowing electronically. It’s a true success story, in my opinion. It’s also gratifying.

Recently I was listening to a panel of physicians talk about and complain their electronic health records. I asked them, "OK, I’ve heard all these negative things, but what do you like most about your EHR?" To a person, they said electronic prescribing.

For someone who has been in this business for nearly 20 years, that made me feel proud. But it didn’t happen overnight and we’re not finished yet. The areas where we still need to address are e-prescribing of controlled substances and e-prescribing of specialty medications. We still have some challenges around data quality, such as formulary files, as well as unintended consequences of e-prescribing or data issues where maybe inadvertently the wrong dosage was chosen or something like that.

Companies like Surescripts have built networks and seem to have ambitions that go beyond just pushing transactions around. How do those networks fit in the big picture of interoperability?

I also have a great deal of experience in health information exchange arena. I worked in the mid 1990s for the largest Community Health Information Network or CHIN vendor of that era. It was pre-Internet and only a small portion of the data was digitized. What we learned is that once a pipe is established, it can be used for more than just what it was originally intended for.

But sometimes it’s not so easy. For example, we have worked with companies focused on administrative and financial transactions who aspired to exchange clinical information. The challenge is that the user of the administrative and financial information is not necessarily the user of the clinical data. As always, we need to really think about workflow, especially in the physicians’ office.

The other advantage the national networks have over public HIEs is that it’s not just local competitors glaring at each other across a small room. Providers don’t seem to worry about connecting to a network that has a big competitor as just one of many national members. Will the balance shift towards proprietary networks?

About 10 years ago when RHIOs were first forming,  eHealth Initiative retained me to bring forward some lessons learned from the CHIN era to the RHIO – and subsequently HIE – era. I was uniquely positioned to seek out and speak with some of the founding fathers of the previous era and asked them if they thought it would work this time around.

There were mixed reactions. All pointed out the advantages we have today, including the Internet, digitized data, and federal and state governments that have passed supportive laws and regulations. About half were optimistic, but the others thought the biggest challenge that still remains is that of the competition you just mentioned.

It’s nearly universally agreed that healthcare is local. You get local competitors in the same room and to decide how to exchange information and they all say the right things. But when it comes to prioritization, investment, and those kinds of things, they’re not always stepping forward and supporting in the way that’s needed for a successful initiative.

To answer your question directly, yes, some of these larger, more national exchanges don’t have the competitive issues, but they have other issues. You really need to look at every situation differently and adjust to the different situations.

How do pharma and medical device companies see provider EHRs and the information they contain?

Pharma is waking up to EHRs. They’ve always been part of my consulting equation, having previously been employed by companies owned partially by Merck and Lilly. In the early days of my consulting — especially around electronic prescribing — they would say, "Come back to me when all of my doctors are prescribing electronically," A Surescripts report just came out that said that 56 percent of doctors are prescribing electronically, but I had a side conversation with a Surescripts executive who said that 80 percent of specialists who practice in the ambulatory environment are prescribing electronically. 

We may not have all, but we’re pretty much there. Pharma gets that electronic health records are the center of the healthcare universe at the moment and want to understand how it’s impacting them, both positively and negatively.

Several years ago, we had an engagement with a company that was concerned that patients with COPD were being misdiagnosed with asthma. With that diagnosis, the prescriber could choose from several medications that were optimal for asthma, not COPD. That situation was not only sub-optimal for the manufacturer, but for the patient as well. They wanted to understand how to get guidelines – a series of five simple questions – included in the EHR that would help diagnose patients as having COPD. Then, yes, the prescriber might write a prescription for their drug. But this company didn’t even have the largest market share in that category. They were satisfied with the patient being properly diagnosed. Wouldn’t that be good for us all?

Do you have any final thoughts?

I just got back from Health Datapalooza and there was a lot of talk there about the future. A lot of excitement and enthusiasm for being able to use data more effectively in healthcare. I believe we have a lot of challenges with healthcare data, but we’re making progress. Like health information exchange; like e-prescribing. We have to start somewhere and it’s not going to happen overnight.

Eventually I believe I will be at a conference with a panel of physicians talking about how they practice medicine. When I ask them what tool they like the best, I expect they’ll say their EHR. I know we have a ways to go to get there, but I believe we’re on the way. It won’t happen overnight, but it will happen. I’m extremely excited to be leading a firm that is helping to make that a reality.

Morning Headlines 6/10/15

American Well Corp v Teladoc, Inc

Telehealth vendor American Well sues rival Teladoc for patent infringement, alleging that Teladoc is using American Well’s patent-protected technology to match patients with doctors. The lawsuit comes just as Teladoc prepares for its IPO.

NHS details released against patients’ wishes, admits data body

In England, the Health and Social Care Information Centre reports that 700,000 patients have had their medical information shared against their wishes. The organization, which is responsible for processing patient requests to prevent data sharing, reports that it does not have the staff to keep up with the volume of requests it is receiving.

Charities struggle to share care data

In England, the CIO of Combat Stress, a charity dedicated to providing mental health services to  veterans, reports that a lack of interoperability with NHS health IT systems is hindering care delivery. He is calling for a standards-based approach to document sharing between the organizations.

Veterans Adding Life Story to Medical Records

The Madison, WI VA Medical Center is piloting an initiative aimed at capturing the life story, as told by the patient, for every patient’s medical record. The initiative is designed to permanently record the traumatic events behind many of the veteran’s injuries so that they do not need to retell the story every time they see a new doctor.

News 6/10/15

Top News

Video visit provider American Well sues competitor Teladoc for patent infringement, claiming that Teladoc continues to use American Well’s patented doctor-patient visit matching and queuing technology even after American Well turned down its request for a license.

Reader Comments

From Stickler: “Re: Epic. It is NOT an acronym. MEDITECH is an acronym. I have personally heard a CIO say he automatically deletes any vendor email that spells Epic as EPIC. Anyone who does it immediately loses any credibility they might have otherwise had – it shows they don’t know or don’t care and neither does a positive impression make.” Vendors let their marketing people run amok in peppering company names with bizarre extra capitalization, non-capitalization, conjoined words with capitalization in the middle, extraneous symbols, and other heinous and overly attention-seeking insults to the English language in trying to create a memorable company brand. The important distinction in Epic’s case is that they spell their own name correctly – it is clueless others who spell it EPIC. I agree with your CIO friend that I would hesitate to do business with a company claiming Epic expertise that doesn’t include knowing how to spell the company’s name. MEDITECH, by the way, is not an acronym, which is defined as an abbreviation made up of the first letters of several words that can be pronounced as a single word (IBM is not an acronym since it can’t be pronounced – it is instead an initialism, while NASA is an acronym). For that reason, Meditech’s name should not be capitalized even though the company does it – it’s an artificially, informally shortened version of the company’s real name, Medical Information Technology, Inc. The AP Stylebook for publications is clear that all-caps company names are not to be used unless the letters are individually pronounced, such as IBM or BMW, no matter how the company registered its legal name or trademarks.

From Richard Head: “Re: Leidos tweet. Is there a possible interpretation that could make this true?” I’ll challenge the Leidos and/or Cerner folks to provide details, especially since “healthcare facilities” seems like a pretty broad group given the large number of “healthcare facilities” in non-Cerner parts of the world such as China and Russia, for example.

From Bud Fox: “Re: DoD EHR bid. A private recruiting firm contracted by the DoD has been contacting my health system’s Epic analysts to recruit them for its EHR project, with starting salaries of over $100,000. Perhaps the DoD has already quietly selected Epic?” My sources say that no decision has been made and won’t be for at least another month. If there’s a frontrunner, DoD is keeping quiet about it even among the bidders.

From Dusty Wind: “Re: DoD EHR bid. Leidos will say or do anything to keep the business, which is supposedly contributes 20 percent of their revenue in maintaining CHCS.” Unverified, but Leidos wins under two scenarios – (a) DoD chooses Cerner, or (b) DoD decides to do nothing. Either way Leidos gets the lucrative operations and change orders business for many years. They will take significant revenue a hit if DoD chooses Epic or Allscripts.

From Point Taker: “Re: grammatical errors. And you worry about the small ones!” The Twitterverse loves this gaffe by a headline writer who confused “ambidextrous” with “amphibious,” with wags adding comments as “Faces Aquaman in next outing” and “He loves rain delays.”

Webinars

None scheduled soon. Contact Lorre for information about webinar services.

We had a great turnout for Tuesday’s Medicity-sponsored webinar titled “Successful HIEs DO Exist: Best Practices for Care Coordination.” Participation was so extensive that we ran out of Q&A time, but we’ve sent the remaining questions to speakers Brian Ahier of Medicity and Dan Paoletti of Ohio Health Information Partnership and will provide their answers by email.

Acquisitions, Funding, Business, and Stock

Cardiac biomarker lab company Health Diagnostic Laboratory files Chapter 11 bankruptcy two months after agreeing to pay $50 million to settle Department of Justice charges of giving kickbacks to doctors to order its tests.

Medsphere closes a $7.5 million venture-backed loan that the company will use for working capital.

Sales

Accountable Care Medical Group (FL) chooses HealthEC’s population health management solution.

People

Pratik Chakraborty (Wipro) joins home care data collection platform vendor CellTrak as VP of R&D.

Announcements and Implementations

Orion Health incorporates the image exchange system of eHealth Technologies into its HIE platform for the North Dakota Health Information Network.

EClinicalWorks will offer its users electronic prior authorization services from Surescripts.

Ochsner Health System (LA) launches Healthgrades-powered appointment scheduling that updates its Epic EHR.

Apple’s always-in-June developers’ conference announcements: (a) the Apple Music streaming service that will even eventually run on Android devices; (b) iOS 9; (c) OS X 10.11 El Capitan; (d) support for native Apple Watch apps; (e) a smarter Siri; and (f) public transit directions in Maps. 

Government and Politics

The Senate’s HELP committee will review AMIA’s just-published “EHR 2020” report in a Wednesday morning session available as a live video stream. Witnesses include incoming AMIA chair Tom Payne, MD, Carolinas HealthCare SVP/CIO Craig Richardville, Christine Bechtel, and Cerner CEO Neal Patterson.

The Madison, WI VA hospital encourages patients to spend an hour telling a trained volunteer their life story, which is written up, edited by the patient, and then added to their electronic chart. Army veteran Jennifer Sluga (above), who served in Kosovo, describes the “My Life, My Story” program, which is expanding to other VA hospitals but unfortunately not to hospitals in general:

“Even if you do get asked about your story, you get tired of telling it over and over. You hold back information. With this interview, I get it out and it’s in the record. I don’t have to talk about the hard stuff if I don’t want to. I don’t have to be strong and put on the soldier face. I know it’s there for the provider to read. There are a lot of younger providers who don’t have the life experience to know what it means. You might be sitting across from an 89-year-old veteran but you don’t know what experiences he has under his belt. If you have his story in the record, you might realize that he isn’t just an old man, but a hero. Anything you can do to make a veteran feel special is worth it. Interviewing them and writing their stories does that.”

Privacy and Security

In England, the NHS’s information center admits that the information of 700,000 patients may have been shared without their permission because technical and workload requirements left the department unable to record opt-out preferences.

Innovation and Research

The 28 members of the Greater Dayton Area Hospital Association (OH) launch Ascend Innovations, a business to commercialize healthcare technology from hospitals, the Air Force Research Laboratory, and other sources that combine “Dayton’s biggest industries – defense and healthcare.” 

Other

In England, the CIO of a veterans’ support organization says it could provide better service to its clients if it had access to their NHS healthcare records, but it can’t afford the integration and auditing costs involved. He also notes the barrier of outside groups like his being unable to update the NHS records.

Independence Blue Cross applies algorithms to its databases to assign health coaches to coordinate services for high-risk patients, reporting a 40-50 percent reduction in expected CHF admissions. A Harvard law professor questions whether patients should have the right to opt out, but the insurer says their information is used only in its role of improving their care and that should be perfectly fine.

A study finds that long-term care hospitals seem to time patient discharges for maximum Medicare payment rather than clinical needs.

Industry groups want pathologists to follow standard case review protocols before sending results to referring doctors, hoping to reduce the 10 to 25 percent of cases where experts don’t agree that a growth is either benign or malignant. A possible solution is digital pathology that allows pathologists to share scanned images and to apply biomarker algorithms, although FDA won’t approve it for primary or secondary diagnosis until it’s convinced that the quality of the digital image is as good as that of the original tissue slide.

A study finds that 50 US hospitals are charging uninsured patients more than 10 times the actual cost of their care vs. the 3.4 times national hospital average, with all but one of those 50 being for-profit hospitals. Researchers say it isn’t just uninsured patients who are getting gouged – it’s also those being treated out of network, using workers’ compensation, and being reimbursed by their auto insurance carrier, adding, “They are price-gouging because they can. They are marking up the prices because no one is telling them they can’t.” Community Health Systems owns 25 of the hospitals, while HCA has 14. The hospital owners predictably disagree with the findings, saying they offer discounts and charity care and need the money to keep their safety net hospitals open.

Weird News Andy says of this patient who performed “Yesterday” by the Beatles during his brain tumor removal surgery, “All his troubles seemed so far away.”

Sponsor Updates

• PeriGen will introduce its PeriCALM CheckList OB solution at the AWHONN conference June 13-17 in Long Beach, CA.
• A Forward Health Group video features the use of its PopulationManager by ARC Community Services to address substance abuse in women.
• Wellsoft will exhibit at the National Freestanding Emergency Center Conference June 17-18 in Dallas.
• Health Catalyst’s Dan Burton, Steve Barlow, and Tom Burton are named “EY Entrepreneur of the Year” in the technology category of the Utah region.
• Accreon client OntarioMD is recognized with the CHIA Innovation Award at the eHealth 15 conference.
• AirWatch shares its reaction to the Apple Worldwide Developers Conference announcements in a new blog.
• CareSync highlights National Cancer Survivors Day.
• ChartMaxx exhibits at NYHIMA through June 10 in Syracuse, NY.
• E-MDs customer Orlando Heart Specialists (FL) is chosen as one of five sites to pilot the American College of Cardiology SMARTCare ischemic heart disease treatment options program.
• CommVault advances to preferred solution partner with Cisco.
• Aventura is named as a 2015 Red Herring Top 100 North America Tech Startup.
• CoverMyMeds will exhibit at the Next Generation Payers Summit June 10-12 in Miami.
• Richard Helppie of Santa Rosa Holdings and Sandlot Solutions is interviewed for an article titled “The missing link in interopability: what patients want.”
• CTG posts a new podcast featuring patient advocates in its #TalkHITwithCTG series.
• Bottomline Technologies will exhibit at ACE June 17-19 in Austin, TX.
• Divurgent receives the Small Business Award from the US Chamber of Commerce.
• Burwood Group is named to the 2015 CRN Solution Provider 500 list.
• CitiusTech will exhibit at DIA 2015 June 14-18 in Washington, DC.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

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Morning Headlines 6/9/15

Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations

CMS publishes its final rule addressing changes to the Medicare Shared Savings Program. The final rule introduces a new program, called Track 3, based on the successful aspects of the Pioneer ACO Model. The rule also beings to address performance benchmarking concerns, and promises additional performance benchmarking regulations later this year.

Back to the Future

Outgoing AMA president Robert Wah, MD, rails against the Meaningful Use program and ICD-10 implementation at the AMA Annual Conference this weekend in Chicago, saying “the Meaningful Use requirements for electronic records are a heavy burden and a prison for innovation,” and “We believe ICD-10 will further disrupt physician practices when we’re already facing headaches like Meaningful Use.”

ICD-10 ‘Grace Period’ Bill Introduced in US House

Representative Gary Palmer (R-AL) introduces HR 2652, titled Protecting Patients and Physicians Against Coding Act of 2015, which if passed would establish a two-year grace period during which both ICD-9 and ICD-10 codes would be accepted. It is the third bill introduced in the last two months that attempts to delay the upcoming ICD-10 switchover.

Curbside Consult with Dr. Jayne 6/8/15

I was visiting some friends this weekend and we drove past a niche primary care clinic. It advertised “Healthcare for Guys!” which certainly caught my eye. Although the location I saw was next to Costco, a quick Web search revealed that they apparently also have a location next to a home improvement store. I’m always interested in new models of care and thought I’d find out a little bit more. Unfortunately, their website was pretty sparse without even a listing of their physicians or the fact that they now have multiple locations. Their Facebook page had multiple posts with grammar errors and typos. Not exactly a vote of confidence, but a great example of why physicians need to pay attention to their social media presence and webpages.

On the flight home, I noticed that the ever-present SkyMall catalog was missing — apparently it’s gone digital-only. After some procrastination (check out the automated pill dispenser above), I was forced to read journals instead. An article in the Annals of Family Medicine caught my eye: “Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians.” The study set out to assess “the feasibility and acceptability” of some of the care coordination objectives in the proposed Meaningful Use rule for Stage 3. Specifically, they looked at referrals, transfer of care, clinical summaries, and patient dashboards.

Researchers surveyed primary care practices that had been recognized as patient-centered medical homes (by the National Committee for Quality Assurance) in addition to participating in Meaningful Use. They also surveyed community health centers with patient-centered medical home recognition. The survey looked not only whether the sites had implemented the proposed objectives, but also at whether the practice thought those objectives were important. The results were similar to anecdotal comments I’ve heard in the field. While 78 percent of the physicians thought it was important to be notified of hospital discharges, only 48 percent were using IT systems. Conversely, while 77 percent of practices were providing clinical summaries to patients, only 48 percent of them considered providing summaries to be “very important.”

Similar to what we know about vaccine delivery (namely that non-physicians do a better job of following protocols and ensuring vaccination), the study found that care coordination was more often done using IT systems when a non-physician was responsible. The practice’s “capacity for systemic change” was also positively associated with using health IT for care coordination as was being in a non-urban area. The study concludes that “health IT capabilities are not currently aligned with clinicians’ priorities” and that “many practices will need financial and technical assistance for health IT to enhance care coordination.”

Those aren’t earth-shaking conclusions for anyone who has been in the trenches during the Meaningful Use era. While those practices that had already transformed care coordination prior to MU will continue to do so, those arriving later to the dance are struggling. It’s hard to identify dedicated resources to manage patient panels without negatively impacting the bottom line of practices already on thin margins. Although there is the promise of future money for demonstrable outcomes, you have to demonstrate quality to get the money. It’s a somewhat perverse chicken-egg-chicken loop.

I also wasn’t surprised by the fact that the survey only had a 35 percent response rate. Additionally, the study found that the most commonly implemented care coordination processes were not those with the most IT involvement. Respondents cited the top barriers as time, money, and IT systems. There were several other interesting data points from the practice demographic data: approximately one-third of clinicians were concerned about practice financial health; more than three-quarters of practices received help improving care coordination; and referral tracking was less than 100 percent. My former risk/compliance department would have a field day with the latter statistic since everyone was expected to track 100 percent of referrals 100 percent of the time.

Now that we’re getting a critical mass of providers involved using IT systems, we need more surveys such as this to determine where physician priorities really are and whether we can align systems to support those clinical priorities rather than trying to drive clinicians based on what systems will support. Interestingly, the next article I read discussed the idea that payment reform isn’t the only factor turning medicine on its ear. The NPR headline caught my eye: “A Top Medical School Revamps Requirements To Lure English Majors.”

Having been a non-science major myself, I support approaches like this aimed at bringing more diversity into the field. Some of the problems we’re trying to solve are extremely complex with a high number of psychosocial factors. It’s going to take more than biochemists and fruit fly-counting biology majors to help solve them. There were a decent number of non-traditional majors in my entering medical school class, but it certainly wasn’t the norm.

What was your undergraduate major? Would you do it again or is it just good for cocktail party discussions? Email me.

Email Dr. Jayne.