Morning Headlines 2/26/15

CMS Pushes MU Attestation, PQRS Reporting Deadlines to March 20

CMS has announced that both the Meaningful Use attestation and PQRS reporting deadline for eligible providers has been extended to March 20.

Pentagon Narrows Down List Of Contenders For Multibillion-Dollar Health Records Contract

The DHMSM EHR procurement has moved to its final stage and the list of vendors has been narrowed to three finalists: CSC/HP/Allscripts, IBM/Epic, and Leidos/Accenture/Cerner. Sadly, the VA’s VistA platform, proposed by PwC, was eliminated.

Anthem: Hacked Database Included 78.8 Million People

Anthem reports that 78 million records were exposed during its recent cyber attack, including up to 19 million non-Anthem customers, and 14 million “incomplete” records. The newly released data also breaks down records breaches by state.

FBI Is Close to Finding Hackers in Anthem Health-Care Data Theft

In other Anthem news, the FBI reports that it is close to identifying the group responsible for the attack, with signs pointing to a Chinese state-sponsored hacker group.

Readers Write: Want to Read the Briefs in the Epic vs. Tata Consulting Case? That’ll Cost $0.10 Per Page (Unless We Do Something About It)

Want to Read the Briefs in the Epic vs. Tata Consulting Case? That’ll Cost $0.10 Per Page (Unless We Do Something About It)
By Reluctant Epic User

As Americans, we tend to assume that we have the most open and transparent courts in the world.  Unfortunately, that probably isn’t the case. The reality is that all of the public documents filed in a court case are locked behind the world’s largest paywall. Including the Epic Systems vs. Tata Consultancy Services Limited case. 

It doesn’t have to be this way. The courts give every person in America $15 per quarter in free downloads. The Free The Law project has created a clever workaround which places these documents in the public domain. 

Five of 82 documents in the Epic vs. Tata case are available to the public. You can increase that number. Follow these steps:

1. Install the “RECAP the law” Firefox Extension.
2. Open a PACER account as a view user (credit card required).
3. Once you have an account open, go to the Western Wisconsin Court District site and log in.
4. Click Query and enter 3:14-cv-00748 in the case number field.
5. Click Docket Report, accept the default values, click run.
6. Click on one of the document # hyperlinks which doesn’t have a “RECAP the law” logo by it (examples in green boxes).
7. Read the document if you’re interested. If you aren’t, click back and find another one. At most, a document will cost $3.00. Therefore, don’t open more than four documents and you’ll stay under the $15 free limit.

Some of you may be wondering, why do this?  To date, documents like Epic’s Standard Consulting Agreement (circa 2005) have been unavailable to the general public. The case offers us the chance to get a glimpse behind the Epic’s veil of secrecy, something any HIT observer should happily support.

Since this will be an ongoing case, we’ll need people to regularly contribute. If you comment on this post, you’ll be updated on an ongoing basis as we gather all the documents we need.

Readers Write: Working Around Health IT: The Nurse, the Workaround, and the Question You Need to Ask

Working Around Health IT: The Nurse, the Workaround, and the Question You Need to Ask
By JoAnne Scalise, MSN, BSN, RN

Are nurses just BAD? (That’s not the question.)

Why are they so adamant about working around health information technology (HIT)? Is it to give the CIO chest pain? Annoy the IS people? Give their nurse leader heartburn?

How can a simple process — do this, then do this (perhaps multiplied a few or many more times) — turn into a spin with the Mad Hatter (teacup optional)?

It would be easy to leave it that “nurses don’t follow directions,” “nurses are difficult to deal with,” or my personal favorite, “nurses don’t like change” (of course, everyone else likes change!) Those crazy nurses are still wearing disco-era bellbottoms and a mullet. And if you are, that’s ok – it works for you. With 55 percent of the RN workforce at age 50+ (from a 2013 survey reported by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers), that may have been some of the best of times.

But what about making right now better? So much HIT is intended to make life better: for patients, for healthcare systems, and yes, for those crazy nurses. Better, as in efficient and safer for everyone – and in getting paid so we can take care of people tomorrow.

Even knowing that, why do nurses choose to work around the very things that could save their patient, their colleagues, their organization – and themselves? Why does an expert nurse scan a contraband wristband or label instead of the one on the patient for medication administration or specimen collection? Why circumvent the EHR when guidelines for use have been given? Why take that patient  (and personal and professional) risk?

This is the opening of dialogue. Not to defend what many call “the bad apple,” “the bad actor,” or those who just act “bad,” as in, “I don’t care about people” people. I’m not talking about nurses or specific roles. I’m referring to those outliers who are clear that they don’t care about patient safety or care, their colleagues, or healthcare. Those people are the rarest of the rare because they don’t last long in our system – we can’t tolerate bad apples or bad care. Bad is about behavior and not the person.

As a perennial patient safety student, I know that the professionals who have chosen to be entrusted with providing care to every one of us who enters the healthcare system do not take their responsibility lightly. As a nurse, I know (as do my clinician colleagues) that we have chosen wisely. Our responsibility to our patients and the healthcare system are our primary motivators. Care excellence is the goal we must fulfill in every patient encounter every day. Safety never sleeps.

Why then, the confounding issue of the workaround?

I have been fortunate to work with nurses around the country to help them keep their patients and themselves safe. I have had other departmental staff stand up and point their fingers at me and ask, “How are you going to make these nurses BEHAVE?” And this is with nurses in the room. On occasion, I even get the same question from the nurse leaders. Laboratorians, CIOs, and patient safety and quality professionals have other direct questions on the same topic. I’ve even been invited to speak to groups of lab leaders on “how to communicate with the nursing suite.” When presenting on the topic in national forums, the topic is often addressed in hushed tones by nursing and other leaders who share that the workaround is an “epidemic.”

Indeed, the workaround is a real and persistent danger and with exponential significance: the possible patient safety breach, the trust eroded for collaboration and communication, and the financial loss from the wasting of resources of the healthcare organization.

Health information technology spending was projected to top $6.8 billion in 2014, with individual hospitals and healthcare systems spending millions annually. Not using the purchased technology causes challenges in safety, in culture and process, in data collection and analysis, and in budgets. When enough end users simply “end it” and stop using the technology, the technology can end for that organization. With that end comes significant loss.

At the same time, some organizations decide to not engage the nurse or other end user for a variety of reasons, often because of time for conflict (“we can’t get caught up in nursing demands — they’re going to have to do it.”) I’ve been in meetings where the issue came up of end users (who were not represented or in attendance) and the statement was made, “We’re just going to ram it down their throats.” Tough love, but probably not so effective in the long run. Fortunately, they were eventually receptive to the benefits of end user inclusion and engagement in the decision process, with a very positive outcome.

When nurse and hospital leaders ask me, “What is the most important lesson you’ve learned about adoption?” I tell them that the most important lesson may seem to be a simple one. Engage your end users. You must engage them as you decide that you have an issue to solve. You must engage them before any technology decision is made. If you don’t, they will use the only opportunity that they have to influence this decision – and that is not to use it.

Some technology doesn’t make life easier. Not all technology is the best it can be. We all need to help make these products better through objective feedback and end user engagement in the decision process and ongoing use.

I believe we can support clinicians in moving from compliance to commitment, and not just in technology. I’ve developed a MAP (mindful leadership, authentic communication, personal accountability) to help you do just that so we can do less “around” and more “work.”

I’ll leave you today with what I think is the best question for responding to a workaround. So many times we ask, “Why won’t you do this?” The question implies resistance, and depending on how we say it, frustration and even accusation. The answers may tend to be defensive and deflect the true reason.

Ask instead, “Why can’t you do this?” You will get thoughtful and real answers that may benefit your practice and eventually improve the technology. And the work.

Let’s continue the conversation on how we can work through the workaround. I’ll bring my MAP.

JoAnne Scalise MS-Patient Safety Leadership, RN is the manager of nurse consulting for Sunquest Information Systems.

Morning Headlines 2/25/15

Cerner offers select associates voluntary departure program

Following its acquisition of Siemens, Cerner is encouraging some employees to consider “voluntary departure,” despite the company’s plans of hiring 16,000 new employees over the next 10 years.

Navicure Survey Reveals ICD-10 Optimism despite Minimal Preparation

An ICD-10 readiness survey finds that 81 percent of practices feel they will be ready when the ICD-10 transition goes into effect, but that only 67 percent believe the transition will happen on October 1, 2015, without further delays.

Marketing chief Sona Chawla says Walgreens is both on and in your corner.

The Hub interviews Walgreen’s chief marketing officer Sona Chawla, who says “I think of our customers as shoppers, unless they want to be patients. When they are in our clinics and they are sick, they want to be patients and we recognize them as patients. But no one is in a constant state of being a patient, and we have to be very sensitive to that because we offer a wide range of trip missions. So, when they are coming in to shop for lipstick, they are shoppers. That’s how they want to be recognized, and that’s how we recognize them.”

News 2/25/15

Top News

Cerner offers “select associates” an opportunity to “consider a voluntary departure.” The company didn’t define “select,” but it wouldn’t be too surprising if many of them are located in Malvern, PA and are older (one report says employee age plus years of service must exceed 65 to be eligible). 

Reader Comments

From Dim-Sum’s Little Brother: “Re: DHMSM down-select. Two of the five bids were eliminated. According to my network, IBM (Epic), CSC/HP (Allscripts), and Leidos/Accenture (Cerner) made the down-select. InterSystem (TrakCare) and PwC/GDIT/DSS (Medsphere) were eliminated from the competition.” Unverified, but reported by multiple readers. I said upfront that the chances of DoD choosing VistA from their IT rival VA were zero. A couple of sites reported just in the past week that DoD would choose an open source solution, although I doubt you’ll see a “we were wrong” follow-up if indeed VistA has been shown the door as it appears. That also means the late and sexy addition of Google to the PwC bid didn’t impress DoD (and rightly so since their participation, as described, was minimal).

From Stanley Kowalski: “Re: HIPPA. I was surprised to see such a bold subject line.” Not only was HIPAA spelled wrong, a hyphen should appear between the first two words. At least they didn’t say “complaint” instead of “compliant.”

HIStalk Announcements and Requests

Regina Holliday and Lorre have chosen our five HIMSS15 scholarship winners and they all seem excited. I’ll be running a short bio of each shortly, along with their description of what they hope to accomplish at the conference.

Webinars

March 4 (Wednesday) 1:00 ET. “5 Steps to Improving Patient Safety & Clinical Communications with Collaborative-Based Care.” Sponsored by Imprivata. Presenters: Robert Gumbardo, MD, chief of staff, Saint Mary’s Health System; Tom Calo, technical solutions engineer, Saint Mary’s Health System; Christopher McKay, chief nursing officer, Imprivata. For healthcare IT and clinical leadership, the ability to satisfy the clinical need for better, faster communication must be balanced with safeguarding protected health information to meet compliance and security requirements.

March 5 (Thursday) 2:00 ET. “Care Team Coordination: How People, Process, and Technology Impact Patient Transitions.” Sponsored by Zynx Health. Presenters: Grant Campbell, MSN, RN, senior director of nursing strategy and informatics, Zynx Health; Siva Subramanian, PhD, senior VP of mobile products, Zynx Health. This webinar will explore the ways in which people, process, and technology influence patient care and how organizations can optimize these areas to enhance communication, increase operational efficiency, and improve care coordination across the continuum.

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

CTG reports Q4 results: revenue down 4 percent, EPS $0.08 vs. $0.22, not including a $0.07 expense associated with the October death of CEO James Boldt and a $0.06 write-down of the company’s investment in poor-selling medical fraud, waste, and abuse software. CTG expects its healthcare revenue to drop 14 percent in 2015 and says the year will be a ‘transitional” one for its healthcare business as the EMR market cools. Above is the one-year CTG share price chart (blue, down 49 percent) vs. the Nasdaq (red, up 15 percent).  

Imprivata announces Q4 results: revenue up 34 percent, adjusted EPS –$0.04 vs. $0.84, meeting revenue expectations and beating on earnings. IMPR shares are trading down around 14 percent from their June 2014 first-day trading price. 

Sales

Horizon House (PA) chooses CoCentrix for EHR, care coordination, and billing.

Temple University Health System (PA) chooses Strata Decision’s StrataJazz for financial planning, rolling forecasting, capital planning, and capital equipment replacement.

People

Xifin hires Jim Malone (American Well) as CFO.

Bobbie Peterson (Medsphere) joins Apprio as EVP of health IT.

Announcements and Implementations

NextGen adds the CompletEPA electronic prior authorization solution from Surescripts.

Cleveland Clinic and the VA will provide “seamless access” to each other’s EHR information starting this month. The clinic uses Epic Care Everywhere.

Government and Politics

The Federal Trade Commission fines two developers of melanoma detection apps for falsely claiming that their products work. MelApp and Mole Detective didn’t have the evidence to prove that taking a photo of a mole and then specifying its characteristics can reliably detect melanoma. It’s interesting that the companies were charged by FTC for false marketing rather than by FDA for providing medical advice.

An FDA-funding Brookings Institution report recommends that FDA strengthen its post-market medical device surveillance system to include tracking those devices by a unique ID. EHRs would provide device usage information for national safety surveillance, with such capability being required to meet ONC certification and Meaningful Use requirements. FDA says the system “will require significant financial resources to be sustainable” and recommends paying data contributors.

FCC and FDA will convene a March 31 workshop on test beds for wireless medical devices, saying that the “hospital in the home” concept requires wireless co-existence.

New York Governor Andrew Cuomo wants to close NYDoctorProfile.com, a state-run doctor search tool that he says is too expensive to taxpayers at $1.2 million per year given that similar information is available elsewhere.

Privacy and Security

Researchers find that Googling diseases and medical terms sends information to undisclosed third parties 91 percent of the time, most often because company servers are set up to use free tools such as Google AddThis social sharing as part of Google Analytics. Even CDC.gov and May Clinic pass along search results with user-identifying information such as IP address. WebMD, for instance, sends disease search data to 34 sites including those of data brokers Experian and Acxiom. Healthcare.gov was found to be doing the same, probably due to technical negligence.

A new report finds that medical identity theft jumped 22 percent in 2014.

Anthem says its giant data breach included information on up to 19 million non-Anthem patients who were seen out of network in addition to that of its own customers.

Technology

Microsoft adds a cycling module and a virtual keyboard for its Band fitness tracker, also introducing a Microsoft Health-powered dashboard of Band-collected information.

@AlexRuoff tweeted this screenshot from an AHRQ Meaningful Use Stage 3 readiness webinar, which finds that 71 percent of participants use non-electronic means to share information. You’ll probably be in good hands if you keel over in the fax machine section of Office Depot since odds are it’s a healthcare person browsing them.

Other

Former CIO and current vendor SVP Dale Sanders says in his personal blog that taxpayer-benefiting EHR vendors are intentionally obstructing interoperability via prohibitive contract terms and add-on interoperability license fees while publicly proclaiming their support of open standards (he doesn’t name Epic specifically, but they seem to be the target). He says EHR vendors should offer open APIs and that courts should intervene to stop interoperability-impeding terms and conditions. He quotes a peer who doesn’t think FHIR in its planned form is the answer:

Several EHR vendors are banning together around a new magic bullet technical standard called HL7-FHIR based on JASON technology. While this new standard is great from a technical perspective (XML, REST, etc.), in its current form, based largely on existing HL7 v2, v3 and CDA concepts, it does not improve the accessibility of proprietary EHR data types, and those data types are needed for quality and cost performance improvement in healthcare. While FHIR could be expanded to include this type of data, it appears the first efforts are focused on reinventing the technology for currently defined interoperability data types.

An interview with Walgreens Chief Marketing Officer Sona Chawla contains some interesting quotes, the last of which is pure genius and a useful lesson for providers trying to become more consumer friendly:

• “I think the concept of ‘well’ is broader than ‘wellness.’ It really encompasses the ‘happy and healthy’ feeling. ‘Wellness’ has a more specific meaning than ‘well,’ which is limited to the ‘health’ part.”
• “The service that’s delivered online or in the store should be the same and feel the same in spirit. If you are in the store, you can have face-to-face interaction. If you are online, we offer things like 24/7 pharmacy chat. Those elements of customer service happen in a very specific way based on the channel, but when we put it all together it should feel like one Walgreens.”
• “We have an all-in-one app that is a connecting point between the physical and the virtual for us, to really serve our customers. Our mission was to think about what customers were doing and how we could improve it.”
• “With digital health, it’s really about reinventing the core experience. For example, we launched an immunization app within our main app which records your immunization history and also reminds you to immunize as well as take your pills on time. Technology is changing the way customers behave and we are leveraging the technology to make things easier, but at the same time, enhanced. Then there is the concept of unification, which is connecting these experiences not just within Walgreens, but also with our partners. It gives us a great platform to think of our customers, wherever they are.”
• “I think of our customers as shoppers unless they want to be patients. When they are in our clinics and they are sick, they want to be patients and we recognize them as patients. But no one is in a constant state of being a patient and we have to be very sensitive to that because we offer a wide range of trip missions. So when they are coming in to shop for lipstick, they are shoppers. That’s how they want to be recognized and that’s how we recognize them.”

A Navicure survey finds that 81 percent of physician practices are optimistic that they’ll be ready for ICD-10’s October 1, 2015 implementation date and two-thirds of respondents don’t think it will be delayed again. Practices say their main concern is that payers won’t be prepared. 

A newly built hospital in England issues bells to patients housed in treatment rooms to use as a call system, explaining that it didn’t expect to need electronic call buttons in that location but will now add them.

Weird News Andy wants to know who will pay the CT scan bill. A Chinese statue of Buddha from 1100 BC is found to contain the body of a mummified Buddhist master.

Sponsor Updates

• CTG’s Managing Director of Data Analytics Joseph Eberly will co-present “Using Data Analytics to Improve Care Valuation, Management, and Outcomes” at the Hospital & Physician Relations Executive Summit March 1-3 in Scottsdale, AZ.
• Fujifilm’s Synapse RIS earns ONC HIT 2014 Edition Complete EHR certification.
• PerfectServe will participate in two March annual conferences, the Society of Hospital Medicine and American Medical Group Association.
• Cumberland Consulting Group donates laptops to Back on My Feet to assist the nonprofit’s residential members look for jobs and permanent housing.
• CitiusTech will exhibit at SCOPE Summit 2015 through February 26 in Orlando.
• Clinical Architecture posts a video on “Temporality” as part of its blog series on the road to precision medicine.
• CenterX CEO Joe Reinardy will speak at the 2015 Emdeon Pharmacy Insights event in Nashville on March 4.
• CareSync offers “Ten Ways Medicine Today can Outrun Every TV Doctor You’ve Ever Seen.”
• Besler Consulting’s Jim Hoffman offers an “Overview of CMS Readmission Penalties for 2015.”
• Divurgent will exhibit at the HIMSS SoCal Annual HIT Conference on March 2 in Los Angeles.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

Morning Headlines 2/24/15

Strengthening Patient Care: Building an Effective National Medical Device Surveillance System

The FDA publishes a report outlining its $250 million plan to roll out a national medical device surveillance system over the next seven-years.

Epic vs. Cerner Competition Heats Up

A KLAS report on acute EHR purchasing decisions asks hospitals that are in the market for a new system who their likely next vendor will be: 25 percent reported Epic, 14 percent reported Cerner, 13 percent reported MEDITECH, and 5 percent reported McKesson, while 41 percent are undecided.

Mobile app with evidence-based decision support diagnoses more obesity, smoking, and depression, Columbia Nursing study finds

A Columbia University study published in the Journal of Nurse Practitioners finds that diagnosis rates for obesity, smoking, and depression were much higher when nurses used a smartphone app that explained evidence-based guidelines and triggered clinical decision support prompts during routine exams.

Kaiser tests video visits to cut waits

Kaiser Permanente experiments with telehealth visits as a possible way of reducing ED utilization and wait times.  

Curbside Consult with Dr. Jayne 2/23/15

I’m leaning heavily towards staying with my current employer as we move to a single platform for all our hospitals and practices, but lots of people keep sending opportunities my way. Today a juicy CMIO position came across my desk. It’s in a great location and with a well-known health system that I’ve had some dealings with previously.

It looked pretty exciting until I got to the part about the heavy inpatient focus and complete disregard for those of us who have come up through the ambulatory ranks. I started to move it to my recycle pile until something caught my eye. They’re looking for someone “politically savvy with a high tolerance for ambiguity… who can put all the pieces together and deliver on time and on budget.”

I’ve got a lot of experience delivering the undeliverable and creating successes despite some of the people I work with. Usually hard work and pixie dust are involved, but we never admit it. My general rule of thumb is that organizations are typically 30-50 percent more dysfunctional than they admit, so I’m wondering what that looks like when they’re already warning candidates about ambiguity and the need to be able to patch things up to get a project out the door. They also mention frequent interruptions and constantly changing priorities. I’m not rushing to submit my CV.

Another prospective position (thanks to the reader who sent me an opportunity in a warm climate) looks like it’s much more up my alley. The nine responsibilities bulleted in the job description are things I’ve been doing for years. I’m less sure, however, about the tenth one – supervising and assigning projects to physician informaticists on the CMIO’s team. Sometimes it feels like I’m lucky to get an administrative assistant to support me, so the idea of multiple physicians helping deliver value from healthcare IT is awfully tempting. They’re also looking for someone either board certified in clinical informatics or with a masters degree in the field, so that tells me they value the education and training that many of us can bring to the table.

In the mean time, I’m still waiting to find out how my health system is going to handle the clinical leadership structure for the EHR consolidation project. I don’t have a lot of time to dwell on it, however, since we’re preparing more than a dozen practices to seek recognition as Patient-Centered Medical Homes.

The first time I went through the process was on paper. Although there are certain aspects of the requirements that are significantly easier with an EHR in place, there are still elements that are much simpler in the paper world. Some of our practice managers have actually laughed out loud when I ask them to use a simple three-ring binder for some of the requirements. Although I’m obviously a fan of technology, sometimes a manual process is quicker, easier, and doesn’t require anyone from IT to give it a blessing.

I’d estimate that three-quarters of our practices are ready, with stable processes and solid physician buy-in. The other few still need some work. We’re likely to urge the others to move forward while we continue to tweak workflows in those that aren’t quite ready. They also need some refinement in staff roles and responsibilities. We’re finally helping our administrators understand that PCMH is not a technology project so much as an operational initiative. I want to try to get as many of our joint operational and technical projects completed before the transition to the new system begins in earnest.

I’m also staying occupied looking for interesting ways to use some of my accumulated vacation time. As of January 1, our health system has gone to a “use it or lose it” philosophy and has capped the vacation hours we can have on the books. I’m dangerously close to the limit and certainly don’t want to leave any hours on the table. I’m planning a wilderness adventure for July, and if I don’t get eaten by a bear, I’m looking for a trip in the fall that will provide not only some R&R but some continuing education hours. I also hope to take some long weekends once the weather gets nice. The new policy should make for some interesting resource challenges as everyone tries to lower their balances.

What’s your plan for R&R in 2015? Email me.

Email Dr. Jayne.

Startup CEOs and Investors: Brian Weiss

Startup CEOs and investors with strong writing and teaching skills are welcome to post their ongoing stories and lessons learned. Contact me if interested.

A Tale of Two Healthcare Worlds
By Brian Weiss

Many of my peers in the healthcare IT startup world, like me, are developing applications and solutions intended for a new world of consumer-centric healthcare IT, or CCHIT (I just made up that new CCHIT acronym as part of my contribution to world sustainability. Since what was formerly known as CCHIT has ceased operations, the acronym is ready for recycling.)

Have a seat and join me for a tour of CCHIT-land. You must be this tall to ride, keep your arms and legs in the vehicle at all times, and no flash photography, please.

Over on your left as you look out on the horizon, you can see deceptively colorful cloud-like structures. Those are high-deductible health plans and self-insured employers. See the little figures underneath them with the empty wallets that look like they are about to fall over? Those are consumers who are becoming more conscious of the costs of their healthcare.

Whoops! My mistake. Those are the ones on the right. The ones are the left are actually the physician practices dealing with 30 percent collection rates as the consumers on the right ignore their payment notices. You can tell them apart because the physician practices are the ones with the charts behind their backs titled “Same-Day Cash Discount Rates.”

Watch your head under the overpass. Now back over there, thrashing around between the various giant insurance company logos, are employee health plan benefit managers switching plans every year to get a better deal.

More Like Other Industries?

The CCHIT world is one in which high-deductible-plan consumers and self-insured employers increasingly seek to transact healthcare much as they transact travel services, retail purchases, and employee benefit programs.

Allegedly fueling this trend will be the availability of alternative forms of healthcare services – particularly those intended for people who are generally healthy – that were formally the domain of a traditional primary care physicians and hospitals. Telehealth services, pharmacy-based clinics, urgent care centers, home monitoring and testing kits, employer-provided campus clinics, and in-office wellness visits will compete for healthcare services wallet share.

Similar dynamics will occur in the area of high-margin routine testing from imaging centers and labs. The problematic but already well-established trend of stratification of healthcare services — from low-end, Medicare-reimbursed to high-end, spa-style luxury concierge — will continue. New forms of practices will appear, targeting various socioeconomic groups along the lines of the model of the different types of restaurants from “all the grease you can instantly eat for $1.99” to “hundreds of dollars for food you can’t really find hidden within the art-deco presentation.” An ever-increasing percentage of basic healthcare services will be transacted in cash.

Little Susie Has a Sore Throat. Where’s My Smartphone?

Whether it’s Big Joe tracking his type II diabetes or Little Susie’s mom deciding what to do with the sore throat Susie woke up with this morning, the starting point will be a smartphone for search, comparison shopping, advertising, online ordering, in-drive navigation, loyalty points, and all the rest of what makes us decide where to get our morning cup of coffee, which hotel to book in Barcelona, or how to get a ride somewhere.

In this world, notions like “Patient-Centered Medical Home” (in the sense of a doctor getting the new Medicare CCM reimbursements, not the home where the patient actually lives) takes on many flavors and meanings, from specialty patient advocate/consultant concierge services through “do it yourself” (at your real patient-centered home) with a mobile app.

In this CCHIT world, the idea that patient records are stored exclusively in big EHR systems — which have been networked together with patient matching algorithms (or someday, congressionally mandated national identifiers), record locator services, and on-demand copy-paste of entire EHR records from one system to another – seems about as relevant as the old mainframe-based travel agent systems that spit out those triplicate paper tickets with the red ink.

Fact or Fantasy?

If the CCHIT world is coming any time soon, these efforts seem a bit silly:

• Five-year plans to achieve basic healthcare data interoperability via newly developed standards for provider-to-provider exchange.
• EHR vendor-driven alliances.
• Throwing more government money down the drain on more life support for state HIEs that will never be sustainable.
• Trying to force competing healthcare providers to share their customer data with each other.
• Waiting for acts of Congress to issue national IDs so we can create some grand interconnected database that everyone can access..

Of course, there’s absolutely no guarantee that world is coming any time soon. Even if it does eventually arrive, it’s not clear how it will coexist with the extensive parts of the healthcare system that will likely continue to operate pretty much as they do today.

What happens with the increasingly large percentage of consumers who are not “generally healthy” that can’t be taken care of properly in the CCHIT model? I’m sure many readers are aware of plenty of other flaws in the CCHIT thinking that we can consume healthcare services like online videos and taxi rides.

There are many complex variables impacting how things will play out. Anyone who wants to predict how things will look in three, five, 10, or 20 years is rather brave. No, they’re not brave if they write an article with their predictions — that’s easy. They are brave when they build companies based on those predictions and visions.

The HIT Startup Dilemma

Which brings me to the point of all this.

The innovative and disruptive healthcare IT startups of tomorrow are forced to do two contradictory things. They have to design solutions for a healthcare world that doesn’t exist (and likely will never exist exactly as they imagine and envision it today) while delivering revenue-generating solutions for the healthcare world that does exist today.

This gets surreal when you watch a startup founder with a CCHIT-intended solution pitching to a room full of big healthcare system execs who want to hear nothing about the CCHIT world. Suddenly the founder’s consumer-centric clinical data integration solution is ideal for provider-to-provider data exchange without patient involvement and consent. The directory service for consumer-centric provider or plan selection is ideal for keeping patients in-network. And on it goes. 

Why? Because that is what generates revenue, pays the bills, and justifies the next round of investment funding. For realizing the very different CCHIT vision.

One of the great things about the startup marketplace is that it drives creativity that never ceases to amaze me. I have seen some really great pitches from colleagues of mine that actually had me believing that you can do both at the same time. I’m still figuring out my “have your cake and I get to eat it too” story.

Though it’s not explicitly spelled out that way, I believe that’s what the venture capitalists I need to woo in the coming months expect me to deliver. They want a disruptive vision that offers the dream of future revenues. Value that will only be awarded to those who dare imagine and create solutions for the new CCHIT world, with a clear ROI-driven revenue model for today’s PPCHIT (provider/payer centric HIT) world (yes, I made that acronym up as well, but I don’t think it was ever used or ever will be again, although I just checked and the domain name is taken).

As noted, the CCHIT and PPCHIT visions are not “either-or” alternatives, so it’s not just a question of transition timing. That’s why despite some of my snarky comments that probably have me on the blacklists of some of the big EHR vendors I need to partner with in the future to be successful (hey, nobody said I was really any good at my startup CEO job), we need the incremental next steps along the current path driven by the experienced industry leaders, the established vendors, the standards organizations, and the government funding programs (I’m trying to correct a little, OK?)

In parallel, we also need to allow for the experimentation and disruption that comes from innovative challengers who think that the healthcare emperor’s clothes – which so distinguish him from all the other industries in the kingdom — are increasingly invisible, to the point where we need to question if they’re real.

It’s a tightrope walking act. I find that I regularly fall off the tightrope on one side or the other. Every day I feel the bruises of those falls. Fortunately, as a small early-stage company, the tightrope I’m on isn’t that high off the ground yet, so I can get still brush off the dust and take another step. Forward, I hope.

Brian Weiss is founder of Carebox.

Morning Headlines 2/23/15

$842-million health records project in B.C. faces delays, software dispute

In Canada, leaked documents reveal that a $670 million IBM/Cerner implementation may be heading to arbitration over delays and efficiency issues.

Healthcare Research Firm Toughens Survey Standards as More CIOs Reap the Profits of Reselling Vendor Software

Black Book adjusts its survey methods after discovering that some hospital managers had answered surveys on behalf of end users while at the same time overseeing efforts to resell hosted installs of the EHR to private practices and smaller local hospitals.

Texas Man Charged in $1 Million Fraud Scheme

A Texas man is facing fraud charges after posing as a Cerner representative and then selling an MRI machine to a Dallas-area hospital for $1.3 million.

Monday Morning Update 2/23/15

Top News

In Canada, an IBM/Deloitte-led, $670 million British Columbia Cerner EHR project is delayed with no new timelines announced. Reports say arbitration over a software dispute is a possibility.

Reader Comments

From Jude Lawless: “Re: 23andMe. They’re excited to receive FDA approval to publish ONE new genetic health report. At this pace, I’m not sure what they’re hoping to accomplish for individuals. For researchers, I’m sure that all their genetic information plus all of their surveys are accomplishing a great deal.” The FDA has loosened its rules covering direct-to-consumer carrier screening tests, allowing 23andMe to market its test for Bloom syndrome. It’s a rare condition, but the company makes money based on (a) the number of people who want to find out if they carry it, and (b) the value of selling the genetic data of its opt-in purchasers to drug companies.

HIStalk Announcements and Requests

Poll respondents are evenly split on whether biometric security should be mandatory for protecting PHI. Glen commented that biometric consensus standards are inconsistent, while Clark added that infection control solutions make smart cards and RFID better solutions in clinical areas. New poll to your right or here: why is Epic creating an App Exchange? Click the “Comments” link after voting to explain yourself.

HIStalkapalooza registration has closed and I’ll send out invitations shortly. Every year I get dozens of complaints about the event long before it happens, with these being the most common (and all of which I’ve already heard for 2015):

• “I read HIStalk religiously and didn’t see the signup notice.” I ran the large graphic and notice several times starting January 29 and ending February 18, so anyone who reads HIStalk even casually couldn’t possibly have missed it.
• “My boss is an industry big shot and you can’t turn him away if he shows up uninvited.” I can, and in fact, I will. It’s not that hard for even completely self-absorbed executives to put their name on the list or order some flunky to do it for them. Attendance is nobody’s entitlement.
• “We’re an HIStalk sponsor and didn’t think we had to register our people individually to attend.” I made it clear that every person who wants to attend needs to sign up. The names and emails of the chosen folks populate an Excel worksheet row that is then turned into a badge (and hopefully a door-checked barcodes if I can work that out). I’m still explaining eight years after the first event that this isn’t just a come-one, come-all party – sponsors foot the bill for around $200 per attendee and we can’t just throw open the doors like it’s a fraternity kegger.
• “I’m bringing a guest.” Answer: that’s great if you signed them up and you each receive an invitation.
• “We’re sponsoring the event and will be sending you our attendee list.” This actually isn’t a negative comment – it’s how the sponsorships work. Each company gets a specific number of invitations and they manage those, sending me their worksheets once they’re finished.

Speaking of the HIMSS conference, it was fun having celebrity guests in our microscopic 10×10 booth last year. Contact Lorre if you are famous, notorious, or fun and want to hold court there for an hour.

Last Week’s Most Interesting News

• Shares of Castlight Health dove 31 percent Thursday after an analyst’s downgrade, but rallied almost 10 percent Friday.
• Epic confirms its plans to open an App Exchange for customers and third-party developers.
• Rumors say Apple Watch will be missing several planned monitoring capabilities because they weren’t reliable or would have triggered FDA interest.
• A think tank’s report says the Department of Defense shouldn’t lock itself into a long-term agreement with a commercial EHR vendor, although it also noted the DoD’s hugely expensive and marginally successful efforts at having big contractors develop its current AHLTA system.

Webinars

March 5 (Thursday) 2:00 ET. “Care Team Coordination: How People, Process, and Technology Impact Patient Transitions.” Sponsored by Zynx Health. Presenters: Grant Campbell, MSN, RN, senior director of nursing strategy and informatics, Zynx Health; Siva Subramanian, PhD, senior VP of mobile products, Zynx Health. This webinar will explore the ways in which people, process, and technology influence patient care and how organizations can optimize these areas to enhance communication, increase operational efficiency, and improve care coordination across the continuum.

Acquisitions, Funding, Business, and Stock

CompuGroup Medical acquires South Africa-based practice management vendor Medical EDI Services.

Credit information provider TransUnion plans an $800 million IPO.

Community Health Systems announces Q4 results: revenue up 54.1 percent, adjusted EPS $0.87 vs. $0.30, missing expectations slightly on revenue and meeting on earnings. The for-profit hospital operator’s massive August 2014 data breach wasn’t mentioned in the earnings call.

Sales

St. Luke’s Hospital (MN) chooses perioperative and anesthesia systems from Surgical information Systems.

People

Patrick Hampson (HM3 Partners) joins the board of Canada-based Logibec Group.

MGMA names Halee Fischer-Wright, MD (St. Anthony North Medical Center) as president and CEO. You might think that MGMA would know better than put “Dr.” in front of her name and “MD” after, but you’d be wrong.

Huron Consulting Group names Joe Mauro (Siemens Medical) as managing director in its healthcare practice.

Announcements and Implementations

Black Book modifies its EHR survey methods after finding that some hospitals that provide EHRs to physicians and other hospitals were also completing surveys posing as system users. The company says nearly half of the 800 survey responses it audited from community practices and hospitals of under 100 beds were actually scored by their large-hospital partners, which the company likened to “soliciting a salesman to rate his own merchandise” to boost sales.

In Australia, cancer facility Chris O’Brien Lifehouse goes live with Oneview’s patient engagement solution.

Two Oregon organizations — a behavioral services provider and a health center — exchange patient CCDs via their respective Netsmart and Epic systems.

Employee scheduling software vendor Intrigma launches a free version of its product.

Government and Politics

Kenya’s first lady opens a medical conference by urging medical professions to use IT to solve the continent’s high maternal mortality rate.

Innovation and Research

University of Pittsburgh and UPMC sign a non-exclusive collaboration agreement that will speed up commercialization of medical technologies.

Technology

It’s always annoying to buy a new PC and finding it loaded with bloatware that hardware vendors are paid to install, but Lenovo takes it to another level by pre-installing the hack-prone Superfish adware that not only hijacks search results, but supports a man-in-the-middle attack that can expose all browser-based information to hackers. Lenovo’s CTO starts off with a refreshingly blunt apology (“we messed up badly”) but then ruins it with a bald-faced lie in claiming that the company’s only purpose in pre-installing adware was “to supplement the shopping experience” rather than Lenovo’s income. You can test your laptop here and Lenovo and antivirus makers are providing removal programs. The many forms of crapware that the California-based Superfish is responsible for has earned it $20 million in VC investments. It’s sad when the first thing you have to do after buying a new PC is to reformat the hard drive and reinstall everything to make it usable.

An interesting article on technology in 1.3 million-citizen Estonia brings up interesting points:

• The country’s president is a technology geek, tweeting regularly after honing his skills at expressing himself concisely by writing one sonnet per day.
• Half of Skype’s employees work in the capital of Tallinn.
• The country offers an electronic identity program that citizens use to participate in 3,000 public and private services and to vote in elections, saving an estimated two weeks per citizen each year. It is available to e-residents, in which non-residents can obtain a state-issued, microchip-powered digital identity for digital document signing and transacting business with Estonian firms, or as the government says, “to make life easier by using secure e-services that have been accessible to Estonians for years already … we are moving towards the idea of a country without borders.”
• Estonians sign 50 million documents electronically each year.
• The government has developed a contingency plan to upload its entire digital infrastructure to the cloud if Russia were to invade the country.
• The country created a “maximum coverage, maximum use” 4G broadband policy in giving the winning bidder for the frequency spectrum 21 days to provide country-wide 4G coverage, with the next goal being 300 Mbps LTE-Advanced coverage. 

Other

Federal prosecutors charge a Texas medical technology company owner with impersonating a Cerner employee in selling a $1.3 million MRI machine to Dallas Medical Center (TX) claiming he was representing Cerner. The man was also charged with perjury related to a previous legal case in which he allegedly falsified documents claiming a relationship with Cerner in winning a $25 million judgment against another company for breach of contract, theft of trade secrets, and several other charges. 

Montreal’s Jewish General Hospital urges patients to stay away after a power surge takes its computer systems down.

Healthcare IT Leaders posts a pretty funny “5 Apps We Want to see in the New Epic App Store.” Here are mine:

1. A personalized countdown timer that shows Epic employees how long it will be before they’re old enough to rent a car.
2. A Verona-optimized weather app for Epic educational attendees that in September through May adds 30 degrees to the predicted daytime high.
3. A “Buy Epic Now” button for the health systems that haven’t already implemented Epic, which is all that’s needed since the company doesn’t negotiate prices or contract terms anyway.
4. A real-time map of patient records being exchanged between Epic and non-Epic systems so we can settle this “is Epic interoperable or not?” thing one way or another.
5. A real-time National Debt Clock-type display of how many billions Judy Faulkner is worth.

Sponsor Updates

• Black Book Research names Medicity a top-ranking “Core Private Enterprise HIE Solutions Vendor.”
• Five Versus clients will present on RTLS at HIMSS15.
• Jim Morrow, MD shares his experience with Shareable Ink’s Patient Xpress Solution.
• SRSsoft’s Scott Ciccarelli writes about “Dreams vs. Reality.”
• T-System’s Molly Golson, RN shares “How I Got into Healthcare.”
• Valence Health is featured in a Trustee Magazine article on the role of the attribution process in population health.
• Verisk Health’s Lee Stephenson describes “How Population Health Management Becomes Self-Management.”
• Voalte client Boulder Community Health’s transition to smartphones is featured in the local paper.
• WeiserMazars employees raise over $5,500 for the American Heart Association’s “Go Red for Women” campaign.
• ZeOmega’s Ron Wozny writes about “The Key to Delivering Healthier Babies.”
• Sentry Data Systems outlines seven basic steps to annual 340B FQHC recertification.
• Qpid Health will exhibit at HealthIMPACT East February 27 in New York City.
• PMD’s David Cote advises readers, “Don’t Buy a Porsche if You Want an iPhone.”
• PeriGen will exhibit at the AWHONN California Section Conference February 27-28 in Napa.
• Quest Diagnostics makes Fortune magazine’s list of “Most Admired Companies.”
• Tony Kanaan will pilot the No. 10 NTT Data Chevrolet in this year’s Verizon IndyCar Series.
• Nordic’s Scott Gierman offers advice on how to “Prepare for a Successful Season with EHR Spring Training.”
• The New York eHealth Collaborative will exhibit at the ePharma Summit February 24-26 in New York City.
• Navicure Founder and CEO Jim Denny will speak at a panel during National Health IT Day at the Georgia State Capitol.
• MEA / NEA launches a free website facelift contest for physician practices.
• MedData’s Sean Biehle introduces patient engagement to billing in a new company blog.
• McKesson releases a new case study on “Evidenced-based Care Management across the Continuum.”

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

Readers Write: Big Data / Shmig Data

Big Data / Shmig Data: Thoughtflow 2015 and the Coming Age of Incessant Data
By Samuel R. Bierstock, MD, BSEE

In the years following the Institute of Medicine’s “Crossing the Quality Chasm,” there was widespread acknowledgement that we could do a better job in caring for our patients and a shared belief that the path to accomplishing that task lay in the adoption of clinical information systems. That idea was great, but actual attainment of the goal was hindered by the failure of vendors and designers of electronic clinical information systems to fully understand the full vantage point of their target end users. Clinicians simply resisted the structured workflows that designers assumed would make for acceptance. There followed more than a decade of physician resistance, dismal adoption rates, and billions of dollars spent in implementation efforts to encourage clinician utilization of EHRs.

It was not the long anticipation of the attrition of aging computer-resistant retiring physicians, nor was it their replacement by tech-savvy young doctors that caused the uptick in the number of clinicians using electronic health records (EHRs). It took the good-old US government and the mandates of Meaningful Use to do that.

Unfortunately, neither can the increased adoption of EHRs by physicians be attributed to a better job in the design of clinical workflow processes by vendors. In fact, if anything, the financial pressures on hospitals fearing loss of Meaningful Use dollars and associated penalties resulted in pressure being exerted on physicians to use whatever hospital EHR systems were in place in spite of negative impact on clinical efficiencies and the ability of physicians to get their work done. As a result, we embarked upon and remain in a period of administrative / medical staff friction wherein hospital administrators need their medical staffs to be using their EHRs while many physicians feel impeded in simply getting their work done and view hospital pressure as purely financially motivated.

In 2003, I first described what I felt was the missing essential ingredient to physician adoption of EHRs. The widely heralded and sought-after workflow support was not the answer. Workflow is a mechanical approach to a goal or task – “do this, then do that” and “click here, then click there.” It seemed clear to me that what needed to be supported was not workflow, but Thoughtflow, a concept I defined as the process by which a clinician identifies, accesses, prioritizes, and acts upon data and information.

In 2006, my article entitled “Thoughtflow — The Essential Ingredient for Physician Adoption of Implemented Technologies: Why Clinicians Have Still Not Adopted Clinical Technology and Where Vendors and Clinical Leadership have had it All Wrong” received a very widespread and supportive response. While a great many changes in EHR design could have helped support Thoughtflow, they were slow in coming and for the most part inadequately based on a true understanding of what it is like to practice medicine. A decade later, they remain essentially missing.

Are more physicians using EHRs today? Yes. Do they find that EHRs make their lives easier or their professional work more efficient? Clearly, no.

Emergency rooms represent the ultimate environment for needed efficiencies in the delivery of care. Emergency rooms with EHRs in use have an average of 35 to 40 percent drop in physician efficiency and up to 40 percent increase in the number of patients who leave without being seen due to long waiting room times.

The 2013 KLAS report showed that the largest EHR hospital vendor is consistently rated in last place on virtually all parameters of clinical efficiency by physician users.

While I think it can be said that vendors have failed to recognize the need to support Thoughtflow and to build in creative feature functionality to truly support the way clinicians think and act, in fairness it must be pointed out that technologies essential to success in this regard have simply not been available. Today however, they are.

• Voice recognition software has steadily improved with respect to both accuracy and reliability.
• Language processing tied to vocabulary standards and ICD-9 / 10 coding and increasingly accurate optical character recognition allow for ever-improving accurate extraction of structured data from unstructured data in a variety of formats (dictated notes, PDF documents, etc.)
• Increasingly maturing clinical decision support systems that are integrated into clinical documentation systems can be linked directly to order sets and treatment protocols – effectively presenting clinicians with what they need to choose from, refine, and work from.

In short, the technology exists to anticipate the needs of the clinician quite literally from the spoken word to suggested action. Coupled with innovative and creative designs, capabilities such as these can minimize the age-old pariahs of EHRs — the number of required clicks and the amount of multiple-screen navigation required to accomplish both simple and complex tasks.

Aside from these issues regarding EHRs, it is obvious that the healthcare industry is about to be revolutionized by wearable, implantable, and digestible devices resultant from the exponentially explosive micro and nanotechnology world. Literally, devices appear every six months that were inconceivable only six months previously. Examples are too numerous to list, but consider Intelligent pill bottles that report if medication has been taken, watches that can produce a full six-lead EKG from one point of contact with the skin, shirts and vests that measure and report the amount of fluid in the lungs, cell phone apps that create and display ultrasound images and even X-rays, necklaces and bracelets that report sleep and ambulatory patterns, vital signs, falls, position — and on and on. The vast majority of these are applicable to ambulatory people, the elderly requiring remote monitoring for hypertension, cardiovascular disease, and diabetes.

Hospitals need this data to mitigate against the risk of readmission. HIE, ACOs, and population management entities need this data for trend analysis, quality of care assessment, and predictive analytics. Clinicians need this data to track their patients’ progress and intervene as required.

The concept of big data is about to appear minuscule compared to the barrage of data we are about to be capable of capturing. We are not talking about big data. We are talking about incessant data.

The data must be delivered in a way that enhances care by those responsible. The last thing an internist wants is 24-7 data pouring in with the blood sugar levels of all of his or her diabetic patients. The data is going to have be in standardized format and integrated with the EHR in use in a fashion that it is properly absorbed into the patient record, run through appropriate knowledge engine algorithms, and delivered in a useful fashion only if caregiver awareness is of essential importance or an action is required. It must support Thoughtflow so that it can be efficiently applied to and enhance workflow patterns — not congest them and thereby diminish efficiencies and make clinicians’ lives harder in getting their work done.

There is also to consider the additional data that is going to hit servers as we get better and better at extracting structured data from unstructured data (PDF documents, dictated documents, free text documentation, and eventually handwritten notes).

And let’s not forget the data coming from the increasingly popular use of micro- and nano-technological wearable devices used by the healthy and sports-minded population. Most or all of this data is on the servers of the companies selling heart monitoring watches, intelligent sneakers, devices that count steps, report posture, and record sleep and wake patterns. Eventually I believe this data will be important to population managers in retrospect, in real time and for predictive analytics, and also available to clinicians in the same manner and with the same challenges accompanying data related to active disease and health problems.

All of this data has to be delivered in a way that enhances Thoughtflow or it will become a barrage of information to be sorted through and further compromise the efficiencies of caregivers, care delivery entities, quality assessors, payers, and analytic models.

As monolithic, stagnant EHRs that dominate the healthcare market remain encased in mechanical workflows, innovative EHRs will have to maximally utilize evolving technologies to support clinical Thoughtflow if we are going to be able to derive maximal benefit from the coming exponentially explosive amount of incessant data.

Sam Bierstock, MD, BSEE is the founder of Champions in Healthcare. The term “Thoughtflow” as applied in healthcare is a registered trademark with all rights for commercial use reserved by the owner.

HIStalk Interviews Mike Jefferies, VP/IS, Longmont United Hospital

Michael Jefferies is vice president of information systems at Longmont United Hospital of Longmont, CO.

Tell me about yourself and the hospital.

I started off as an intern way back when with McKesson. I started with their support center, answering the phones and doing support tickets. That grew into doing technical administration work. I had my roots in technical work and then grew into business leadership and started doing some outsourcing and consulting work with ACS Xerox. From there, I felt strongly that I’d like to get closer to the delivery of care.

T hat’s how I found myself at Longmont United Hospital. The hospital is a 201-bed facility. It’s a community, not-for-profit hospital Longmont, Colorado, which is in Boulder County.

As someone who previously worked for McKesson and is now a Horizon customer, how has the company handled the Horizon product and trying to get its users to migrate to Paragon?

I have a lot of respect for McKesson as an organization. I got my start there and they have some wonderful people working there. The Horizon product got its start as a startup in Boulder. It was a great product to start. It grew organically in some great ways.

As McKesson rushed to be first to market with a comprehensive, integrated solution, they used an acquisition strategy, which led to not achieving that goal of having an integrated product. While they were first to market, they came to the conclusion with their Better Health 2020 announcement that the acquisition strategy created technical, geographic, and personnel challenges. Making an integrated product through an acquisition strategy was not a feasible way to go about it. That was unfortunate because it was a product that early on had great promise.

I would agree with their decision that they’ve made in Better Health 2020. It was no longer an integrated solution. They were right to shift their strategy towards an integrated solution.

I’ve had the fortune of being a product manager and leading the implementation of the Paragon solution, It was a KLAS market leader for smaller community hospitals. They had good satisfaction. For a lot of customers, it was their first EMR.

The idea of trying to get folks that were Horizon customers with higher expectations to move to the Paragon product was premature. It was something that most of the customers did not see as a feasible solution or alternative. That’s what you’ve seen. The vast majority of Horizon customers have gone elsewhere.

The other thing working against Paragon is that the healthcare market, due to other forces, needs economy of scale. You’ve seen a huge consolidation in healthcare. That consolidation has favored EMRs that can handle a large scale, which in our market means Cerner and Epic. When a larger organization consolidates smaller hospitals and organizations, they certainly aren’t going to uptake that smaller community EMR. They’re going to continue to deploy Cerner and Epic. That has contributed to their market dominance.

Do Paragon and Meditech have significant problems that would prevent them from being successful in large academic medical centers?

Yes. Paragon right now doesn’t have an ambulatory solution, so people that are making the jump to Paragon right now are putting faith into that product developing into a comprehensive solution. Their ED product is brand new and their ambulatory product does not exist yet. That’s a major limitation for Paragon right there.

With Meditech, they’ve made some great changes in strategy recently. They’re very strong in the market. But a colleague accurately described Meditech as, “The EMR that your materials management department would choose.” It hits all the checkboxes on everything you need, but when it comes to the end user experience, there’s something wanting there. They’re a great organization, they fill a market niche that is needed, and they are moving in the right direction with listening to their customers. They have a lot of great really satisfied customers as well.

Will Athenahealth be able to compete with Cerner and Epic via its RazorInsights and BIDMC WebOMR acquisitions?

I would love to see that. Athenahealth’s approach to the private practice or ambulatory market has been that customers want to be health providers, not IT organizations. We’re not in the IT business, we’re in the healthcare business, and I think Athenahealth supports that. Their fundamental makeup gives them the chance to make a run for it. Now if they’re actually going to be successful — that’s yet to be seen. I would love to see a different competitor come in because we know that while Cerner and Epic are dominating the market, they each have their own blights as well.

What are the most important initiatives that you see happening in your hospital over the next several years?

One thing that’s come to the forefront has been IT security. This is one that I’m pleased to see has gotten traction, but all of us in healthcare IT have very suddenly gotten large targets drawn on our backs and we need to move quickly. When I see the percentage of organizations out there that don’t have liability insurance for IT, that’s concerning. 

It’s also concerning that a lot of the security incidents that have been reported are around theft or loss. It’s really under-reported because a lot of people don’t know that their systems have been breached. There’s an ignorance factor there as well. As we ramp up that, that’s going to be a major IT initiative — protecting our borders and raising our awareness around protecting our information. I was pleased to see that appear in the State of the Union address.

My other personal belief is that IT security — not just in healthcare, but in all industries — needs to start being addressed as a governmental issue. We have national security protecting our borders. We have a lot of protections out there. Our local municipalities have firemen and policemen. Yet hospitals essentially have to put guards at their doors and bars on their windows when it comes to IT security. We’re on our own to defend ourselves. Something that’s as critical to the US infrastructure as healthcare, financial, and other industries needs to be a larger governmental conversation.

Other than security, we’re looking at the desktop experience for our users. Having a greater awareness and a better experience for those users, especially the clinical users, to be able to roam from PC to PC and carry their session. We were an early adopter of something called Symantec Workspace Corporate and we’re now moving to an Imprivata and VMware combination solution. We’re going to be focusing on improving that end user experience with regards to speed, with regards to single sign-on, and maintaining security while making it easy for the user to carry their session throughout the hospital and for that delivery to be seamless. That also comes into location awareness and the other technologies that can be ahead.

The other item that we’re doing is working with Hill-Rom, which also comes into location awareness with our nurses. For tracking what they’re doing, but also giving them greater communication tools and greater meaningful alerts with some of the smart beds. That’s been an important strategy for us as well.

Integration between nurse call systems and IT systems for clinical alert management, communications, bed status reporting, and patient education has been a quiet change. How will that play out as bed manufacturers move into IT and the IT side of the house has the technology they need?

It’s fascinating that the bed management people are trying to figure it out. I had the pleasure of being in a focus group at the last CHIME conference with Hill-Rom. What I understood from them is they’re trying to figure out where there’s going to be overlap and not overextend their business where they’re not going to be welcome or where they’re not going to be able to make progress. 

Longmont United Hospital has been a market leader in throughput and bed management and visibility solutions. We use what I’d call a command center in our shift manager office that has a view of every unit of the hospital. At a glance, you can see the occupancy of every single one of those beds. Over the next year, that will tie into our smart beds that will be connected. You’ll be able to know whether or not the patient is in the room.

It’s also tied into our CPOE system. When new orders are placed on the units, monitors show a map of the unit and there will be an alert showing that there’s new orders on the patient. Or perhaps it would show an alert that this patient is a fall risk or some other identifier for that patient without violating their privacy.

This has been an amazing success for us. It has reached every corner of the hospital. Our environmental services team is using this system where the beds get marked as no longer occupied to quickly identify that the beds are in need of cleaning. During busy periods of time, we can then quickly get patients from the ED into beds. We’re seeing an increased throughput and increased patient satisfaction. It integrates into our EMR. That visibility system has displays on all the units that our environmental services team looks at. if someone in a room has C. Diff, there will be a flag for the environmental services team so they know to use special cleaning precautions for that room. Through that simple alert, we’ve eradicated C. Diff as a hospital-acquired condition here at LUH.

With the smart beds, when a rail drops and a patient is a fall risk, you can have an alert that’s appropriate go to the nurse. We’re seeing a lot of opportunity. We’re also seeing a lot of overlap.

It will be interesting to see where the EMR vendors end and where those bed manufacturers like Hill-Rom and Stryker end. The bed manufacturers are trying to figure that out themselves because they have a lot of great technology that can be helpful, but I think they also know that they might not be welcomed into some markets that the EMR vendors own.

Tell me about your palm vein scanning project.

We were looking at how to improve the patient check-in experience. We started exploring kiosks similar to the airline check-in. From there, it evolved into how we would identify the patients as they checked in.

We started exploring the ability to use palm vein scanning technology as a biometric to identify patients. It uses near infrared light to looks at the vein pattern within your palm, which is 100 times more unique to an individual than a fingerprint. It also doesn’t have that criminology sort of connotation that some people associate with fingerprinting, so it has a higher patient adoption rate.

That palm vein pattern is developed in the womb and it’s even unique between twins. It’s a really unique and useful biometric that has high adoption rates among patients where you might not get it because a retina scan is pretty uncomfortable and fingerprinting has the criminology connotation. With palm vein scanning, you can get better adoption.

We’ve rolled that out where the patients need to initially enroll in the program. They go through the normal registration process, provide a form of identification, and then place their palm down onto the scanner. It’s a very simple process. That biometric is saved, so from then on when they put their palm down, we know who they are.

We no longer need to ask them sensitive information. The next time they come in, they have a better experience, because by just simply placing their palm down, they can avoid having to share sensitive information that can be within the earshot of someone else. They don’t have to show their ID every time.

The other places I’ve seen this technology used has been in test-taking, like the GMAT and the SAT, so that when people leave to go the restroom and come back, that they’re not switching for someone else to take their test. It’s also used in some other countries in banking. But I think the use in healthcare has extremely great promise. 

Now that we have people enrolled, we’ll be able to use that as the identifier in the kiosks. In the next few months, we’re going to be installing these kiosks so that when patients come to check in at our hospital, they can simply put down their palm on the kiosk and then immediately be identified. It will ask them for some of their information to verify that it is accurate. If there are updates, they can correct that with the registrar. It will also know if they have a payment due — they can quickly swipe their credit card and we can accept payment there, which makes that more convenient for the patient as well. The purpose here is around improving the patient experience.

The other benefit is something that plagues hospitals and health systems nationally — duplicated and overlaid medical records. We spend a lot of time merging records because of minor differences when they come in. In large metropolitan areas, it is quite common that you have people with the same name and the same birthday whose medical records might be accidentally shared. That can be extremely dangerous since you have clinicians that are making medical decisions for those patients potentially based on someone else’s medical history.

Morning Headlines 2/20/15

Most Admired 2015

Fortune Magazine names Cerner to its 2015 Most Admired Companies list.

Castlight Health Announces Fourth Quarter and Full Year 2014 Results

Castlight Health announces Q4 and 2014 year end results: Revenue for 2014 closed out at $45.6 million, a 252 percent increase over 2013, but still resulting in an overall $86.2 million operating loss, EPS -$1.16 vs. -$6.28. Stock prices dropped 31 percent Thursday following an analyst’s downgrade.

Oregon Sues Oracle Over Health Insurance Site

Oregon has filed another lawsuit against Oracle, seeking to bar the company from doing business in the state, over claims that Oracle is preparing to pull the plug on hosting Oregon’s state insurance exchange.

U.S. FDA approves 23andMe’s genetic screening test for rare disorder

After a long regulatory battle with the FDA, genetic testing service provider 23andMe earns regulatory approval to market its personal genome testing service. The company is only approved to test for a genetic mutation associated with Bloom syndrome, a rare disorder that leads to an increased risk of cancer.

EPtalk by Dr. Jayne 2/19/15

We always love hearing about ways that vendors are contributing to the greater good. I was excited to receive a Valentine’s Day card from our sponsor Medicomp Systems, who offered to donate $10 to Doctors Without Borders for each person who views a brief demo of Quippe. It was supposed to end this week, but the executive team generously agreed to extend it a few more days for HIStalk readers. They’re willing to donate up to $5,000, so stop by to do your part for Doctors Without Borders. You’ll also be able to pre-register to compete in their Quipstar game show during HIMSS. I was a celebrity contestant in 2013, so I can attest that it’s a lot of fun.

The Texas Regional HIMSS Conference is taking place this week in Austin. Thursday’s keynote was Ed Marx, speaking on, “Extraordinary Tales From A Rather Ordinary Guy.” Other topics included screening for emerging diseases, interoperability, population health management, health literacy, and of course Meaningful Use. Texas has a reputation for hospitality, but one of my readers was not impressed when another attendee made snarky comments about the fact that she was taking notes during the meeting, asking, “Did you get all your work done?”

Wednesday was National Drink Wine Day, which reminds me of an EHR story a friend shared with me. During a trip to the emergency department, she was asked about her alcohol intake. Do you drink alcohol? Yes. How often – once a day or socially? Yes. She was told she had to pick one or the other. As a clinician, I always wondered what documenting “socially” really tells me about a patient. Does that mean they have drinks once a year at the company Christmas party or twice a week in the stands at their kids’ baseball games? Are they socializing at the bar every night after work? It just goes to illustrate that data collected for the sake of collecting data (and without valid clinical intent) is not only a poor use of scarce time, but meaningless.

There are plenty of phishing scams riding the coattails of the recent Anthem breach, but they’re a drop in the bucket compared to the daily deluge of random emails trying to grab our attention. I am always amused by people trying to get content on HIStalk when they clearly don’t read it. One of yesterday’s offerings tried to convince us that we need guest bloggers to keep up a constant flow of content so that we can relax. There were also a handful of emails that were barely coherent and those are just the ones that made it through the spam filter. I recently read “The 4-Hour Workweek” and the idea of having someone to pre-screen my email is more appealing every day.

Speaking of email, my EHR vendor sent a nice one this week about the recent CMS approval for lung cancer screening using low-dose CT scanning. What would have been even nicer would have been instructions on the best way to identify and track impacted patients since they have to be in a certain age group, have smoked a certain amount, and must be either current smokers or have quit within the last 15 years.

Even as a member of the HIStalk team, I can’t possibly keep up with all the health IT news out there. HIStalk Practice mentioned a study at Michigan State University. It looks at using children’s fingerprints to track immunization records. Comments on the article immediately seized on it as a way for the government to force individuals to provide their fingerprints. The article reminded me of VeriChip, which was similar to the computer chips many of us use to permanently identify our pets. Reading the article about its FDA approval in 2004 was a blast from the past as it referenced then-President Bush’s EHR initiative. It also mentioned the disparities in animal vs. human medicine, noting that implantation for a pet would have been $50 but for a person it would have been $150 to $200.

Jenn also told me about a review on physician dress done by a team at University of Michigan Health System. The team performed a comprehensive review of studies on physician dress, looking at 30 studies involving more than 11,000 patients in 14 countries. They confirmed what many of us suspected: that older patients prefer their physicians to be more formally dressed, where members of Generation X and Y were more accepting of casual attire. There were some differences in preference depending on physician specialty. The team plans to conduct their own study, “Targeting Attire to Improve Likelihood of Rapport” or TAILOR. Hospitals in three countries have already agreed to participate. My new clinical posting involves monogrammed scrubs, so I might just spring for a new pair of clogs to match.

With this winter’s seemingly-perpetual cold and abundant snow, I’ve been tending to warm, non-skid footwear. But with the promise of spring around the corner, a reader shared these smart little shoes. “There’s No Data Like Home” by artist Steven Rodrig definitely lifts my spirits, appealing to both my fashion sense and techie tendencies.

What warms your heart with thoughts of spring? Email me.

Email Dr. Jayne.

News 2/20/15

Top News

Epic will launch App Exchange, which will publish Epic-compatible software developed by both customers and vendors, in the next few weeks.

Reader Comments

From Pima Pundit: “Re: Cerner. Saw this on the wall of a Carondelet Health Network office. They’re moving from Greenway Intergy to Cerner.”

From CC Ryder: “Re: Skycare. We implemented their EHR in 2014 to meet Meaningful Use requirements but found out today that the company has ceased operations. They told us that all employees were let go Friday and no further support is available. I’m the EHR champion at our small family practice and could use help understanding how to switch EHRs and any advice on what will happen for our 2015 attestation year.” I will forward information from anyone who can help.

HIStalk Announcements and Requests

This week on HIStalk Practice: Walmart mulls over mobile and telehealth. Laguna Beach Community Clinic and Village Family Practice implement new HIT. A new study finds that the cost of ICD-10 conversion for a small practice is just over $8,000. EHR company adds some robotic sizzle to its 5K. SHIN-NY’s connection costs hamper physician participation. University of Miami Pediatric Mobile Clinic implements new telemedicine IT. Dr. Gregg shares this year’s collection of “Top 10 Dubious HIT Bumper Stickers.” Thanks for reading.

This week on HIStalk Connect: A systematic review of patient portal studies finds few correlations with improved outcomes. Walgreens partners with PatientsLikeMe to embed crowdsourced feedback on medication side effects on its health app. Breakout Labs welcomes its next three startups, all focused on healthcare research. HIStalk Connect interviews Aterica CEO Alex Leyn, founder of a digital health startup building smartphone-connected EpiPen cases.

@JennHIStalk joined Eric Topol, MD and Geeta Nayyar, MD, MBA in a Xerox-sponsored Google Hangout covering patient engagement.

I was helping a friend find a primary care provider for her new UnitedHealth insurance obtained via Healthcare gov. My suggestions, based on having worked in hospitals for nearly forever, was to look for a doctor with these criteria: (a) educated at a decent US-based medical school and reasonably good residency; (b) board certified in internal or family medicine; (c) graduated from medical school no more than 25 years ago since studies seem to show that mortality rates increase with each year after a doctor’s graduation. Extra points for good Healthgrades reviews and an affiliation with a good hospital. We called one doctor and group after another and the answer was always the same – not a single physician who met these criteria is accepting new patients. Nearly every available doctor graduated from a foreign medical school, while some were old enough to make you realize how hard it is to retire from primary care (one graduated from medical school in 1961, which must put him in his late 70s). UnitedHealth’s online provider directory incorrectly listed many doctors as accepting new patients when in fact they aren’t, making for a frustrating couple of hours of calls and web searches figuring out how to make undesirable compromises despite having a top-of-the-line medical plan. I’m beginning to realize that while it’s challenging to find and afford medical insurance, the battle isn’t won once you do.

Webinars

March 5 (Thursday) 2:00 ET. “Care Team Coordination: How People, Process, and Technology Impact Patient Transitions.” Sponsored by Zynx Health. Presenters: Grant Campbell, MSN, RN, senior director of nursing strategy and informatics, Zynx Health; Siva Subramanian, PhD, senior VP of mobile products, Zynx Health. This webinar will explore the ways in which people, process, and technology influence patient care and how organizations can optimize these areas to enhance communication, increase operational efficiency, and improve care coordination across the continuum.

Acquisitions, Funding, Business, and Stock

Castlight Health reports Q4 results: revenue up 182 percent, adjusted EPS –$0.17 vs. –$1.79, beating estimates for both. Shares dropped 31 percent Thursday following an analyst’s downgrade, dropping the company’s market capitalization to $591 million. Above is the share price chart of CSLT since its March 2014 IPO (blue, down 84 percent) vs. the Dow (red, up 12 percent).

The Wall Street Journal names as one of its 73 startups valued at more than $1 billion Proteus Digital, whose smart prescription pills report back to doctors and drug companies when patients take their medicine. 

Fortune places Cerner among its “World’s Most Admired Companies 2015.”

Sales

Mission Health (NC) chooses Qlik for enterprise-wide visual analytics.

People

Park Place International names Bob Green (EMC) as VP.

Anthony Lancia (TriZetto) joins ClaimRemedi as VP of sales.

Announcements and Implementations

University of Missouri-Kansas City’s Center for Health Insights and Truman Medical Center (MO) will conduct research using de-identified patient data provided by Cerner. The company’s Health Facts Reporting extracts and de-identifies information from its customer databases that sells to drug companies as “the industry’s only data source offering a comprehensive clinical record, with pharmacy, laboratory, admission, and billing data from all patient care locations time-stamped and sequenced.”

ZeOmega launches a maternity management offering for its Jiva population health management solution.

Government and Politics

Oregon sues Oracle and seeks to permanently bar the company from doing business with the state, claiming Oracle reneged on its promise to continue running the state’s Medicaid enrollment system and instead plans to shut the system down at the end of February. Oracle says it made no such promise and the state should have developed a contingency plan, adding that Oregon defamed the company in saying its system isn’t working, then claiming that same system is essential. The state previously sued Oracle over its failed health insurance exchange.

Privacy and Security

A “CBS Evening News” segment quotes a security expert who says, “Digitized health records are jet fuel for medical identity theft. The healthcare system built a digital record system without building the corresponding privacy-security safeguards.” It points out that HHS has audited only 115 of 700,000 healthcare providers.

NPR’s “All Things Considered” finds Medicare IDs being openly sold on the Internet, with a set of 10 costing $4,700. An expert says healthcare providers have grown to the point they often don’t even know how large their networks are, much less that those networks are secure. A comments says it’s surprising that many providers don’t realize that a Medicare number is just a Social Security number with the letter “A” at the end, while another says she opted out of her physician’s patient portal because the consent form said the company running it isn’t responsible for hacking or even if its own employees steal patient information.

I Googled how Medicare numbers are created and the comment above is correct: CMS came up with the idea of placing SSNs on cards that 50 million people carry in their pockets, claiming that it would cost nearly a billion dollars to reprogram its systems to use a different ID. GAO wasn’t buying CMS’s excuses, saying it should have considered options to print only the last four SSN digits on the cards or to switch to barcodes or magnetic stripes.

Technology

Automated Assembly Corporation will market its InfoSkin near field communication (NFC) skin stickers to the healthcare industry. NFC allows a smartphone app to communicate with an inexpensive RFID-like tag over distances of a few inches, most commonly to make payments but with potential for identifying patients and communicating with implanted medical devices.

Other

Chuck Feeney donates another $100 million to UCSF — part of the money earmarked for hospital construction and aging research — raising his total donations to the school to nearly $400 million. The 83-year-old billionaire philanthropist made his money running duty-free shops. Reports say he’s frugal: he doesn’t own a house, uses public transportation instead of owning a car, flies coach, and wears a $15 watch. His motto: “If you want to give it away, think about giving it away while you are alive because you’ll get a lot more satisfaction than if you wait until you’re dead. Besides, it’s a lot more fun.”

Rice University and the Baylor College of Medicine offer a free, four-week online course called “Medicine in the Digital Age” that begins on May 5.

A Forbes article about chief innovation officers says they have 16 months to shake things up radically or risk being fired, providing as an example an unnamed health system CINO who lasted less than three years because he played it safe by choosing board-pleasing, low-impact projects.

Sponsor Updates

• Greenway Health signs a strategic referral agreement with Orion Health.
• Park Place International launches a Meditech disk defragmentation solution.
• NextGen releases the results of its practice revenue cycle management survey, which finds that practices are faring poorly at managing denials and that 35 percent of incoming patient calls involve billing issues.
• Caradigm announces a solution package to support DSRIP participation.
• PatientSafe Solutions President and CEO Joe Condurso posts “Reimbursement Continues to Drive Strategy.”
• Iatric systems integrates its Security Audit Manager with incident response software from ID Experts.
• Orion Health is ranked as the top “Government Payer and Commercial Insurer HIE” vendor and is a second-place finisher in “Core HIE Systems Enterprise Centric Solutions” in a Black Book Rankings report.
• Logicworks points out that “Healthcare’s New ‘Anthem’ is Encryption, but Not Everyone Sings from the Same Hymnal.”
• Intelligent Medical Objects will exhibit at Hack Illinois February 27-March 1 in Urbana, IL.
• InterSystems talks with Dave deBronkart (“e-Patient Dave”) in its latest blog, “Seeding the Growth of Patient Engagement Through Innovative Interoperability.”
• InstaMed will present at the World Health Care Congress on February 26 in Orlando.
• Annie Meurer of Impact Advisors focuses on telehealth in the second part of the company’s blog series on unified communications.
• Extension Healthcare and Holon Solutions are exhibiting this week at the 2015 Texas Regional HIMSS Conference in Austin. 
• Healthwise will exhibit at Preventive Medicine 2015 on February 25 in Atlanta.
• Hayes Management Consulting’s Paul Fox offers “4 Ways to Improve Your End User Systems Testing.”
• Max Stroud of Galen Healthcare Solutions asks “Are Electronic Notes a Pain Point for Your Physicians?”
• DocuSign focuses on the Internet of Things in its latest blog.
• The HCI Group offers “Best Practices to Achieving HIMSS Stage 7.”

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

Morning Headlines 2/19/15

Epic Systems to open its own app exchange

A local Madison paper reports that Epic is about to launch an app store that let customers buy apps from third-party developers that integrate with the core EHR system.

Number of the Day: 11.4 Million

The Obama administration announces that 11.4 million consumers have signed up for health insurance through the state and federal marketplaces, of which 6.7 million were automatically re-enrolled from last year.

Cutting the Gordian Helix — Regulating Genomic Testing in the Era of Precision Medicine

Eric Lader, PhD., MIT professor and principal leader of the Human Genome Project, publishes an article in the New England Journal of Medicine discussing the need for tighter regulatory oversight on personalized medicine recommendations coming from genetic testing.

Another Study Shows ACC/AHA Risk Calculator Overestimates CVD Events

Four out of five cardiovascular risk-prediction algorithms, including the new ACC/AHA risk calculators, have been found to overestimate the risk of a cardiovascular event. The 2013 ACC/AHA risk calculator overestimated risk of cardiac-related deaths by 86 percent for men and 67 percent for women.

Morning Headlines 2/18/15

ObamaCare’s Electronic-Records Debacle

Jeffrey Singer, MD writes an op-ed in the Wall Street Journal lambasting the Republican party for focusing solely on repealing Obamacare, and not also targeting the repeal of the HITECH Act, explaining “electronic health records have harmed my practice and my patients.”

Syracuse hospital loses $21.6 million, wants to join big health system

After losing $22 million in 2014, largely to one-time Epic implementation costs, St Joseph’s Hospital (NY) is exploring a merger with a larger hospital network, likely Trinity which St. Joe’s has an existing relationship with.

Duke University alum and former offensive lineman is helping college players across the nation keep up with demanding schedules

Duke University rolls out new software for football recruits designed to organize their schedules, remind them of doctors appointments, track their performance, and store their medical records. Duke reports the system saved the university $244,305 in materials and employee hours over a six-month period, a 345 percent return on investment.

What Exactly Is an Apple Watch For?

The Wall Street Journal covers some of the last minute design sacrifices Apple made before unveiling the Apple Watch, including scrapped plans for blood pressure monitoring and stress level monitoring.