March 13, 2015Dr. JayneComments Off on EPtalk by Dr. Jayne 3/12/15
I mentioned in Monday’s Curbside Consult that I took some time off from my day job this week to immerse myself in the routine at my new moonlighting gig. I also used some of the time yesterday to finish my tax return. As I went to put my documentation in the file cabinet, I realized that the drawer was full and I should probably spend some time dealing with some non-hospital document retention.
At work, we’re rabid about document retention. We keep everything exactly as long as required by laws or regulations, and then it’s off to the physical or virtual shredder. There’s a certain liability in keeping things longer than you need to, and as a risk-averse organization, we don’t want to shoulder any more liability than required. I definitely had files at home that were well past the need for retention, so I started culling through them. The amount of document detritus that can accumulate over a physician’s career is pretty impressive.
In addition to the usual household paperwork such as tax documentation, financial paperwork, mortgage paperwork, and important receipts, physicians have a host of other documents to manage. If you’re lucky enough to work for the same employer for most of your career it might not be too bad, but for those of us that have worked for several groups, the paper carnage can be impressive.
I’m not even talking about patient records or office-related information – just the personal ones. There are medical liability insurance documents, payer credentialing documents, hospital privilege documents, employment contracts, CME documentation, licenses, and DEA and state narcotics documents. There are college and medical transcripts, records of licensing exams, diplomas (and their certified translations if you went to a Latin-loving med school like I did), board certification documents, and now maintenance of certification documentation.
The pile was impressive. For conventional financial documents, there are retention standards. Some of the professional documents need to be kept for even longer, especially if they relate to liability insurance. I’m not going to rely on a former employer to prove that I had liability coverage if a claim occurs at the end of the statute of limitations. With the prevalence of identity theft, I’m not going to get rid of some of my original documents that relate to licensing or board certification. I was, however, able to weed out quite a bit of documentation and reduce the pile. Now that it’s more organized I should scan it all, but that’s a project for another day.
After I made it through the “official” file drawers, I turned to some of the documents I had kept for more personal reasons. It was a reverse chronological tour through what it takes to become a doctor. I started with student loan payoff documents and worked my way back through the application to defer payment during residency and the heart-stopping promissory notes I originally signed as a 22-year-old. I distinctly remember the day I signed the first one – if nothing motivates you to not wash out of medical school, it’s the possibility that you could have upwards of $200K in debt with no way to repay it.
The tour down memory lane also included rejection letters from a handful of medical schools and acceptance letters from others, as well as my original Association of American Medical Colleges application packet. Back in the days of the typewriter, I had filled it out by hand first and then typed it up. Both copies were there and it was funny to think about doing business without the now-familiar fillable PDF or online form. Reading the essay made me smile – it was a good reminder of youthful optimism, untarnished by E&M coding regulations, fear of litigation, or Meaningful Use.
One might ask why I still had all that. Although I do probably tend to be overly sentimental, I think it is more due to the realities of rushing from college to medical school to residency to solo practice without a break. The boxes just moved from one tiny student apartment to another and then to a house. With the crazy hours we work, as long as you have space to keep it, there’s little motivation to spend your free time sorting it all out. It got me thinking about the volume of electronic documents I might have, where space is not a limitation.
For good or bad, my hospital has a fairly liberal retention policy for email. A CMIO buddy of mine works at a hospital where all emails delete after three months and they have limited archive space allotted, so he’s constantly having to either save emails to other file formats or risk deletion. I try not to keep email too long but there’s never time to sit down and clean it out. I realized I hadn’t purged my archive folder in what looked like about two years. I spent a couple of hours deleting tens of thousands of emails. In that history were both the mundane and the heroic. I looked back fondly on standing up the region’s first HIE, but with the bittersweet sense that it is now defunct.
Those electronic missives tell the story of hundreds of thousands of hours of work. Not only by the IT teams, but also by the clinicians and other end users that did the work alongside us, whether enthusiastically or reluctantly. I know the emails needed to go and it was somewhat cathartic to watch those massive chunks of data disappear from my folders. On the other hand, it made me miss the simpler days when our main goal was to do the right thing by our patients rather than checking boxes and counting measures.
I enjoyed being reminded of colleagues who have moved on to bigger and better things as well as some pretty crazy stories. The hail storm that struck during one of our EHR design sessions, totaling cars. The analyst who ran our first EHR upgrade and slept at the office all night in a folding lawn chair while the rest of us went to our vendor’s user group meeting (bad plan, by the way). The vendor rep who got food poisoning during a site visit and still called in to our meetings while lying on the hotel bathroom floor (that’s dedication). Team-building tricycle races, cosmic bowling, and mini golf. And the software developer who put up with my newbie questions and helped me bring a feature live that no one else seemed to care about but that made a huge difference for our users.
Those are not exactly the stories you memorialize in a scrapbook but I’m grateful for the memories and to everyone who has helped me along the way. We may not always have Paris, but we’ll have the EHR.
In just 24 hours, Stanford University enrolled 11,000 people in a cardiovascular study through Apple’s recently unveiled medical research API ResearchKit, a feat it says would have taken 50 medical centers a full year to accomplish.
In Michigan, 11 people have been charged with ID theft and fraud after a Blue Cross and Blue Shield employee stole the personal information of 5,000 customers and then shared the information with a team of criminals that fraudulently purchase $742,000 worth of merchandise from Sam’s Club.
Stanford University reports that 11,000 people signed up for one of its cardiovascular studies using Apple’s ResearchKit in the first 24 hours of the app’s availability on the iPhone. The university says it usually takes a year and 50 medical centers to hit the 10,000-enrollee mark. However, the best metric won’t be known for some time and may never be announced – how many of those 11,000 casual applicants will be actually be accepted into the study and participate? My suspicion is that the majority of responses are from people screwing around with their new Apple toy who don’t realize what’s involved, so it’s going to take quite a bit of work for Stanford to get down to usable subjects. Someone make a note to ask Stanford in a month how large their cohort is and what percentage of the Apple self-submitters were accepted.
I was thinking about the “research” part of ResearchKit. Traditional medical studies involve carefully assembling a cohort of people who meet narrowly defined study criteria, with the intention of proving a specific hypothesis in a specific population. On the other hand, research using patient-generated data may uncover relationships that nobody thought of or that may prove useful in managing an individual patient’s condition even in the absence of a generalized population study. Direct care lives at the interesting intersection of big, decisive research studies and anecdotal “it just works” clinician practice based on experience. A given patient’s endless supply of non-inpatient electronic data, along with similar data generated by people like themselves, could improve that patient’s life more decisively than any study, provided that physicians are willing to practice based on data snapshots rather than studies that take many years to complete. Another positive is that studies are often funded by drug companies or special interests that have a vested interest in manipulating data in particular way or in killing a study that might hurt product sales.
Reader Comments
From Clinic Director: “Re: Meaningful Use audits. We are now at 96 audit requests of our 139 Epic-using physicians and have passed all. CMS says providers are chosen randomly, but is 70 percent of our providers really random? I needed help, so I asked our congressional office, which referred me to the auditor. ONC referred me to the CMS EHR Info line, which referred me to the auditor. The auditor referred me to the CMS Info Line. It feels as though I’ve entered the Twilight Zone.”
HIStalk Announcements and Requests
Several CMIOs expressed interest in a HIMSS get-together. I booked a table for Tuesday, April 14 at either noon or 1 p.m. right in McCormick Place and I’ll buy lunch for up to 20 attendees via the Bistro HIMSS program. CMIOs or physicians working in a CMIO-type role regardless of title can sign up here. It’s a convenient location near the exhibit hall where you can actually sit to eat (unlike most other convention center locations), the food should be decent (salads, lemon-sage chicken with polenta cakes, and dessert with healthy options), and Lorre will be on hand to say hello and introduce everybody since it was her idea.
Speaking of events, some readers are confused by the two I’m having at the HIMSS conference. Event #1: HIStalkapalooza is the big event on Monday evening – it’s open to those whom I will invite from the list of folks who previously submitted the online form indicating their desire to attend. Event #2: the sponsor-only networking event is Sunday evening and is open only to sponsors of HIStalk, HIStalk Practice, and HIStalk Connect. We’ve reached out several times to our sponsor contacts (not all of whom are efficient in passing the word along to the suits upstairs who might want to come), so Lorre will still entertain invitation requests for that event (and new sponsorship inquiries from companies anxious to talk business with their peers in a social setting). I suppose we now have Event #3: the CMIO lunch above. I just know I’m writing a lot of checks. Anyway, just to be clear, walk-ups will be politely turned away from all three events since I’m working with a fixed attendee count.
You can wear one of the four “Secret Crush” sashes like the above at HIStalkapalooza if you email me explaining why you have a crush on Dr. Jayne, Jenn, Lorre, or me. People like being sashed and I couldn’t come up with anything more original than the “Secret Crush” ones I’ve done before. I don’t expect many responses, so your odds of winning are good. Of course you need to have signed up for HIStalkapalooza and plan to attend to be sashed since I’m not mailing it for someone to wear around the house.
I’m going to stop mentioning press releases that list a hospital or health system without including its location (both city and state) because I’m annoyed at lame PR people who expect me to do their jobs in deciphering an over-edited company announcement into something factual. Surely it’s not hard to understand that “St. Mary’s Hospital” could be anywhere, as could a hospital whose location is stated only as “Missouri” (if the location is named at all). I’m also annoyed at ‘’announcements” that are too vaguely worded to tell whether a hospital has bought a new system, is beginning its implementation, or is continuing a previous installation (the latter two of which aren’t really news). Attention PR people, especially the lesser competent ones: I’ll consider running your announcement if it’s newsworthy, but being newsworthy means that you provide the five Ws: who did it, what they did, when did they did it, where it happened, and why it happened. Anybody want to see me call out exceptions?
This week on HIStalk Practice: Mental health professionals weigh the pros and cons of moving to EHRs. HealthSpot and Pacify secure new funding. LaHIE launches a patient portal. Kareo acquires DoctorBase. PatientPoint partners with Telemundo for point-of-care content. St. Peters Health Partners Medical Associates and Northwestern Memorial Physicians Group implement new population health management tools. Jim Denny digs deep into physician ICD-10 readiness.
Apple introduces ResearchKit, an open-source API designed to help medical researchers collect data from iPhone and iPad users. The Department of Homeland Security launches an accelerator program targeting wearable technology startups building applications for first responders. TechStars welcomes its second class of digital health startups to its Kansas City campus for a 12-week program. SocialWellth raises $7.5 million to expand its digital health app formulary service platform.
Webinars
March 31 (Tuesday) 1:00 ET. “Best Practices for Increasing Patient Collections.” Sponsored by MedData. Presenter: Jason Bird, director of client operations, MedData. Healthcare is perhaps the last major industry where the consumer does not generally have access to what they owe and how they can pay for their services. Collecting from patients is estimated to cost up to four times more than collecting from payers and patient pay responsibility is projected to climb to 50 percent of the healthcare dollar by the end of the decade. Learn how creating a consumer-focused culture, one that emphasizes patient satisfaction over collections, can streamline your revenue cycle process and directly impact your bottom line.
Here is the video of Thursday’s webinar by West Corporation titled “Turn Your Contact Center into a Patient-Centered Access Center.”
Acquisitions, Funding, Business, and Stock
Government contractor Maximus acquires Acentia for $300 million in cash from private equity owner Snow Phipps Group, with Maximus lustily eyeing Acentia’s contracts with HHS, FDA, NIH, CDC, CMS, and the Military Health System.
Austria-based blood sugar tracking app vendor mySugr raises $4.8 million in funding. Its FDA-approved product synchronizes data from medical devices, even using the smartphone’s camera to import readings from the displays of non-connected glucometers (that part works only in Austria).
Sales
DaVita selects Cureatr for secure messaging and patient care transition event notification.
Citizens Memorial Healthcare (MO) chooses Summit Healthcare Web Services Adapter to send public health and immunization information to the state’s HIE, with plans to expand its use to meet Meaningful Use Stage 3 requirements.
Trinity Health (ND) chooses managed cybersecurity services from Leidos Health.
People
Dana Alexander (Caradigm) joins Divurgent as VP of clinical transformation.
William Bria, MD (The HCI Group) joins CHIME as EVP of medical informatics and patient safety.
Announcements and Implementations
Craneware will offer its customers analytics software from Aridhia Informatics. I’m baffled that someone thought this would be a good product name: “Aridhia Analytixagility.” It looks like the result of my snoozing off at the keyboard after working too late.
Cerner will use Validic’s digital health platform to incorporate data created by home medical devices and wearables into Cerner’s HealtheLife patient portal.
Online doctor visit service HealthTap launches RateRx, which lets its member doctors rate the effectiveness of individual drugs and treatments.
Mediware releases MediLinks Outpatient for pulmonary rehab.
Todd Fisher, who founded consulting and software engineering firm Intraprise Solutions in 1997 and was CEO of MobileMD when it was sold to Siemens in 2011, launches Intraprise Healthcare.
Government and Politics
The family of a VA patient who died of low blood oxygen levels sues the hospital after its former nurse admits turning off the patient’s alarms.
SAMHSA (HHS’s Substance Abuse and Mental Health Services Administration) launches Suicide Safe, an app that provides guidance for PCPs and behavioral health providers who are faced with potentially suicidal patients.
Privacy and Security
The US attorney indicts 11 Detroit-area residents after a former Blue Cross Blue Shield of Michigan employee provides 5,000 subscriber screen shots to accomplices who used their information to obtain phony credit cards to buy $742,000 worth of merchandise from Sam’s Club. The BCBS CEO announces new steps (the key here being that these practices weren’t already in place) that include limiting employee access to Social Security numbers, enforcing employee password changes, and installing secure printers that require employees to scan their badges before their document prints. The US Attorney makes the point that while technology makes it easier to commit identity fraud, it also makes it easier to capture those who do so. Interestingly, BCBS of Michigan brags on its site that it wasn’t part of Anthem’s breach while not featuring its own breach prominently.
Other
A small survey-based study of children’s hospitals finds that inpatient EHRs don’t support peds very well, adding speculation that vendor and customer fixation on Meaningful Use is delaying rollout of needed pediatric functionality. It’s somewhat of a subjective study, the survey results are old (going back to September 2011), and dumping responsibility for customer-needed features on ONC rather than the vendors selling EHRs (and thus the customers who drive their development agendas in chasing MU money) seems biased. Correlation also seems skimpy since some hospitals seem to be doing fine, presumably using the same EHR although the study didn’t ask the important question of “which product are you using and how long have you used it?” In addition, some hospitals said they weren’t interested in implementing the features that were missing, such as weight-adjusted blood pressure percentiles or immunization contraindication warnings. It would also have been helpful to know whether those that reported missing features have worse outcomes since simply having the feature available doesn’t necessarily improve care. I was going to to check the supplementary material to see how the survey was worded, but the link is dead. Quite a few publications and tweets summarized this report as thought it’s decisive and insightful, while I would say the only thing newsworthy about it (and thus why I’m mentioning it) is that it really isn’t and those writers and tweeters need to spend more time analyzing the study itself rather than dreaming up attention-seeking headlines.
Here’s a pretty funny commercial from Cox Business, tweeted out by Eric Topol, MD as an unintended reference to his new book, “The Patient Will See You Now.” He adds, “Suck it, doctor’s office.”
Ireland rolls out a national patient identifier, with the CIO of its health services saying it offers “patient safety and ensuring that the right information is associated with the right individual at the point of care. The IHI will also help in managing our health services more efficiently and ensure that health information can be shared safely, seamlessly across different healthcare organizations associated with patient care. ” The government points to effectiveness studies from Canada and the UK showing that a national ID reduces errors, improves EHR data, increases efficiency, and protects privacy.
The bond rating agency of 445-bed Memorial Hospital of Gulfport (MS) notes the hospital’s “sharp decline in liquidity in 2014” due to a Cerner EHR conversion that inflated its accounts receivable by $25 million and jumped A/R days to 100.
NBC News fires Chief Medical Editor Nancy Snyderman, MD over fallout from her previously admitted violation of voluntary 21-day Ebola quarantine when she and her crew, fresh back from Liberia, picked up takeout food. She also appeared to be impaired during a February 22 live broadcast. She will be taking a faculty position at an unnamed medical school.
Cerner’s Neal Patterson and his wife Jeanne (who has cancer) are featured in a KQED series on EHR interoperability. Jeanne says she has given up on having 20 health systems share her records with each other, so she instead carries around a bag of printouts and DVDs. Neal says, “The paradox is that I am one of the few people that should be able to fix this. I’m frustrated that we’re not moving faster.” He adds that the US is one of few countries that don’t have a national patient identifier and streamlined consent processes and that he’s putting his money where his mouth is in funding CommonWell. Epic responded to the reporter’s question of why they haven’t joined CommonWell in saying that its clients can already exchange information and Care Everywhere is “much more mature” than CommonWell. Neal says that if the industry commits to interoperability and the government creates “compelling guidelines,” the interoperability problem can be solved within 10 years.
I ran across some email exchanges between an ambulatory EHR vendor (one I’ve never heard of) and one of its practice clients. The practice, which is replacing the vendor’s system, gave its new vendor access to the old vendor’s system so they could convert patient data. The old vendor says giving them access violated its copyright and is thus a breach of contract. The old vendor is suing the practice and says it will drop the lawsuit for $25,000, adding that lack of immediate response doubles the settlement fee to $50,000. My reactions: (a) practices never seem to pay adequate attention to the contracts they sign, happily agreeing to terms that any lawyer would advise against; (b) practices also seem to choose their systems and vendors with questionable amounts of research; and (c) the old vendor has every right to hold the practice accountable for the contract it signed but shouldn’t have, although the “pay fast or we double it” part is scummy for sure. I suppose vendors are like significant others – you don’t really know what they’re capable of until you try to move on without them.
Forbes should know better than to let a private wealth advisor try to explain “How Telemedicine Can Kill You.” The lack of insight is stunning given the article’s two “potentially devastating problems”: (a) possible computer glitches that “can alter medical records” along with implantable devices “that can go haywire”; and (b) hackers. The fact that neither of these theoretical “problems” have anything specifically to do with telemedicine was missed by whoever crafted the click-baiting headline. I couldn’t decide whether to be angry at the article’s failure to deliver or to laugh at some of its unintentionally hilarious conclusions, such as “being able to control if a person lives or dies can readily lead to exhortation and murder-for-hire” (I’m assuming the author meant “extortion.”) Just last week the same editorially ubiquitous author wrote an equally lame telemedicine piece consisting entirely of quotes from a telemedicine company CEO, who not surprisingly didn’t mention killing any of his patients.
Quantros produces a video to support National Patient Safety Awareness Week, which is this week.
BIDMC CIO John Halamka, MD says that “outsourcing your mess to someone else to host is not cloud computing,” suggesting that CIOs instead focus on “Outcomes as a Service” where vendors are paid for managing people, processes, and technology.
Sponsor Updates
Navicure completes ICD-10 testing with eight Medicare jurisdictions, to be followed by testing with all 16 jurisdictions in April.
Nordic leads off its “HIT Breakdown” podcast series with an episode on population health and adds a new video in its series on Epic conversion planning.
Hayes Management Consulting offers “Overcoming Resistance to Change: It’s All About the Buy-In.”
LifeImage will exhibit at the American College of Surgeons Committee on Trauma Annual Meeting March 13 in Chicago.
HCS will exhibit at the National Association of Psychiatric Health Systems Annual Meeting March 16-18 in Washington, DC.
Healthfinch posts “Apps that optimize your EHR workflow are essential for care redesign.”
IHS posts a blog on “Making the Hard Decisions” when going through the HIT selection process.
Healthgrades gets a nod in a Forbes piece on a need for bipartisan action on healthcare transparency.
VMware posts “Creating the Perfect Clinical Desktop with Horizon View.”
Galen Healthcare Solutions posts the second installment of its series og on shifting to value-based payment models.
HealthMEDX will exhibit at the LeadingAge PEAK Summit March 16-18 in Washington, D.C.
Healthwise commemorates Patient Safety Awareness Week with “Why Safety is Personal When it Comes to Medical Care.”
Logicworks will present at the National HIPAA Summit March 16-18 in Washington, D.C.
Holon Solutions will exhibit at the NW Regional Critical Access Hospital Conference March 17-19 in Spokane, WA.
Ingenious Med posts the fourteenth installment of its blog series by President and CEO Hart Williford.
InterSystems outlines the factors creating excitement around patient engagement.
Lifepoint Informatics will host its annual users conference March 18-19 in Orlando.
Influence Health will exhibit at TIPAAA (the IPA Association of America) March 19-21 in San Antonio, TX.
CMS introduces a new ACO program that it is calling the Next Generation ACO Model, that will allow providers to assume a higher level of risk than either the Pioneer ACO or Shared Savings Program, and will generate a larger financial return for providers that successful manage those risks.
FDA efforts to create a medical device ID numbering system have received political pushback from CMS administrator Marilyn Tavenner, who says that adding a medical device ID number on claims forms would require significant work from her department and would result in significant unanticipated costs.
Louisiana’s state health information exchange will rollout a state-wide patient portal, providing patients with a centralized portal with medical information from all care settings.
Antelope Valley Hospital (CA) is challenging claims made by a local nurses union after the group claimed that unplanned EHR downtime forced the hospital to close its ED. The hospital acknowledged redirecting some patients to other hospitals during the downtime, but reports that it still treated 900 ED patients during the event.
March 11, 2015Readers WriteComments Off on Readers Write: Telehealth: Ready for Prime Time
Telehealth: Ready for Prime Time By Jonathan Leviss, MD
Telephone rings. “Hello?” answers Sonia, age 73 with heart failure and living at home.
“Hello, Sonia. It’s Linda, your telehealth nurse. I received an alert that you gained two pounds a day for the last three days.” Further assessment reveals that over the last few days Sonia has eaten more salt than usual and has leg edema. Linda prescribes furosemide under protocol, educates Sonia about her diet, establishes a plan of care, and sends a report to Sonia’s cardiologist.
Why is Sonia’s tale becoming more common? Accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and other models of value-based care and bundled payments require reducing readmissions, addressing problems before they require more expensive interventions, and reducing high cost utilization. Telehealth is now a proven solution for all three.
Telehealth means robust, real-time, patient management solutions including remote patient monitoring of blood pressure and glucose; self-reported symptoms and medication compliance; live video visits with clinicians and health coaches; alerts for risks of clinical compromise; the ability to organize actionable information into dashboards or into a provider’s EHR; and the power of analytics to predictably detect problems earlier and develop new treatment approaches.
These real-time tools connect patients to the right care in the right place at the right time, and most commonly, that connection occurs in the patient’s own home. Not only does this save provider, payer, and patient resources, it’s most convenient for the patient and often most effective.
The effectiveness of telehealth is no longer a matter of speculation. There is a growing body of rigorous research published in peer-reviewed journals that validates these benefits, including the following findings from AMC Health programs. This sampling of peer-reviewed studies demonstrates the significant value that evidence-based telehealth programs provide across care settings, disease states and patient populations.
Medical Care, January 2012. Geisinger Health Plan reduced all-cause 30-day hospital readmissions for high-risk patients by 20 percent by adding interactive voice response calls to their care management outreach.
Journal of Managed Care Medicine, November 2012. New York City Health & Hospitals Corporation combined personalized case management and real-time patient management solutions to enable Medicaid patients with poorly controlled Type 2 diabetes reduce HbA1c levels by a mean of 1.8 points.
Journal of The American Medical Association , July 2013. When Health Partners of Minnesota added telehealth and pharmacist management to their usual care for hypertension, 71.2 percent of the patients participating in the program had their blood pressure well-controlled after 12 months versus 52.8 percent of the control group.
Population Health Management, December 2014. Geisinger Health Plan significantly reduced hospital readmissions and cost of care for patients with heart failure. For every $1 spent to implement this program, GHP saved about $3.30, which translated to 11 percent per patient per month between 2008 and 2012.
As the healthcare market continues its transition to value-based care, this compelling evidence combined with exciting new technologies that expand how patients can engage in care virtually is fueling demand for customized telehealth programs ranging from full turnkey programs to the ability to seamlessly augment existing care management resources. To facilitate the adoption of telehealth, legislative and regulatory barriers are also being addressed:
The Tele-Med Act of 2013 (H.R. 3077), introduced to the House in September 2013, amends title XVIII of the Social Security Act to permit certain Medicare providers licensed in a state to deliver telemedicine services to Medicare beneficiaries in a different state.
The companion Telehealth Modernization Act of 2013 (H.R. 3750), introduced to the House in December 2013, calls for states to authorize health care professionals to deliver healthcare to individuals through telehealth.
The ACO Improvement Act (H.R. 5558) introduced on September 22, 2014, would permit ACOs to use remote patient monitoring and store-and-forward technology that delivers images to remote providers. The bill also strives to improve care coordination by improving the process through which data are shared between ACOs and the Medicare administration.
Not having visibility into a patient’s condition in real time when the patient is at home and outside of a clinical setting is like a chef overseeing a kitchen, but not being able to view the prep line. In the era of accountable care and pay for performance, the primary objective for patients with chronic conditions is to keep them healthy with fewer high-cost visits to the hospital or other clinical settings. Therefore, gaining at-home visibility is critical.
By incorporating proven telehealth services as part of a well-designed care plan, the entire care team can work with a patient to manage a chronic condition between clinician visits, altering treatments or creating early interventions to keep a patient healthier and reduce the spiraling cost of care.
As healthcare reform continues to drive providers to share risk and deliver greater value, understanding what is happening with their patients with chronic conditions outside the clinical setting is no longer a nice-to-have. It’s a must have. It’s time for telehealth to go mainstream.
Jonathan Leviss, MD is SVP/medical director of AMC Health; staff physician at Thundermist Health Center; and assistant clinical professor of health services, policy, and practice at Brown University School of Public Health.
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March 11, 2015Readers WriteComments Off on Readers Write: The Pursuit of Health Optimization
The Pursuit of Health Optimization By Jeff Margolis
For over 30 years I have been burdened with Crohn’s disease, a serious and currently incurable illness. It may seem ironic that I am on a crusade to enable all the “mostly healthy” people to achieve their highest possible health status at the lowest possible cost. After all, a number of excellent physicians, nurses, hospital staff, and technicians of all varieties performed skillfully in the US “sickcare” system with surgical and medical interventions that kept me alive.
These expensive interventions, which were largely paid for by my health insurance plan, would have otherwise financially disrupted me and my family. Let me be clear in saying that I am not ungrateful for the currently inefficient sickcare system nor do I have anything less than admiration for the efforts and capabilities of the medical professionals who comprise it. And yes, I am in a small minority that fully understands the critical role of our health insurance plans in weaving together the incredibly complex fabric of access and economics for our population.
I would be unequivocally grateful for a highly efficient and holistic “healthcare” system, whereby a cultural norm of admiration and rewards for each of us being skilled healthcare consumers would co-exist in a complementary way alongside our skilled medical professionals. After all, most of us in the population are healthy most of the time. In other words, except for the sickest of us who cannot care for ourselves at all at points in time, we have the opportunity to make choices and take actions every day that affect our health status and costs.
Our society has developed the cultural norm of seeking professional medical assistance when we become sick. How do you argue that such behavior is not rational? We start that behavior when we are young, throughout adulthood, and into our last days.
Let’s play this out in contrast a bit. When we are young and hungry, we typically rely on an adult to cook for us and feed us. Likewise, when we are children most of us (unfortunately not all) receive unconditional love whether or not our actions are deserving. Somehow, as we get older, we take responsibility for feeding ourselves when we’re hungry and we learn that loving relationships require effort to maintain. We generally learn to navigate abundant consumer options in order to get nourishment – ranging from five-star restaurants to growing our own food. We also pursue multiple pathways to personal relationships.
So, who decided that we should not be responsible, either individually or as a population, for the status of our health? And when was it decided that the way in which our actions impact our controllable health factors and costs was not our responsibility?
We have a challenge to solve in the affordability of healthcare and a huge opportunity to have a healthier population. Let’s begin by embracing the incredible array of consumer-facing resources that each of us healthcare consumers can wield — whether on our own or in coordination with our doctors and health plans. These resources, propelled by the digital age, include education and content about health benefits and care; methods of connecting to other consumers with common issues; wearable and carry-able devices that give us anytime access to capture and share health-related data; programs that increase our levels of fitness, nutritional, and physical well-being; programs that help us manage our known health challenges; methods that understand our motivations and lower our likelihood of developing depression or malaise; and capabilities to incentivize and reward us to do the right things.
The challenge is (and has been) that these types of consumer-facing resources are 1) fragmented into thousands of partial solutions; 2) constantly being innovated and updated in the marketplace; 3) disconnected from the way the current sickcare system operates; and 4) not contextually attached to any meaningful intrinsic or economic benefits for the healthcare consumer.
Stated another way, the well-intended ecosystem of things that a consumer can do to achieve their highest health status at the lowest possible cost exist in a state of confusion and chaos for the healthcare consumer. Further, the consumer is not incented or rewarded (i.e., paid for performance) to be skillful in matters of our health, as contrasted to the medical professionals to whom we turn.
The promise of health optimization platforms are both practical and staggering in its enormity. Think of it this way: If we place such a platform and its capabilities alongside the existing sickcare system (which remains essential for the aspect of our health that we cannot control as consumers), then we get a new kind mathematical equation in the US healthcare system. One where the sum of the parts becomes less than the whole – with that whole being the current three trillion dollar cost of US healthcare spend.
Jeff Margolis is chairman and CEO of Welltok of Denver, CO.
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The views and opinions expressed in this blog are mine personally and are not necessarily representative of current or former employers.
Why IT Governance is Impotent
Every CIO I speak with struggles with IT governance. Despite everything written, numerous conference sessions, and creative processes, IT governance is a quagmire.
I wrestle with the “why.” I write extensively about it, give sessions, and publish creative models, but have not yet hit the mark. The literature is full of theory and process flows, but none seem to pass the test of time and stress. IT Governance remains a struggle for the majority of organizations across industries.
This riddle won’t be answered with new models. Innovation and creative models will inevitably fail unless we address three key factors. If accounted for, these influences will help ensure It Governance success: culture, leadership, and identified outcomes.
Culture
It does not matter who sits on the IT Governance committee or what model you use. When I switched organizations a few years ago, I transferred in what was a reasonable model. But what works in the North may not work in the South. It is a mistake to believe that models are portable, yet that is our focus. We keep thinking the answer is in the model.
You can leverage any model to achieve effective governance. Let’s stop copying other organizations models and start homing in on and adopting the principles that run through the few working models out there. Build these values in your IT Governance fabric and you will find success.
Leadership
CIOs forsake our IT Governance leadership responsibility. Consensus is the enemy of collaboration. In an effort to appease key stakeholders, we no longer walk in our authority and thus the entire process has become deluded, rendering us impotent.
If you are not making people mad, you are not leading well. Stirring up contention is not the point. But when you lead with authority, not everyone will like your decisions. If our goal is to not upset the apple cart, our produce will eventually spoil and nobody will be happy.
So make the tough calls. That’s what you are paid to do. Don’t give it away and shortchange your organization. You, not a committee, are responsible for IT.
When will you know IT governance is successful?
The answer to this question will drive your model and principles. Collaborate with organizational leaders to establish desired outcomes.
If a focus is leveraging IT resources to do more strategic initiatives, then adjust your model accordingly. Set targets and then measure and report on them. Use these to prioritize requests. What percentage of your resources should be spent on strategic versus tactical? Know this answer and lead accordingly. Make adjustments to hit the outcome.
An outcome might be financial, related to establishing and defending budgets. I always have clinicians and executives as co-chairs in my models. Practically, I gain three times the influence, as they are surrogate CIOs when it comes time to acquire or defend resources. Adoption and usability are no longer on my shoulders, but rather the responsibility of all stakeholders. I retain authority by sharing it. Yet I remain accountable.
Strategic alignment is a valuable outcome. Ensure that everything you do is aligned with organizational objectives. You can build this into your process. Establishing alignment as a measurable outcome is one of the most effective ways to ensure the continued allocation of scarce resources. Moreover, you are demonstrating that your focus is not IT, but the greater good of helping your organization fulfill its mission and vision.
Focus less on the model and more on culture, leadership, and desired outcomes and the odds for effective IT governance increase exponentially.
Ed Marx is a CIO currently working for a large integrated health system. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this post. You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook and you can follow him via Twitter — user name marxists.
The GAO audits the Patient-Centered Outcomes Research Institute, concluding that the organization’s $271 million on PCORnet research network will struggle to support researchers because EHR vendors do not subscribe to an industry standard data model and therefore the organization will need to hire additional staff to support data migration and mapping.
Epic CEO Judy Faulkner tells Modern Healthcare that she will create a charitable foundation that will fund not-for-profit organizations working in and out of healthcare. “Nearly every share of stock that I own will be put in there,” she says.
Erasmus MC and UMC Groningen, two Netherlands academic medical centers, cancel their Siemens implementation citing concerns about the future of Soarian EMR after the Cerner acquisition.
A GAO audit of the PPACA-mandated Patient-Centered Outcomes Research Institute (PCORI) predicts that its PCORnet research data network will struggle because EHRs have no common data model, which will require hiring resources to process the submitted information manually. GAO also questions whether the organization’s funding will be ongoing and sufficient, but notes that PCORI plans to sell data to drug companies. (Does any healthcare organization’s business model not involve selling data to drug companies?) PCORI also notes that it doesn’t always have or need claims data. It also acknowledges that its information will rarely be complete because of lack of a national patient identifier. PCORnet has spent $106 million so far of an expected total cost of $271 million through FY2019.
Reader Comments
From Justin Graham: “Re: infectious disease informatics docs. There are a handful of us ID/IT types. Harris Stuttman at Memorial Long Beach, Gifford Leoung at Dignity, and David Classen in Utah and a few others immediately spring to mind. I’m sure there are more since the ID procedure of choice is the chart biopsy.” I shouldn’t have ignored that tiny warning in the back of my head as I was interviewing Ogechika Alozie and mentioned that he was probably the only informatics person I know with an ID background. I’ll hide behind my carefully placed “probably” in claiming good intentions while admitting poor off-the-cuff execution. Justin and I also talked about CMIO networking at the HIMSS conference and I volunteered to coordinate something for those CMIOs who are interested – let me know if that describes you (maybe Dr. Jayne will hang out with her peers).
From Solilliquist: “Re: NantHealth rumor. They aren’t making Allscripts their sales organization. Just a few salespeople were let go and in fact new sales leadership is coming on board.” Unverified, but the source is sound.
From Watcher of the Skies: “Re: eClinicalWorks. They have installed an inpatient system in 10+ hospitals in India. They are looking at hospitals in Europe and may someway bring the product to the US.” Unverified.
From Nurse Tina: “Re: Antelope Valley Hospital EHR failure. The nurse union is asking the LA County Department of Public Health to investigate.” The California Nurses Association wants to know why the hospital didn’t have a backup plan for its unexplained system failure, which the nurses say caused a variety of clinical problems. The financially struggling hospital raised eyebrows a couple of years ago when it admitted marketing its OB services to pregnant women in China, who in return for paying their bills, earned their newborns instant US citizenship.
Cerner’s Implementation of OpenNotes
I mentioned my interest in talking to an EHR vendor about their support of OpenNotes. Cerner connected me with Brian Carter, senior director and general manager of member engagement.
Brian says Cerner’s HealtheLife patient portal has given patients access to provider documents for at least five years, so it wasn’t challenging to expose yet another document in the form of provider notes. Cerner created a facility-wide configuration setting of whether the client wants to expose the notes. A second level of granularity is provided by allowing each client the option to allow their providers to designate a specific note as “private,” but interestingly only one client has chosen that option – none of the rest of its customers allow doctors to hide individual patient notes.
I asked Brian if clients are monitoring whether patients are reading their notes. He says clients use a lot of patient engagement reports, such as showing how long it takes each provider to respond to electronic patient inquiries, and seeing how patients are interacting with the notes about them will probably become a popular measure.
Brian says that no customer has complained that a patient saw something awkward or misleading. Any issues of that type lead to having a conversation with the patient that was probably important to have for other reasons. He mentioned an HIE-like example where a confused ED patient remembered that he had access to his records at another hospital via OpenNotes and he helped staff read up on his condition, avoiding an expensive battery of lab tests that was about to be ordered (I joked that it was like a patient-carried HIE, where the providers can’t access each other’s records except through individual patients, which isn’t a bad model).
I asked about planned support for OurNotes, where patients can annotate or add their own thoughts to the chart. Brian says patients could use that to correct their meds list or report a new allergy. I asked if that is wise since the hospital would be on the hook legally to actively monitor and react to those messages that could be coming in around the clock. Brian says the option will be offered only if the patient has a scheduled appointment within an upcoming window of time, which would then allow the provider to review all of their generated notes at once and reconcile their official EHR information during the visit.
I asked if Cerner plans to support patient-entered forms to make visits more efficient. The company is developing a custom form generator to create documents that patients can complete in advance, conserving their face-to-face provider time for more important interaction. Brian gave an example of a neurology practice that has a 90-question form that the patient can complete at home, which not only saves time, it also populates discrete Millennium data fields that can trigger alerts or document workflow.
Webinars
March 12 (Thursday) 1:00 ET. “Turn Your Contact Center Into A Patient-Centered Access Center.” Sponsored by West Healthcare Practice. Presenter: Brian Cooper, SVP, West Interactive. A patient-centered access center can extend population health management efforts and scale up care coordination programs with the right approach, technology, and performance metrics. Implementing a patient-centered access center is a journey and this program will provide the roadmap.
Acquisitions, Funding, Business, and Stock
Evidence-based imaging analysis vendor HealthMyne raises $4.5 million in a Series A funding round led by two Madison-area venture firms.
Kareo acquires patient engagement and marketing technology vendor DoctorBase.
Doctor house call vendor Pager raises $10.4 million from existing investors despite what would seem to be significant scaling barriers.
In Scotland, Craneware announces six-month financial results: revenue up 2 2 percent, adjusted EPS $0.165 vs. $0.143.
Epic CEO Judy Faulkner tells Modern Healthcare’s Joe Conn that she has created a private foundation that will receive all of her billions’ worth of Epic shares upon her death or any time at her discretion, guaranteeing that the company will never go public. She explains,
“One, I didn’t want the money, personally, or for my family. What would you want with all that money? It doesn’t seem right and I can’t tell you why. (We’re) putting it into a trust that can be used for the benefit of healthcare organizations, other exempt organizations and our communities. We can use it to (help) other charitable organizations that have contributed to our success. Because that’s where it came from.”
Sales
St. Peters Health Partners (NY) chooses Phytel for population health management.
Cornerstone Healthcare Group (TX) chooses MModal for documentation services and technology.
Greenville Health System (SC) will implement performance management tools from Practical Data Solutions as part of its Epic implementation.
People
New York’s Healthix RHIO names Todd Rogow (HealthInfoNet) as SVP/CIO.
Announcements and Implementations
Northwestern Memorial Physicians Group (IL) goes live with Forward Health Group’s PopulationManager.
For-profit consulting firm Ethisphere has been criticized in the past for charging companies to apply for its “World’s Most Ethical Company” award and charging winners again to use the resulting logo. If you’re still interested, the healthcare-related 2015 winners are Novation, Premier, Baptist Health South Florida, Cleveland Clinic, HCA, North Shore-LIJ, University Hospitals, and three Blue Cross companies. HCA also made the ethical list for the sixth year in a row despite having paid $2 billion in a 2002 settlement for Medicare fraud and another $20 million in 2005 for share dumping by several HCA executives right before the company announced poor earnings.
Zynx Health releases Consensus Builder, a web-based addition to its Knowledge Analyzer that allows clinicians to discuss and approve clinical content being developed.
Cleveland Clinic will partner with lab testing high flyer Theranos to explore the possibility of reducing testing costs and turnaround time.
Two academic medical centers in the Netherlands halt their implementation of the former Siemens Soarian, saying they are uncertain about the product’s direction under its new owner Cerner. A reader from there suggests that Cerner wasn’t showing much enthusiasm for the project at Erasmus University Medical Center Rotterdam and University Medical Center Groningen, adding that the small country has only eight academic medical centers and they are each going their own way instead of working together. Siemens announced the $55 million deal a year ago.
Allscripts will embed Elsevier’s CPM Framework nurse treatment plans product in its Sunrise EHR, clearly hoping (given the fawning press release wording) to bolster its DoD EHR bid chances. The announcement is interesting since Sunrise developer Eclipsys (acquired by Allscripts in 2010) originally owned CPM Resource Center and sold it to Elsevier in 2007 for $25 million. Eclipsys originally bought the well-traveled CPMRC in 2004 for $5 million.
Chesapeake Regional Medical Center (VA) will implement Epic using services from Bon Secours Health System subsidiary Good Health Connections, replacing McKesson Horizon.
CoverMyMeds publishes the Electronic Prior Authorization (ePA) Scorecard. Facts from it:
ePA volume is increasing 20 percent per year.
40 percent of prior authorizations are abandoned because of the workload involved.
70 percent of patients with prescriptions requiring paper-based prior authorization don’t receive the meds originally prescribed.
54 percent of EHR vendors have committed to supporting ePA, but only Allscripts, DrFirst, Epic, NextGen, NewCrop, and Practice Fusion have it available now.
67 percent of payors and 70 percent of pharmacists have committed to supporting ePA and most of them are live.
Telehealth solutions vendor Ostar Healthcare technology announces its cell-enabled, vendor-neutral gateway that integrates payer and provider systems with remote monitoring devices such as scales and glucometers.
Mark Neuenschwander has been around pharmacy-related IT for a long time, having brought out early comparative reports on automated dispensing machines and then on bedside barcoding. His new focus is on technology-assisted sterile compounding systems, those IT systems used in pharmacy IV rooms to make sure custom bags are correctly prepared (robotic systems, barcode scanning, imaging, volumetric and gravimetric analysis, etc.) His new report is available to hospitals for $349 and to everyone else for $499. I will say that when I was once asked to approve the purchase of one his reports for the IT department I was skeptical about the value, but once I saw it I (and used it) I declared it to be one of the most cost-effective information sources I had seen and I used it to plan our medication automation strategy. I’m mentioning it here since I know his work and some readers will be interested in it.
Government and Politics
Oregon finally legislatively kills its Cover Oregon health insurance exchange, having not enrolled a single citizen for its $248 million cost and generating lawsuits between the state and its developer Oracle.
The cost of the Vermont Health Connect health insurance exchange could reach $200 million and the backlog of coverage change requests stands at more than 11,000.
FDA issues draft guidance (in the form of Q&A) for using electronic informed consent in clinical studies. It addresses such issues as how subject questions are handled, how to make sure subjects understand the information, and subjects are notified of changes during the study, and whether electronic signatures can be used.
Bizarre: FDA recently developed a smart plan to stamp implantable medical devices with barcodes to allow tracking and recording them for clinical purposes. IT-inept CMS bureaucrats (the folks who brought you Healthcare.gov) are trying to kill the project, saying it’s too much trouble for them to add the ID number to claims forms, or as recently departed CMS Administrator Marilyn Tavenner explained in a February 23 complaint to two senators, “including UDIs on claims would entail significant technological challenges, costs, and risks” (to her agency, not to patients, just to be clear.) HHS Secretary Sylvia Burwell is on record as favoring including device IDs on claim forms.
Technology
Apple announces its smartwatch and its long-awaited price — $350 to $17,000, depending on style (surely only rich fools would pay $17,000 for a first-generation electronic device that will be obsolete in a year). The ship date for the Apple Watch is April 24. As expected, it requires an iPhone for connectivity and does little that the phone can’t do perfectly well on its own, with the most obvious minor benefit being that people who stare at their phones all day instead of the world around them might appear slightly less self-fixated in staring instead at their wrists. Its most important feature is that fanboys will love it and toy with it conspicuously to make the rest of us feel that our lives are barren without it. The reviews have one point in common: nobody can figure out why it exists other than because Apple says it’s cool. The best reason to stick a new, expensive input device between you and your iPhone would have been the health tracking capabilities that Apple had to leave out.
Apple also announces ResearchKit, an open source iOS software framework that allows people to connect with medical research studies via their iPhones. Developers can create testing apps that analyze voice patterns, handwriting, and gait that can then connect possible research subjects to programs and allow subjects to submit forms from their iPhones. Apps have already been developed for asthma (Mount Sinai), breast cancer symptoms (Dana-Farber), cardiovascular health (Stanford), blood glucose (Mass General), and Parkinson’s disease (University of Rochester). Sound good except that self-selected research participants don’t necessarily form a representative cohort, limiting the ability to draw inferences from their experience. There’s also the question of positively identifying candidates and their suitability based on something they type onto an iPhone screen.
A fitness app developer says wearables (a term he deems “insufferable”) are making people less healthy as they focus entirely on hitting their easy 10,000 walking steps instead of doing actual strenuous activity. I’ve said that many times – an exercise program that doesn’t involve cardio and weights isn’t really an exercise program and instead is just plain old “activity,” which at least is better than sitting on the couch or at a desk.
Personal ECG app vendor AliveCor earns FDA approval for providing a “normal ECG” message to users or to let them know their data is unreadable and to try again.
Influential 10-year-old technology blog Gigaom shuts down due to going broke.
Other
A HIMSS Europe report that brashly declares that health IT reduces inpatient mortality, which it “proved” by simply matching up EMR Adoption Model scores vs. weighted mortality (note the not-very-many data points wandering around all over the place). It “confirms” its conclusion by asking IT people in hospitals that spend more money on IT if those systems improved outcomes, which of course resulted in a lot of “yes” answers. Skip all the verbiage to the end, where you’ll find, “Organizations with a higher EMRAM score tended to have a low mortality rate.” That’s an Evel Knievel-sized jump away from proving that if A correlates to B, then A must have caused B. Maybe higher-spending hospitals had more cash to invest in hiring better people, or were located in an area with a milder flu season, or were more enlightened about processes and outcomes which resulted in their buying technology rather than vice versa. We also don’t know how those hospitals performed before they implemented technology, which might be the most useful of the omitted information. HIMSS has a multitude of vested interests here: selling its EMRAM, pitching the wares sold by its Diamond members, and selling memberships and publications. They failed to prove anything decisively.
Sponsor Updates
PatientSafe Solutions publishes “Unsecured Texting – The Monster Underneath the Bed.”
Direct Consulting Associates is profiled in a regional business publication after being named a NEO Success Award winner recognizing top-performing companies in Northeast Ohio.
Surgical Information Systems releases a quality extract for surgery-related eMeasures.
Novation will offer its members Versus RTLS workflow solutions.
First Databank posts “Sharing Lessons Learned in NDC Data Collection and Publishing with UDI Initiative Stakeholders.”
CoverMyMeds will exhibit at the sPCMA 2015 Business Forum March 16-17 in Orlando.
Clockwise.MD is named a semifinalist in the HIMSS HX360 Innovation Challenge.
CareTech will exhibit at the ACHE Congress on Healthcare Leadership March 17-19 in Troy, MI.
Bottomline Technologies will exhibit at Microsoft Convergence 2015 March 16-19 in Atlanta.
Clinical Architecture posts “The Road to Precision Medicine.”
CitiusTech offers “Making Clinical Data Actionable for Payers.”
Culbert Healthcare Solutions highlights “Issues to Consider When Sunsetting a Legacy Practice Management System.”
Apple unveils Research Kit, an open source API designed to connect medical researchers with research study participants to improve communication and streamline data capture. Five projects are already live on the framework, including a breast cancer research project from Dana Farber, a diabetes project from Massachusetts General Hospital, and a Parkinson’s disease diagnostic tool from the University of Rochester.
A Peer60 report finds that 60 percent of hospitals plan to invest in health IT-related projects in 2015, with most hospitals focusing on ICD-10, population health, and patient engagement tools.
CHIME and AMDIS announce a new partnership under which CHIME will provide operational, administrative, and staff support to AMIDS and AMDIS will act as the primary physician informatics advisor to CHIME. A similar arrangement was announced between the organizations in June.
March 9, 2015Dr. JayneComments Off on Curbside Consult with Dr. Jayne 3/9/15
I mentioned last week that I’ve been gearing up to start a new urgent care position. Unless you have been on the provider side of things, it may be difficult to understand all the moving pieces that go with a physician starting a new job.
It’s not just about adding them to the EHR and making sure they have logins. There are countless steps before you can even consider that. In addition to passing the normal steps in the hiring process (interview, reference checks, background check, drug test, pre-employment physical, etc.) there are applications for medical liability insurance and credentialing applications for all the different insurance payers. We also have to update our licenses and DEA registrations, not to mention state narcotics board certificates, hospital privileges, and more.
Since I’ve done a fair amount of locum tenens work, I was lucky to have all the required documentation already organized and scanned. The practice’s onboarding coordinator was excited about that, as was the medical liability carrier. Rumor has it that my onboarding process was one of the most streamlined they’ve had. I suppose that’s the benefit of having been on the employer side – I’ve seen what happens when a new physician stalls in filling out the paperwork and I didn’t want to be “that doctor.” It can literally take months to get everything ready to go if there’s a lot of back and forth with the documentation.
Based on the initial progress, they were convinced things would come together quickly and scheduled me for some shifts. They use staff management software that not only proactively asks me for my schedule requests, but also makes sure recipients acknowledge their receipt of the final schedules.
I started my EHR training last week while waiting for the above dominoes to fall into place. The online training was engaging, but I didn’t get very far due to the length of the modules and competing priorities on my schedule. Luckily I had completed the EHR overview, so I crossed my fingers and headed to my first day of work.
With as long as EHRs have been around, practices expect new physicians to be able to hit the ground running. Even if physicians haven’t had an EHR in the office, most of us have used electronic records in the hospital to at least some degree. Even if we’re not writing our notes on a computer, we may be doing CPOE or reviewing nursing documentation.
The practice arranged for one of their in-house trainers to stay with me during my shift. I was fortunate that she is not only a trainer, but also one of the most skilled medical assistants in the practice. She was able to teach me about office workflow and how the staff handles various situations in addition to making sure I wasn’t missing key EHR documentation.
I was honest and told her that I hadn’t completed all the training. Apparently getting through any at all was a big plus compared to other physicians she had trained. She said that most physicians don’t bother to do the self-directed learning until they work their first shift and realize they’re unprepared.
I guess that’s one way to figure out whether an EHR is truly intuitive or not, but I’m glad I didn’t take any chances. The EHR wasn’t as smooth as it had looked during the training, which was no surprise because trainers by design are skilled at making things look easy.
Most systems perform differently in the heat of battle than they do in the rarified air of the training room. This wasn’t the first time I’ve been trained on the job in an ER or urgent care – most of the time when you are a fill-in physician, that’s how things happen. Physicians who are paid hourly aren’t willing to donate their time for training and employers aren’t likely to want to pay for training time.
This system wasn’t any different from others I had used in that the first four or five patient notes were acutely painful as I tried to develop muscle memory and a feel for the different variations in the layout for the different patient complaints. Although there was another physician in the office, he was there only to back me up if I got too far behind. The organization prides itself on short wait times and immediate care and he was there to maintain standards while I got my feet wet.
By the end of the shift, I was feeling pretty good, but I’m nowhere close to the productivity I know I’ll have after two or three days in the office. Since I’ve spent the last year documenting most of my work using a paper-based template system, I was happy to be back in the EHR world. I’ll take some extra clicking any day in exchange for allergy and interaction checking, medication refill history, and clinical decision support. The e-prescribing system acted a little quirky, but I’m guessing it’s due to the fact that I’m enrolled on multiple vendor systems. Hopefully a couple of phone calls will sort that out.
At the busiest part of the day, I had 8-10 incomplete charts with a full count of patients in the exam rooms. Things slowly got easier, but I still had a pile of half-finished charts when we accepted our last patient for the night. While she received some IV medication, I was able to complete the rest of my documentation so that I could walk out the door right behind the patient. That’s always a good feeling and I know the staff appreciated the effort so they could get home as well.
Although the practice allows me to complete my charts from home, I’ve never liked that approach. I had to do that during my first EHR implementation and it was too easy to forget patient details and miss documentation. Processing refill requests and reviewing lab results is one thing, but trying to do visit note hours after the fact has never worked for me. I’m taking the immersion approach and working three shifts this week, so hopefully by the weekend I’ll be where I need to be to feel like I’m pulling my weight. It’s a heck of a way to spend a week of vacation, that’s for sure.
How long does it take your new physicians to get up to speed? Email me.
All I Needed to Know to Disrupt Healthcare I Learned from “Seinfeld” (and “SNL"): Part III – Serenity Now By Bruce Brandes
Competition. A foundational element that drives greater success in a capitalistic society. And yet, examination of the array of perceptions and reactions regarding one’s competitors in business is both fascinating and revealing.
As we get to know an entrepreneur and assess a prospective investment, an important insight is their response to the multidimensional question, “How do you view your competition?”
How an entrepreneur expresses awareness, insights, differentiation, and honesty in recognition of competition can illuminate market opportunity, commercial viability, and personal credibility. Do you deny, dismiss, disparage, or do you choose to recognize and embrace others in your space? How does that answer vary when discussing competition internally or externally? Does the stress of competition drive your organization to catalyze improvement or to react with paralyzing stress?
What lessons can be learned from the competitive battle between George Costanza and his nemesis, Lloyd Braun? Serenity now.
In our early days at Eclipsys in the late 1990s, the market was peaking with good, old-fashioned street fights to win new business from a hospital. An expansive bevy of vendors were lined up for marathon beauty pageants. Even Miss Rhode Island had a chance to compete. I was oriented with a friendly disdain for Cerner, our chief competitor of the day (hindsight obviously shows who got the last laugh).
Each vendor’s sales reps were diligently trained to know as much about what the other company could not do as they did about what their own company could do. Accuracy and validity of this information was inherently suspect. Some vendors became adept at lying better than others could tell the truth. I sometimes wonder if this was how the Soviets learned about Americans during the Cold War.
Whether with a prospective customer, recruiting a new hire, or in seeking capital from an investor, there are several potential reactions when questioned about your competition and important implications for you in how your answer may be interpreted.
Reaction 1: Denial
Apart from the Soup Nazi’s crab bisque, how many products or services today are so uniquely innovative that they are beyond compare? Yet some entrepreneurs communicate they are such game-changers that they face no competition.
Upon further questioning, they may reluctantly concede that “doing nothing” is a prospect’s only alternative. While potentially valid on rare occasions for true breakthroughs, this is almost always wrong. The arrogance of holding this belief (and the manner in which this position is often communicated) generally discredits the individual and their organization. In most procurement processes in healthcare over the last quarter century, “doing nothing” has won more competitions than anyone.
Reaction 2: Disparagement
Sometimes more intentional and overt than others, the speculation and innuendo concerning another company often elevates that other vendor’s status as a leader and reflects more poorly on you 100 percent of the time.
When Seinfeld dentist Tim Whatley announced that he had become Jewish, Jerry disparaged Whatley to a priest claiming that he only converted to Judiasm for the jokes. "This offends you as a Jewish person?” inquired the priest. No,” replied Jerry. “It offends me as a comedian.” Jerry is subsequently outcast, labeled as an “anti-dentite.”
Reaction 3: Logo Bingo
Virtually every pitch deck will have one of two versions of this slide, both of which can be effective but dangerously predictable.
The first version shows a checkbox-a-palooza with a limited number of vendor logos on one axis and a capabilities list on the other. I have never seen this slide that did not have the presenting company with the most check marks possible, which immediately raises the question what other capabilities are not on the list that should be. The second version depicts four quadrants which universally position the presenting company in the farthest upper-right corner with no competitive logos even close to the neighborhood.
Reaction 4: Just Dance
Put your best foot forward and honestly assess if this is the best mutual fit. Be realistic about how you compare with your competition and gracefully admit that you are not always the best choice. The decision may or may not be close, as Chris Farley and Patrick Swayze remind us in this classic skit from Saturday Night Live.
In a free and transparent marketplace, given fair access to decision-makers and equal opportunity to compete, the innovators delivering a superior solution with a compelling value proposition should have better than a puncher’s chance to succeed. Even better than Little Jerry Seinfeld in a cockfight. How you perceive, understand, and communicate your place in a competitive landscape is a critical factor that may dictate your market success. Here’s to hoping you don’t end up living in a van down by the river.
Bruce Brandes is managing director at Martin Ventures, serves on the board of advisors at AirStrip and Valence Health, and is entrepreneur in residence at the University of Florida’s Warrington College of Business.
I’m chief medical informatics officer at Texas Tech University Health Sciences Center in El Paso. That’s a mouthful. We became an independent campus last year. We were part of the Texas Tech system, which includes Lubbock, El Paso, Amarillo, Odessa, and Dallas. We’re a separate entity legally. We’re doing a lot of separation things that happen when two organizations have been together for tens of years.
The biggest thing of interest for our environment is that El Paso is about 70 to 80 percent Hispanic and we’re also on the border. It creates some unique challenges in terms of language, socioeconomics, a lot of things that big cities have anyway, but they don’t have them in the magnitude that we probably have them. We’re a new medical school as well, so that creates some of unique challenges of financing. We’re just moving forward with the challenges of healthcare, academic healthcare, and academic education that a lot of other people are dealing with at the same time.
You’re probably the only informatics person I know whose background is infectious disease with an ID fellowship. Does that impact how you think about informatics?
I hope it that it changes it a little bit. I hope I think of things in a more of a public health manner.
How I got into ID and then informatics … I was born in Nigeria, but grew up in the Twin Cities. I went back to Nigeria to go to medical school. I did a lot of public health work while I was post-medical school in Nigeria. I realized that I had no idea what I was doing in terms of the skills of basic statistics and epidemiology. I came back to Minnesota, got my MPH from there, and then did residency and fellowship.
It was during residency that my mentor, Kevin Larsen, who’s at the ONC now … we started flipping to Epic. We were one of the first hospitals in the Twin Cities to go to Epic. That whole process of EMR and notes and things being digitized for me just seemed really cool. I hated writing, so for me, it was very selfish in that it was just easy.
I’ve taken that going forward as I think about things like HIV and hepatitis C, which are my clinical specialties. I hope that I think about things at a more population level. Instead of thinking about it as one patient at a time, every encounter is important. When I talk to our president and CFO and CIO, I try to look at, how is this going to affect the organization as a whole? Not only the organization — how’s it going to affect the El Paso population as a whole?
I’ve sometimes said that public health in a sense mirrors in a way some of the thinking in clinical informatics. You have to think about populations and how it will change the effect of a population. Payment is always important to whether you’re thinking of public health or informatics. I think I’m cognizant of the fact that the public health background and the infectious disease background lets me think about that a little bit better.
We’ve always exported our public health expertise to other countries while here we just cranked out encounters. Is public health thinking now essential for practicing physicians?
I’m not sure it is necessarily essential to be a practicing physician. A lot of providers across the country, especially in Texas, do not look at healthcare IT as a good thing. They don’t look at it in an improvement in care. No matter how much information you give them about reduction in drug-drug interactions, drug-allergy interactions, cost, or sending a patient off to get five x-rays in under a week just because a couple of providers were too lazy to go get the chart from their next door neighbor … think that’s kind of crazy. But I do think that as Meaningful Use and PQRS and a host of other quality measures start to actually measure bits and pieces of what we do as providers or as health systems, it starts to build a case whereby doctors for the first time have to look at, "Oh, wow, this is how I’m doing on a global scale."
As part of my job, we have private practices that we either own or help them or do technical assistance with. It’s always amazing to me when you put just the PQRS numbers in front of a provider and they say, "I do excellent diabetes care" … we can argue about whether A1C is a process or outcome, but the fact is this: it’s what we use for parts of diagnosis and parts of monitoring, so if you haven’t ordered one in three years and you say you’re a great diabetes manager, I’m not really sure what you’re looking at. If you haven’t done a foot exam or an eye exam or any of those basic things that are outcomes of having long-term, uncontrolled diabetes, it’s really hard to make that case.
When I put it in front of some providers who are private practice guys, one or two docs who probably have four or five thousand patients, it’s always amazing to see the shock on their faces. For the first time, public health has intersected with their lives in terms of their practice and what they have to do to change their process to hopefully give their patients better care.
What systems have you worked and what do you think of the technology that’s available?
For Nigeria, I worked with a pen-and-paper technology [laughs] It was what it was. When I was at Hennepin County Medical Center in Minneapolis, we initially had a homegrown system. When I was an intern, we switched over to Epic, so we were the first residency in the Twin Cities to have Epic. By the time I became a fellow at the University of Minnesota, it was switching over to Epic. As a fellow, you know how it is — you go from the university hospital to a private hospital to the VA. I used CPRS at the VA. We had Allscripts at that point in time at the University of Minnesota. We eventually switched over to Epic.
When I came to El Paso, our county hospital, University Medical Center, uses Cerner on the inpatient side and NextGen on the outpatient side. We used CPRS for about a year and now we’re on GE on the ambulatory side. In my private practice, I have Athena, so [laughs] seven or eight different EMRs.
At one time right now, I have to understand at least four of them, which is as you can imagine, kind of a pain after a while. One of my biggest pushes to our president and our CFO is that we really need to be on one platform — to improve our interoperability, to improve the efficiency of training, a host of other things that I think it will bring to us. That’s one of the biggest pushes that we’re having right now.
Having seen those systems and thinking about population health aspects, are those systems going to be appropriate for where the payment model is shifting?
My personal take on it right now is that none of them are adequate to really do what we need to do. If we’re going to leverage data to change the way we treat patients and bend the cost curve, I don’t think Epic or Cerner or anybody on their own has the ability to do that. They’re getting into that space after the whole MU debacle and trying to get certified, but I just don’t think they have the tools right now.
There are a lot of other organizations or vendors out there that probably do it a little better. At some point in time, the big players are just going to have to collaborate or cooperate with some of the other smaller population health vendors that are out there to make it a better system because I don’t think any of them owns enough pieces right now to make it work from one end of the spectrum to the other.
What are the key projects you’re working on?
We have a pretty amazing lady who works on medical education cartoons, which you’ll say, "OK, so?" But especially for us in our region, where English is not a first language or even a language of a large percentage of our patients or clients that come into our system, it’s important that we give them ways to understand what’s going on in the healthcare system, whether it’s by pictorials that explain that one to two tablets Q4 hours is not necessarily one tablet or two tablets, you make the decision.
We as providers take a lot of things for granted. We write all these prescriptions and we never really explain it to the patient because that’s not our thing. We just send the patient off to the pharmacy, and if the line at the pharmacy is 30 people deep, it never gets explained. That’s one of the things we’re trying to put on our portal right now — some of that pictorial education and cartoons and some animations that will help patients understand their medical issues and some of their medications.
We’re in the process of aligning ourselves with Tenet Healthcare out of Dallas. They have three hospitals here in El Paso. We’re in the process of aligning ourselves with them to create a clinically integrated network. We’re just starting to look at how our data exists in each hospital and how we can create a data warehouse and start to look at our payment data and our patient data and outcomes data, things like that. For us, it’s staffing. We use a lot of that information to determine how many doctors we need in a certain specialty or a certain space over the next two to three to four years.
On the education side, we’re probably behind the curve a little bit in what some of the other places have done, but we’ve just started using secure messaging with Imprivata Cortext. The residents are really excited about that. It was interesting to me how much we pushback we had from some of the more mature physicians in the organization regarding secure texting. But the people that were doing most of the patient care and the visiting in the hospital — if you look at counts of who puts in the labs and the orders and the images — it’s all the residents. If you talk to them, they were all excited about it. That basic information of a simple count of who’s actually doing work within the EMR to justify finally to security and compliance that we really needed the secure texting process. We’re about to go live with that in our PCMH.
Those are some of the big things that we’re looking at. You know how it is. It feels like there’s always a million things going on at the same time and you’re just trying to keep abreast of them so that you don’t drown. But then you have some of the fun projects. The secure text messaging project is really cool. I’m excited about that.
We have an external referral management process that we built in-house. It’s a web-based tool that our clinics use to track referrals, see who it’s going to, and send transition of cares, so we’re excited about that, too. Those are the main things we’re working on right now.
You’ve done quite a bit of work with HIV. Are you finding ways that technology can help improve the lives of people with HIV?
Yes. One of the things that I really enjoy about being CMIO and also in practice is that I was able to get some advanced toys or to move things along quicker in my clinic. It’s kind of sad, but because politically it was a marginalized population and I had really young patients … the average age of the patient in my HIV clinic was about 24 to 26, so that’s the range. They just allowed a lot of things to happen. If you look at my HIV clinic for example, about 70-80 percent of them were already on the portal. That’s probably the highest adoption rate throughout the organization.
For me, it’s fun to be able to get — I call them my kids — my kids on the portal and have those conversations back and forth. I have two full-time case managers whose job is just to respond on the portal and get people information and access and a whole bunch of other things. We set up a system with Google Voice about two or three years ago where we were sending text messages to our patients — this was before we had the portal — that gave them reminders 72 and 24 hours before an appointment and allowed them to respond to the Google Voice message as an anonymous text from them if they weren’t going to make it. We saw our no-show rates drop from almost 40 percent to about 20 percent, which is about 50 percent improvement, so that was kind of cool to us, too.
We do Google Hangouts once in a while. I haven’t done any this year, but once a quarter we would just send out a Hangout link to people on the portal and say, "Hey, free-for-all, come online, either myself or the case manager, the pharmacist, will be online for 30 minutes to an hour and we’ll answer any of your questions." Unrestricted, talk about sex, drugs … marijuana is always the biggest question clients have, not surprisingly. We would just go at it like that, which was fun.
I also do hepatitis C and a lot of my patients are co-infected, so just getting that education out to them on the portal or using our text messaging system for me has just been really cool. You have clients come back maybe a month or two later and they say, "Hey, I read this on the portal,” or, “Thanks for sending me the reminder about my appointment. I wasn’t able to make it because I was in Las Cruces or Juarez or whatever, so I responded and rescheduled it." Just a lot of missed opportunities that we would have had before that I hope we’re reducing with some of those … I call them the little technology pieces, but they seem to have a big effect on our clients.
Do you have any final thoughts?
It’s just exciting work. I enjoy being at that intersection between public health and ID and health informatics. It’s really exciting for me, looking at work I’ve done in TB and some other stuff globally, to start to think that now we can start to measure what our providers are doing. And hopefully what our patients are doing as we talk about the bring your own device, not just from a tablet standpoint, but from a consumer trackables standpoint, be it a Fitbit or a Jawbone, I’m beginning to get clients asking me, "I have this thing, what should I do with this data?" We don’t have anywhere to ingest it yet, so we’re starting to think about that.
Even though there’s a lot of angst in the overall healthcare community about where health IT is right now, I do think that we’re going in what is sort of the right direction. We’ll probably have to branch off as time goes on, but eventually that will get us to a place where we’ll have a better idea, or at least better transparency about what our healthcare really is.
St. Mary’s Medical Center (IN) is informing 4,400 patients that their personal information was compromised when hackers gained access employee email accounts in January. The exposed information included names, date of birth, gender, date of service, insurance information, health information, and Social Security numbers.
Southern Regional Medical Center (GA) lays off 80 employees after implementing a productivity benchmarking system that shows how other hospitals around the nation of a comparable size and case mix are staffing their own departments.
The New York Times profiles Jeffrey Hammerbacher, a 32-year old Harvard trained data analytics expert that started out in finance before moving to Facebook to build their data analytics team, and is now a professor at the Icahn School of Medicine at Mount Sinai working with computational biologists to apply data analytics in medicine.
St. Mary’s Medical Center (IN) notifies 4,400 patients that their information was exposed during a January phishing attack. It’s yet another example of securing the cyber-perimeter only to have it blown wide open by unwitting employees duped by fake “click here” emails.
Reader Comments
From EpicAlready Won: “Re: DoD. Did they really just say they expect to have their EHR — the contract for which hasn’t even officially been awarded — up and running by EOY 2015? Do they have any idea what they are getting into? What does this imply in terms of the likely winner?” DoD says it hopes to have the infrastructure in place by December 31, 2015 for a Pacific Northwest test site.
From Oh Nant: “Re: NantHealth. Bob Watson lives up this his reputation by firing the entire sales team at NantHealth. All sales will be done through Allscripts.” Unverified, but the companies signed a partnership agreement last week.
HIStalk Announcements and Requests
One-third of poll respondents say provider CIOs are always more believable than vendor VPs, although some added clarifying comments suggesting that they would have voted yes had the word “never” been replaced with “most often.” Anonymouse elaborates that both provider and vendor executives put the best possible spin on their organizations, while HIS Junkie opines that “you can’t tell a CIO from a vendor without a score card.” New poll to your right or here: do you feel welcome and appreciated when you make contact with your preferred hospital by calling, emailing, or driving to their facility? Vote and add your comments because I’m sure you have some great stories that add color to your Boolean response.
I haven’t sent out HIStalkapalooza invitations yet, so there’s no need to email me to inquire (and thus no need for me to respond, which is my real motivation in saying so). I will probably get them emailed out in a week or so, plus having learned from years past that emails don’t always get through spam filters, I’ll post an encoded list — like the upgrade list at the airport with some combination of name letters — so you’ll know you’re invited.
I’m about to close down registration for our sponsor-only networking reception that will be held Sunday, April 12. Those who sign up (and show up) will mingle with their normally competitive peers, eat and drink at my expense, and enjoy a low-pressure evening in which nobody is either selling or buying anything. I suppose those who don’t have will chosen an equally invigorating alternative. Contact Lorre.
Listening: Denmark-based Volbeat, whose hard rock music lies somewhere in the continuum between Metallica and Johnny Cash but still sounds fresh.
Last Week’s Most Interesting News
A group of five Republican senators says HITECH hasn’t provided taxpayer return on investment, EHRs aren’t useful to physicians, and ONC’s interoperability roadmap is too vague to guide EHR vendors.
Five healthcare IT vendor founders make the Forbes list of billionaires.
The AMA says CMS should release more ICD-10 testing details and develop a contingency plan for the upcoming switchover.
Truven Health Analytics is rumored to be planning a $3 billion IPO.
A Wall Street Journal article questions the appropriateness of drug company-paid alerts and reminders sent to patients whose doctors use Practice Fusion’s free EHR.
Allscripts says in its earnings call that it is disappointed in 2014 revenue and it should not have allowed overly optimistic Wall Street expectations to go unchallenged.
A reporter’s posthumous editorial urges that every willing cancer patient’s information be loaded to a database that both patients and doctors can access as a one-person clinical trial.
Webinars
March 12 (Thursday) 1:00 ET. “Turn Your Contact Center Into A Patient-Centered Access Center.” Sponsored by West Healthcare Practice. Presenter: Brian Cooper, SVP, West Interactive. A patient-centered access center can extend population health management efforts and scale up care coordination programs with the right approach, technology, and performance metrics. Implementing a patient-centered access center is a journey and this program will provide the roadmap.
Here is the recording of Zynx Health’s recent webinar, “Care Team Coordination: How People, Process, and Technology Impact Patient Transitions
Acquisitions, Funding, Business, and Stock
Golub Capital provides a $250 million senior credit facility to support Netsmart’s recapitalization by its owner, private equity firm Genstar Capital.
Lenovo will launch a healthcare division (for the second time in four years) on April 1, probably hoping that cybersecurity-sensitive providers will forget about its recent Superfish preinstalled spyware debacle. The company’s 2011 healthcare push tanked quickly and probably could have been easily predicted given its self-stated motivation in reviewing the healthcare market: “I know we want a piece of that, I know our partners want a piece of that, and we want to go get it with them together.” There’s not a whole lot they can do except take a few off-the-shelf products that seem interesting for healthcare users, market them separately, and train partners to sell them.
Apple will live stream the announcement of its Apple Watch today (Monday) at 1:00 p.m. Eastern, although Apple says the video will work only on specific Apple hardware and software combinations. Several Internet wags remarked that they lost an hour Sunday morning due to the DST time change and then will lose another three staring at Tim Cook and company on their screens.
Sales
Baltimore-based Emocha Mobile Health signs a one-year, $65,000 contract with Harris County, TX to monitor medication adherence in TB patients by having them record themselves taking their prescriptions and sending the smartphone video to their doctors via the company’s app (maybe nobody ever looks at it, but the fact they might could make patients more diligent, I guess). The seven-employee company, which licenses technology from Johns Hopkins, is trying to raise $1.8 million in seed funding. None of the folks involved have any apparent healthcare experience.
Depression solutions vendor SunSprite chooses Validic to collect information from its bright light exposure tools.
Announcements and Implementations
SRS will offer its users SurgiMate surgery scheduling software.
340B pharmacy platform vendor Sentry Data Systems partners with Avella Specialty Pharmacy.
Agfa Healthcare launches a patient and physician portal to display images from its system, which should be wonderful news to those patients and physicians who love logging on to separate portals for each system a hospital uses.
Government and Politics
The Illinois HIE, having blown through $19 million in HITECH money in four years and still running at a loss, doesn’t have funds allocated in the proposed state budget that will take effect July 1.
The Washington Post profiles telemedicine and other technology services offered to veterans through charity groups and the VA itself.
Technology
The New York Times profiles 32-year-old Jeffrey Hammerbacher, a Mount Sinai medical school data analyst and assistant professor who previously made fortunes working as an equities analyst, creating Facebook’s data team, and founding multi-billion dollar company Cloudera. He’s married to Rock Health co-founder Halle Tecco. His Mount Sinai team is applying data science to chronic disease for the development of personalized medicine. When at Facebook, he famously said not long before he quit knowing he was leaving IPO money on the table, “The best minds of my generation are thinking about how to make people click ads. That sucks.”
Other
LA County’s Department of Health Services is using clinical decision support software developed by Chief Research and Innovation Officer Jeffrey Guterman, MD that applies clinical rules to encounter data to manage chronic diseases. He’s modest about his work: “It’s pretty sophisticated for healthcare, but it’s pedestrian for any other industry … As a large governmental bureaucratic organization. I think people are happy to say, ‘The providers look happier, the patients look happier, no one is complaining, this is a great change.’”
Ed Marx is writing a book called “Voices of Innovation” and invites readers to contact him about being part of it.
Medical school dean Art Kellermann, MD tweeted out this graphic created by Daniella Meeker, PhD of Rand Corporation.
Struggling Southern Regional Medical Center (GA) lays off a bunch of employees after realizing from benchmarking software reports that it was overstaffed. I always have the same question after reading stories like this: was management too stupid to notice lack of productivity until they found out that similar hospitals have fewer employees? We might as well have just one national hospital since none of them can take any action without seeing what the others are doing, with that lack of competence and/or confidence fueling an entire industry of conferences, software, and consulting services.
Unrelated, but bizarre enough to worth mentioning since it made me laugh out loud even if I did feel guilty afterward. A judge dismisses a lawsuit against Applebee’s in which a patron claimed the restaurant’s waitress should have warned him that his platter of sizzling fajitas was hot. The waitress sat the fajitas down, at which time Hiram Jimenez decided to take his brother’s hand and bow to say grace, causing his face to get splattered with hot grease. It just got worse: the man claims he pushed the platter away as a reaction but instead it ended up in his lap, which caused him to injure his arm. His attorney, Dick Weiner, is unhappy that the judge ruled that it shouldn’t have been necessary for the waitress to warn anybody that a furiously sputtering skillet full of meat might be hot. The man was fine, with no scarring, permanent injury, or financial windfall.
Sponsor Updates
The SSI Group will exhibit at the VA/DC 2015 Spring Education Conference March 11-13 in Richmond, VA.
TeleTracking offers insight into how RTLS is enabling high-visibility health.
T-System’s blog focuses on “Nurse Debate: Communication Silos.”
Verisk Health will exhibit at the 15th annual Employee Healthcare Conference – East March 12-13 in New York City.
Truven Health Analytics releases its annual study identifying the 100 top U.S. hospitals based on their overall organizational performance.
Vital Images will exhibit at the ACC 15 Annual Scientific Session & Expo March 14-16 in San Diego.
Voalte discusses the challenges healthcare facilities face when moving to a new facility.
The Chicago Sun-Times features Huron Consulting Group’s Arshia Wajid and her work as founder and president of the nonprofit American Muslim Health Professionals group.
ZeOmega offers the second part in its blog series on defining population health management.
The latest ZirMed blog offers “Fresh Insight into Predictive Analytics … and Renewed Focus on ICD-10 Contingency Planning.”
The Daily Practice blog from Navicure asks, “The Times They Are a Changin’ … So How Do You Get Ready for Value-Based Modifier Payment Models?”
NTT Data offers a blog on “The Counter Effect of Mobile and How to Avoid It.”
Patientco posts “Beat Patient Debt, One Payment at a Time.”
The latest MedData blog advises, “Don’t limp towards the ICD-10 finish line. Finish strong.”
ScImage releases updated echo reporting based on new ASE 2015 quantification standards.
PatientSafe Solutions discusses the case of the frustrated phlebotomist in the second part of its quality care and mobility blog series.
The PMD “Charge Capture” blog discusses “Increasing Team Productivity with Paired Programming.”
Orion Health offers insight on “Integrating Device Data with EMR for Better, Safer Care – A Case Study.”
Perceptive Software lists “Four Reasons You Need an Enterprise Capture Strategy.”
Nordic launches a video on its successful affiliate extension project with ThedaCare.
Passport Health will exhibit at AAHAM South Florida March 11-13 in Cocoa Beach.
The latest nVoq blog covers speech-recognition solutions for mobile physicians.
Working with Startups: Assessing Viability By Michael Burke
In a previous article about accelerators and incubators, I made an argument for why it can be advantageous for purchasers of healthcare IT solutions to strike up vendor relationships with emerging startups. A drawback, however, is that more startups fail than survive.
In this article, we’ll take a closer look at the prospect of long-term viability for startups. To make it mildly entertaining (and to pay homage to Mr. H’s eclectic musical interests), we’ll compare it to a band trying to make it big in the music business.
What Are The Odds?
The stats related to long-term viability for a startup are not great. The rule of thumb popularized by the National Venture Capital Association is that 25 to 30 percent of venture-backed businesses fail.
However, this stat may be misleading and a little self-serving. Research from Shikhar Ghosh of HBS says that 75 percent of venture-funded enterprises never return cash to their investors, while 30 to 40 percent of them liquidate assets such that investors lose all their money.
The stats for a band trying to make it big are similarly grim. In 2009, only 2.1 percent of the albums released sold more than 5,000 copies. Of the lucky few bands that sold 5,000 or more albums, most didn’t make any money. The reasons most bands don’t make money are oddly similar to the reasons most venture-funded startups fail.
Winning the Lottery
When a band signs a deal with a major label, they feel like they won the lottery and that their success is guaranteed. They often get a big advance. However, they use a lot of that advance for recording the album and paying professional fees to lawyers and managers.
When the record is released, they may get lucky and sell a bunch of albums, but there are huge “recoupable” costs for video production, tour support, radio promotion, and other odds and ends. Even after selling a million records, they could still end up owing the label money.
When a startup signs a deal with a venture capital company, they feel like they, too won the lottery and that their success is guaranteed. They get a big cash injection (think “advance”). However, the cash doesn’t go in the shareholders’ pockets — it is used to fund and grow the business (just like a band uses the record company money for recording, promoting, and touring).
If the company gets lucky and folks start buying their product, things are looking good for the founders, right? Maybe. Maybe not.
When the startup signed the deal with the VC, it probably included a number of terms that are immensely preferential to the VC. The deal probably included terms that allowed the VC to exert considerable influence (if not outright control) over key decisions. The deal probably included “participating preferred” shares that allow the VC to recoup all their money (sometimes several times their original contribution) before the founders get a dime.
This means that in order for the founders to earn any money, they have to be able to sell the company for quite a bit more than they may have originally expected just to pay the “recoupable costs” (like in our band example). They are clearly motivated to swing for the fences. Because they gave up control, they can’t choose to focus on organic growth or on operating a great business. Instead, they have to go for the grand slam exit strategy.
For better or worse, raising venture capital moves the goal line for an exit, both in terms of time and value. It changes the responsibilities and objectives of an operator / founder. They must grow bigger and faster, with everything that approach includes. This may require a completely different skill set than the existing team can offer.
If you are a music fan, you may have heard of a number of bands going a different route lately. Instead of working with a major label, they release records on their own or work with a smaller label. They may not gross as much, but they’re far more likely to have a higher net. Possibly more importantly, they get to control their own destiny. Similarly, a startup may choose to bootstrap the endeavor on their own or they might take smaller investments from friends, family, or angel investors. This is the path we’ve taken with Clockwise.MD.
Either path is valid. It really depends on the goals and the circumstances.
What Really Matters for Customers
Based on what we’ve learned about the risks of working with a startup, what should purchasers of health IT do? That depends.
A health system that has its own early stage fund ostensibly knows the risks and probably doesn’t expect all of its portfolio companies to succeed. Even without a captive fund, most health systems can control the environment to some degree by leveraging their network to boost the success of the startup through referrals. The basic goal should be to avoid the 30 to 40 percent of startups that end up liquidating assets.
If they’re simply trying to solve a problem with technology and are considering a startup’s offering as a possible solution, they can mitigate risk through some simple reflection and investigation:
Do they want to influence or control the feature set of the product? If so, they should jump in early. Companies often work hardest to serve their early adopters. Those adopters can have great influence in product development and pricing, which can serve everyone well over the long term.
Does the startup have traction? Has it achieved critical mass in the marketplace? Sometimes a startup has a compelling solution but lacks market traction or reference sites to get the customer comfortable with investing time and money. In this case, vendors can enter into a beta agreement to gain the opportunity to prove their value. This can de-risk the relationship.
How is the startup funded? What does its financial picture look like? Don’t be afraid to ask. Venture capital support certainly may not hurt a startup’s viability, but it should not be a requirement.
Talk with current customers to get an idea of how well the solution works and the level of support and flexibility at the company. For vendors, reference sites are worth their weight in gold.
Working with a startup doesn’t have to be a nail-biting adventure. It largely depends on understanding clearly what you hope to accomplish and doing your due diligence.
I’ll close with a quote from Mark Zuckerberg, founder of Facebook:
"The biggest risk is not taking any risk. In a world that’s changing really quickly, the only strategy that is guaranteed to fail is not taking risks."
Michael Burke is an Atlanta-based healthcare technology entrepreneur. He previously founded Dialog Medical and formed Lightshed Health (which offers Clockwise.MD) in September 2012.
Robert Dudzinski is EVP of the healthcare practice of West Corporation of Omaha, NE.
Tell me about yourself and the company.
I came to West via an acquisition. I was a CEO and founder of a company that it acquired about five years ago.
I’m a pharmacist by background with a doctorate. I owned, operated, and sold a prescription benefit management company and a mail-order pharmacy. I kept out of healthcare for a little bit and opened up a chain of baseball and softball stores. I had a great time with that. I got back into healthcare and started a company called SPN, Specialty Pharmacy Network, in 2004. That ultimately became an acquisition of West in 2010.
West is a publicly-traded, technology-driven communication company. We participate in about every industry — retail, finance, banking, and certainly healthcare. We’re about $2.2 billion, about 15,000 employees, and we have a full plethora of communication assets. We take a vertical approach, moving from products and services to value-added solutions in the healthcare space.
Providers for years have gotten away with hiding behind phone trees and doing anything to avoid putting a human on the line. Does that need to change?
Absolutely. The rallying cry in the market today is patient engagement and activation. To your point, that’s never been a primary initiative for provider systems. Today that’s very different. It ultimately ties back to reimbursement and now there’s a great emphasis going on in that area.
Now that providers are expected to manage populations, they have to reach out to patients instead of just waiting for them to call or show up. How can technology help?
There’s all kinds of initiatives that are going on today in trying to do outreach at scale and capacity. That’s been the big challenge for health systems and those are the solutions that they’re looking for. In other words, as providers have moved to managing larger populations, the challenge is, how I’m going to touch those people effectively? How am I going to personalize it? How am I going to change a behavior and improve an outcome? Technology can provide some of that success in doing that if it’s purposed correctly and there’s a good strategy and plan behind it.
Everybody has their own preferred way of being communicated with – text message, email, or phone call. How does a provider choose the best medium for each person?
The provider needs to start with an overarching strategy of how they’re going to approach engagement and activation. We here at West always gravitate to the notion of a unified communicate environment where you are providing preference and choice to that patient. When you do that, you provide contextual awareness amongst those channels and you have a sophistication around content that’s being delivered. Is it relevant? Is it non-redundant? All of those things start to roll up and start to create what we would call an enhanced experience. That’s what the provider is actually looking for.
Providers haven’t had much incentive to getting on the phone or email with patients because nobody was paying them to do so. Are you seeing the demand change now that there is reimbursement for keeping contact with patients and not just having them drive to the office?
Yes. Most certainly as payer organizations look to value-based pricing — we’ve heard that term ad nauseum in the marketplace today — it’s going to be a challenge and edict for the providers to reach not just the chronic patient, but those that have yet to become chronic patients. Having a strategy of addressing that population in totality is going to be an imperative for providers. No longer will they just simply have to be reactive. They’re going to need to be proactive in their approach.
I wrote about the free nurse hotline in New Mexico that is keeping thousands of people out of the ED. Is it hard for hospitals to think about being paid to keep people out of their facility?
They have to have a whole new mindset approaching population health and what it means to implement the Affordable Care Act. In your example the nurse line, we have a nurse on the line doing outreach or at least trying to promote a call prior to an ED visit. That’s a great also application for technology.
We have programs here written against our IVR systems that do a couple of things. They do a reminder on a Friday to make sure that the patient’s got their meds filled so that they’re not going to the emergency room because of a need for a refill. Number two, technology that could actually nudge the patient and remind the patient that if they have floss stuck in their teeth, that’s not an appropriate ED visit — they should be reaching back to the care coordinator or to the case manager.
Technology could play a role in facilitating, as you’ve described, that nurse line. We can do that at scale and capacity, that constant nudge and connection with the patient, allowing them to know there are alternatives to some of the thinking that they have today.
If a hospital calls you wondering what they should do both short and longer term to get more engaged with their patients, what do you recommend?
Historically, providers haven’t had a need to engage the patient and what’s expected of them today. Because of the complexity of health systems and hospital systems, we’ve put an assessment process together. It’s very simple. This usually is our first recommendation. It’s a way to give them clarity as to where they’re heading, the assets they have, what is possible, and a road map to that end.
That strategy has worked well for us. No commitment. It’s just a matter of allowing them to see outside of healthcare what organizations have done to achieve either a world-class call center persona or an understanding of the communication technology that could play a role in their discrete objectives.
As a pharmacist, are you impressed with what Walgreens and CVS are doing to engage with their customers using technology?
Absolutely. Pharmacy has always had a need to engage the patient. Pharmacy by its very nature sees the patient more often, and they also have to do it not only from a healthcare perspective, but from a retail perspective.
Pharmacy and the strategies that the pharmacies are promoting today are great models for other provider systems to look at and engage against. I like what pharmacy is doing and I think we’ll see more of that from pharmacy on a go-forward basis.
We talked about the barricades providers seem to have put up to prevent people from reaching out to them. You could argue that hospitals do that physically as well, where parking is inconvenient and departments are hard to find. Could non-physical patient interaction allow them to work around the huge disadvantage of being located on campuses that are consumer-unfriendly?
We hear that consistently across the country as we’re out there with our offerings. The mere fact of trying to navigate the ever-changing environment of a health system has been a challenge for patients. To be honest, it’s also been a challenge for the patient to call into a health system and intelligently get navigated to where they need to be.
We did a roundtable with a group of patients at a health system. One of the comments that came from the patient was, "I would rather walk to this institution than call it." That was an indictment of the fact that there is a real immaturity around how best engage patients and the importance of that engagement.
The mindset needs to change in the provider market and I think it is. They are shifting to a very different approach. We see it also even in how they present themselves and how they organize themselves. Now we have VPs of engagement. We have VPs of consumerism. We have VPs of population health that now are charged with creating an experience and recognizing all of the touch points that a patient could have. Then obviously the need to translate that into how that will either generate revenue or reduce costs.
Do you have any final thoughts?
It’s a great time to be in healthcare. The provider community has never played a more important role and I don’t think they’ve ever taken on more responsibility. The need to address consumerism, the need to think through engagement and activation strategies, the notion of gravitating to unified communication environment s going to be critical for success and not only in the provider systems. Any healthcare organization that’s looking to manage a population needs to be thinking in those terms.
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