Readers Write: Leveraging Technology to Create Payer-Provider Collaboration

Leveraging Technology to Create Payer-Provider Collaboration
By Andrew Underhill

Although providers and payers play a critical role in elevating US healthcare, these two entities have not traditionally worked collaboratively, especially when it comes to sharing information. Up to this point, the two groups have shied away from exchanging data, with providers holding on to patient clinical information and payers protecting patient financial information. However, the walls are slowly but surely coming down as more providers and payers begin to partner in delivering accountable care.

There are both operational and patient care benefits to smoother provider-payer information exchange. For example, when providers are given access to claims data, they are able to garner a more longitudinal perspective of the patient’s health and treatment to date. This enables more informed care decisions and also reduces the likelihood of duplicative or unnecessary tests. It also limits the reliance on patient memory and perspective, ensuring care decisions are based on facts rather than educated guesses.

On the payer side, having access to clinical data allows the organization to adjudicate claims more effectively, improving efficiency and ensuring the most appropriate care for members. Clinical data also helps payers proactively manage their members’ care rather than responding to issues after the fact.

Despite the advantages, there are some significant roadblocks to payer-provider information exchange. Although some would suggest technology shortfalls have been the primary hurdle, it is the business barriers that present the greater obstacle. Providers in particular have been hesitant to share data with payers because it includes competitive and pricing information they would prefer to keep internal. Moreover, some physicians are concerned that making this kind of data available to payers may open the physician up to criticism on how he or she treated the patient.

To reap the benefits of information exchange while still acknowledging provider and payer qualms, organizations should take a well-considered approach to any data sharing arrangements. Following are a few tips to ensure these agreements meet all parties’ goals.

• Appoint an advocate. To truly realize provider-payer data exchange, organizations must have an advocate who will push the idea forward and raise awareness of the strategic, financial and patient care benefits.
• Develop a strategic roadmap. The advocate should work closely with organization leadership to identify the business drivers for data exchange and craft a strategic plan to lay the cultural and operational groundwork. Basically, this plan should be a roadmap that underscores the importance of provider-payer information sharing and defines how to achieve success.
• Establish trading partner agreements. Before actually exchanging information, providers and payers must set up trading partner agreements that define the types of data to be shared, the appropriate data-sharing standards, and how the data will be used. This should be a customized agreement that reflects the unique needs and characteristics of the institutions involved. By setting the parameters upfront, both parties can be confident any data exchange will meet their needs and not violate internal strategic goals.
• Define an exchange framework. Once organizations have a forward path, they can search out solutions to enable seamless information sharing. Providers and payers may want to consider using health information exchanges—such as those provided by the state or a local entity—to securely share data. A commercial product that facilitates payer-provider information exchange can also be a good option.

Greater transparency will ultimately drive better healthcare, and a key to transparency is robust data exchange between providers and payers. Organizations that embrace this idea now can be on the forefront of collaborative care, improving the patient experience and driving better health outcomes.

Andrew Underhill is a chief technologist at Systems Made Simple of Syracuse, NY.

Morning Headlines 1/5/15

Analytics-based U.S. tech firm Inovalon files for IPO

Inovalon Holdings, a data analytics vendor focused on healthcare, files a $500 million IPO.

Blue Cross starts health system payouts for value-based contracts

In Michigan, Blue Cross Blue Shield pays out $25 million to five hospitals that signed value-based reimbursement contracts in 2011 and 2012.

Wilmington doctor waits for NC Tracks payment

Physicians in North Carolina file a law suit against the state’s Department of Health and Human Services over billing issues that they claim led to doctors being paid lower Medicaid rates for services provided to Medicare patients. The payment problem stems from a custom software system developed by CSC at a cost of $484 million. The state DHHS has filed to dismiss the suit and refuses to acknowledge that there is a problem.

Adviser Guides Obama Into the Google Age

The New York Times profiles Megan Smith, the new White House chief technology officer, and her transition from a Google executive to a federal employee, where she now carries a BlackBerry and supports information systems that still partially rely on floppy disks.

Monday Morning Update 1/5/15

Top News

Healthcare analytics vendor Inovalon Holdings (known until a 2012 name change as MedAssurant) files for a $500 million IPO. The CEO and board chair is cardiologist Keith Dunleavy, MD. The company’s technology is used by NextGen, Greenway, Allscripts, and Walgreens.  

Reader Comments

From KimJongDeux: “Re: Athenahealth. Interesting that Jonathan was the much celebrated, drunk, foul-mouthed (and most un-funny) host of HIStalkapalooza for a few years and the article above seems to indicate the bloom is off the rose. Guess he’s not on the program this year? We seem to have a company run by force of personality. The quote, ‘Those naysayers don’t understand the company’s business model’ is the same cry as we hear from self-styled ‘artists’ when their works are panned and from CEOs who either get no push back from their yes-men staffs or who weeds out or banishes anyone who disagrees. The fact that their corporate meeting involves officially sanctioned heavy drinking games tells me all I need to know. And the fact that the CEO openly supports it as a good thing is troublesome. I agree that if the force of personality ever left, the company would fold like a house of cards. Being brash, loud, and verbally overpowering others can keep the airplane aloft only so long.” The company has a new logo and website, I’ve noticed, moving away from the squint-inducing yellow and green color scheme to a more serious-looking purple and green.

From PM_from_Haities: “Re: Epic’s going public. It would have very little effect. The capital structure of a company (i.e. going from private to public) impacts who owns Epic, but it’s leadership would likely be unchanged. Given Judy has plenty of cash, it would make very little sense for her to add that kind of public scrutiny unless it helped in gaining government contracts. Epic would continue to deliver on its promises and continue to grow. If anything, Epic might get BETTER by being publicly traded as they would typically have a stronger marketing department.”

HIStalk Announcements and Requests

One-fourth of respondents to my poll expressed a positive impression of HIMSS, with 38 percent each having neutral or negative feelings. New poll to your right or here, triggered by last week’s Fortune article: which set of quotes best describes Athenahealth, the positive ones by CEO Jonathan Bush or the negative ones from a skeptical hedge fund manager? Vote and then click the “Comments” link in the poll box to explain yourself.

Attendees of our webinars have asked about the possibility of receiving continuing education hours. I looked into this years ago and concluded that the only way to accomplish that would be to connect with a university already set up to award CEUs to physicians, nurses, and pharmacists. I’m open to suggestions.

I registered for the HIMSS conference this weekend since the early full registration rate of $745 is good through January 27. My impressions:

• The online registration is slow because it tries to upsell you on extra-cost events, but it’s efficient otherwise.
• The registration policies document says that HIMSS doesn’t share attendee email addresses and to report any email received from an exhibitors. I assume that means that, as usual, registrants will receive a barrage of promotional snail mail (some of it invariably arriving after the conference has concluded).
• The registration policy references a “use of photographic images” clause in the same document, but the only related item involves “recording any educational session content,” so apparently the widely ignored ban against taking exhibit hall photos has been eliminated.

Divurgent, Elsevier, Falcon Consulting, Sunquest, and Thrasys have signed on as sponsors of HIStalkapalooza, which will be held Monday of the HIMSS conference week at the House of Blues Chicago. It’s an expensive event to put on — the facility, food, bar, and band add up to more than $175 per attendee — and the number and level of sponsors dictates the number of people I can invite (and thus the number I can’t invite) without going deep into the red. We still have a couple of weeks to add new sponsors – let me know if your company is interested in standing out among all the conference noise that week.

Last Week’s Most Interesting News

• An report looking at six ONC-funded state HIEs finds that large health systems can be either supporters or competitors, HIEs are beginning to embrace Direct despite its poor EHR integration, and the HIEs are still searching for use cases that the market wants.
• A Wall Street Journal report finds that a significant portion of Medicare fraud is perpetrated by the 45,000 newly registered providers each month that CMS says it doesn’t have the resources to review.
• CSC pays $190 million to settle an SEC fraud case that includes its UK NPfIT contracts.
• A Fortune profile contrasts Athenahealth’s high-flying public image with the skepticism of investment advisers and managers who say the company’s tiny market share and flattening performance suggests otherwise.

Webinars

January 13 (Tuesday) 1:00 ET. “The Bug Stops Here: How Our Hospital Used its EHR and RTLS Systems to Contain a Deadly New Virus.” Sponsored by Versus Technology. Presenter: John Olmstead, RN, MBA, FACHE, director of surgical and emergency services, The Community Hospital, Munster, Indiana. Community Hospital was the first US hospital to treat a patient with MERS (Middle East Respiratory Syndrome). It used clinical data from its EHR and staff contact information from a real-time locating system to provide on-site CDC staff with the information they needed to contain the virus and to study how it spreads. Employees who were identified as being exposed were quickly tested, avoiding a hospital shutdown.

People

OB/GYN EHR vendor DigiChart promotes Rodney Hamilton, MD to president and CEO.

Announcements and Implementations

Terrebonne General Medical Center (LA) goes live in its admissions area on RightPatient facial recognition software from Atlanta-based M2SYS Technology.

Government and Politics

The New York Times profiles US CTO Megan Smith, with insiders concluding that while she has a big vision and the president’s ear, she’s also in a position that comes with unclear mandates, minimal budget, and responsibility for outdated technology platforms. The article points out that the newly created United States Digital Service reports to the Office of Management and Budget instead of her office.

A class action lawsuit filed by doctors against North Carolina’s Department of Health and Human Services over software that incorrectly paid practices Medicaid rates for services provided to Medicare patients lingers on a year later. A family practice doctor says the state owes him $100,000, adding that in his pleas to DHHS, “There was a complete lack of courtesy. Those people have no humanity.” The NCTracks system was developed by CSC at a cost of $484 million, with a significant portion copied from a similar system CSC built for New York City. The US Justice Department sued CSC and New York City in October for Medicaid fraud, claiming that the $1 billion New York system didn’t correctly bill Medicaid secondarily to private insurance. Neither system was related to CSC’s $190 million settlement with the SEC last week over accounting and fraud claims involving the company’s work on the UK’s failed NPfIT project.

Oregon’s proposed 2015-2017 budget includes $3 million for a prison system EHR, which is expected to go live in early 2016.  

Privacy and Security

The US Postal Service announces that a previously reported breach of its systems that exposed the Social Security numbers of 800,000 employees also included medical information on 485,000 current and former employees as well as retirees who had filed for worker’s compensation. The most interesting aspect to me is the huge number of injury claims filed with USPS.

Technology

I mentioned last week that John Olmstead, who runs the ED and surgery departments of The Community Hospital (IN), says in an upcoming Versus webinar that he would like to see a GPS-wayfinding type technology so that hospital visitors could navigate around campus using their smartphones. Readers sent information on two companies that offer such technology:

Connexient offers a smartphone app that provides turn-by-turn navigation to visitors at Robert Wood Johnson University Hospital and will bring six more hospitals live on it in the next few months.

Madison, WI startup Solomo Technology is using similar technology to help conference attendees locate session rooms. It offers APIs so that developers can integrate its location and content services into their own apps.

An excellent analysis of the fitness tracker market makes great points:

• Courts are beginning to accept fitness tracker data in cases ranging from vehicular accidents to worker’s compensation, with resulting privacy concerns.
• Wearable device manufactures use glossy marketing to position themselves as health and wellness brands instead of step counters. “You will never find a review for Jawbone or Fitbit that says ‘works as advertised’ because no one knows what they’re advertising.”
• Trackers have penetrated only 3 percent of the market and the washout rate is high.
• The Scanadu medical tricorder-type device holds great promise, as does senior monitoring app Lively.
• Companies that have bought a single brand of fitness tracker for employees haven’t seen broadly successful results because people are motivated differently.
• Users don’t want more data, they want to have devices tell them what to do and to simplify their technology interactions rather than to add new ones.

Other

This headline from the Rome, GA newspaper succinctly describes a lot of what’s wrong with the US economy. Taxpayer-funded organizations that don’t pay taxes themselves shouldn’t be the only hope of employment growth. At least government hiring didn’t top the list.

The Madison newspaper profiles Nordic Consulting co-founder Mark Bakken’s transition from entrepreneur to venture capitalist. He’s putting together a $10-$20 million venture fund that will invest $300,000 to $500,000 in Madison-area companies whose technologies work with Epic. He has raised $4 million so far (including $1 million of his own money) and says several Epic-using health systems have expressed interest in investing. The article mentions that he has personally invested in eight startups (Catalyze, Forward Health Group, Wellbe, Moxe Health, 100health, Quietyme, Healthfinch, and HealthMyne) and four of those have hit $1 million in annual revenue. Bakken, who stepped down from the CEO role at Nordic last month but remains board chair, says he “won the lottery with Nordic,” which had $81 million in revenue in 2013.

A fundraising project for the children of The Johns Hopkins Hospital senior software engineer and bike shop owner Tom Palermo that included a 1,000-participant New Year’s Day ride has raised $60,000 so far, well beyond its original goal of $10,000. Palermo, 41, was killed last weekend when he was run over while bicycling by an Episcopalian bishop with a previous drunk driving arrest who fled the scene. She has been placed on administrative leave pending possible criminal charges following her admission that she hit Palermo, who leaves behind his wife, six-year-old daughter, and four-year-old son. The bishop had previously received probation for her 2010 DUI arrest (before she was hired by the diocese) in which she was driving a car with a tire shredded to the rim, told police she had drunk alcohol and smoked marijuana, and recorded a 0.27 on a blood alcohol breath test.

Five Michigan health systems receive $25 million in value-based payouts from Blue Cross Blue Shield of Michigan, which says the hospitals and physicians are communicating better because of EHRs and HIEs. The systems will also receive $500,000 each over three years to improve their IT systems and care coordination. The chief medical officer of Henry Ford Physician Network says he gets immediate notification if his patient is is seen by any provider in the network or at an area hospital that uses Epic, but otherwise he won’t know about it until he sees the patient next, so he’s looking forward to using the money to improve HIE connectivity and to improve data capture from physician practices.

Lenox Hill Hospital (NY), embarrassed by international press coverage of a British couple unfortunate enough to have their premature baby delivered in the US at a cost of $200,000 instead of free in England, hints that it will simply write off the bill, sticking less-publicized patients with the burden of its profitability. It really annoys me that when media outlets publicize a ridiculous hospital bill involving a feel-good patient, the hospital nobly agrees to cancel the bill as though it doesn’t really need the money. The rest of us who get equally absurd hospital bills are turned over to collections for every dime. Somehow the public never sees through this PR scam to realize that we’re all paying for it. The same hospital annoyed patients and families three years ago by restricting visitor access so that Beyonce and Jay-Z could have their baby in the manner to which they have become accustomed, with the star couple adding their own private security force to guard the VIP suite (the hospital denies rumors that the couple spent $1.3 million to upgrade their room). The CEO of North Shore-LIJ Health System, which owns the hospital, was paid $4.3 million in 2013.

The Sioux City paper describes the interoperability situation between UnityPoint Health – St. Luke’s and Mercy Medical Center, running Epic and Cerner, respectively, and still faxing scanned chart images back and forth. The hospitals are bringing up Iowa Health Information Network with hopes of electronically exchanging at least summary records.

Tennessee doctors are diagnosing and treating people with flu by telephone or telemedicine, telling them not to come to the office for fear they’ll spread the virus to other waiting patients.

A ProPublica investigative article exposes the billing practices of the for-profit debt collection agency run by non-profit health system Mosaic Life Care (MO), which has filed 11,000 lawsuits in five years to collect money from uninsured hospital patients and to garnish their usually low wages. The part of the story that always drives me crazy: uninsured patients are sued for the full (phony) list prices hospitals make up in order to give 90 percent discounts to insurance companies, so people are losing their homes to pay for $12 Tylenols and the ever-accruing interest charges and attorney fees. It seems reasonable that hospitals be required to charge cash-paying patients their lowest prevailing contracted prices.

A JAMA opinion piece written by informatics people from Christus Health points out the rising numbers of medical scribes, the number of companies (22) offering their services, and the creation of a scribe aptitude test and a vendor-led member association. It says that overuse of scribes to make up for EHR inefficiency can lead to compliance and clinical issues, concluding:

The answer to today’s inadequate EHRs is not scribe support. Instead, physicians should demand improved products, should educate vendors to ensure that they understand how physicians think clinically, and should clarify what is needed for an intuitive, quick, and navigable user interface. If such usual market forces are vibrant, and physicians engaged robustly, EHRs will evolve rapidly. Yet even after a decade of use, some EHRs and CPOE may not compete with the speed of a paper checklist, and may never.

The New York Times notes that a doctor whose office was raided by federal agents for writing oxycodone prescriptions for $200 in cash was caught only because neighbors complained about the traffic outside his unmarked office that was guarded by an armed bouncer. The doctor made $2.6 million in cash over two years writing narcotics prescriptions to patients who then turned the drugs over to “crew chiefs” to sell on the street. The practice created false medical records that included MRI reports and urinalysis results.

Dr. Oz makes a lot of headlines, most of them negative. His ABC TV show, “NY Med,” takes heat when a female viewer watches her husband die in an episode filmed at New York-Presbyterian Hospital without the family’s permission. Producers blurred the man’s face in the video, but the woman recognized him and heard his last words as the cameras rolled. Her son has filed complaints with the hospital, the state’s Department of Health, and HHS’s Office for Civil Rights. The hospital and ABC claim the patient isn’t identifiable, ABC says news is protected by the First Amendment, and the hospital says the man’s privacy rights ended when he died and blames the family instead for calling attention to his identity by complaining.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

CIO Unplugged 12/31/14

The views and opinions expressed in this blog are mine personally and are not necessarily representative of current or former employers.

Forever Young

The song ‘Forever Young,” originally recorded by Alphaville, has been covered by numerous artists, most notably Jay-Z. As with many popular lyrics, the meaning differs for each listener. For sure, it’s a reference to the Cold War, during which it was written. But for me, it’s my 2015 anthem.

To live every day with my heart in the moment and only one eye on the horizon.

I’ve missed many heart moments. At age 14, I wanted to be 16 and then I wanted to be 18 and then 21. My first time swimming across San Francisco Bay, all I wanted to do was get out of the frigid waters. I hated it. When I was in college, I wanted to graduate and didn’t give a hoot about absorbing what I was learning. My freshman year, I fell in love, but romanticized the future and focused on getting married instead of developing a solid relationship foundation. When my babies were born, I groaned for the day they’d be potty trained. I missed critical bonding moments between “boring” infancy and tee ball age.

Essentially, I stunted my emotional evolution. Distracted with the stuff of earth, I was so absorbed in what I might gain in the future that I missed the present.

As are some of you, I’m a visionary by design. Without a vision, we go nowhere fast or drive backwards through life’s maze. But if we’re uber focused on vision, we shortchange relationships and forgo eternally valuable opportunities. Both ends of this spectrum are danger zones. When we lean too far toward vision, we lose two critical elements to a fulfilling life. Pain and Joy. And you can’t have one without the other.

“Forever Young” opened my eyes to being in the moment—emotionally.

I want to avoid pain, and relationships are painful. Work is painful. Can’t I just skip all the hard stuff and jump straight to the Promise Land? Why suffer? Let’s introduce new technologies and not deal with required culture and workflow changes. Keep pushing and everyone will eventually accept it as designed. So what if we rub one another the wrong way or talk behind a person’s back? Let’s just pretend that no one ever gets hurt and move on in our grand masquerade. Life is good!

Not really. Really living means we have to touch pain.

Years ago, I suffered rope burns on a challenge course. The skin on my hands was ripped off, exposing flesh. My ER friends could have simply put on salve, a bandage, fed me some drugs, and patted my back as I walked out. But then I’d return in worse condition. Instead, I screamed as they flushed my hand with saline, rubbing Betadine through my wounds and under the remaining skin. Today, you can’t see the trauma because they were willing to touch my wound.

A new year is prime time to change your game. Touch your wounds; touch the pain of those you love. Stop running and put on your big boy pants. I’d prefer putting on an Elizabethan collar (that lampshade thing dogs wear) to keep me from seeing or touching any wounds. Forgive and forget. Pretend nothing happened. Ignore pain. Get over it! I’ll be OK.

No! Pain unresolved only leaves open scars. You’ll feel counterfeit relief for a spell, but emotional scar tissue builds up. Continue to ignore and you’ll never reach your full potential. Every time you run from pain, you deaden part of your soul and become a false you. I am learning to embrace pain. In the moment. “Forever Young.”

Unspeakable joy. Only after you endure pain can you experience true joy. If you skip through the hard stuff, you cheat yourself. Total counterfeit. Superficial. And that’s boring!

The second time swimming the Bay, I stopped in the middle and beheld the San Fran skyline and the Golden Gate Bridge. Not only did I enjoy the moment, I then swam faster than my first time. Climbing some of the world’s tallest peaks, I marvel at the beauty of God’s creation and enjoy the moment. It makes the summit pure joy. I don’t reach the peak without the pain. The same goes for enduring emotional pain. Your soul reaches a new high.

Work conflicts. Not on my fun list. But I won’t run any more, meaning I won’t run away. I’ll run toward it, hoping to put some humanity back into the corporate world—culture shock! Some of my best working relationships will only be born out of pain if I don’t repeat past mistakes.

For example, a while back, an executive director was stuck in his ways and our personalities clashed. We never saw i2i. Did I go through the pain of deeper conversations or opening my heart to him, despite how he might stab me? No. I took the lazy way out. Smiled and nodded then walked out of meetings, rolling my eyes inside. But had we resolved, we could have become a dynamic duo rather than each other’s arch nemesis. We could have changed the future of our hospital. Working through the pain could have led to professional and personal joy.

I’m embracing the pain of my personal relationships. It’s messy! And it hurts deeply with every touch. I have plenty of open scars, and I’ve caused even more. But I have a new vision for healthy relationships, and the only way to achieve joy is to touch the pain. If I don’t change the game, I’ll become so callous I’ll no longer feel.

I am tired of missing moments. Of being shallow. No more counterfeit. Instead, “Forever Young.” I wanna be “Forever Young.”

Ed Marx is a CIO currently working for a large integrated health system. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this post. You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook and you can follow him via Twitter — user name marxists.

Morning Headlines 12/31/14

CSC pays $190M to settle accounting fraud case with SEC

CSC will pay $190 million to settle fraud charges brought by the SEC.

The State HIE Program Four Years Later

ONC publishes a report on the state-level rollout of health information exchanges, the strategies and solutions they’re offering, and the problems they’re working through.

It’s ‘stupidity’ to install health IT without re-engineering workflow

Outgoing Geisinger Health System CEO Dr. Glenn Steele discusses reimbursement reform, health IT, and care management in a Modern Healthcare interview.

Is Athenahealth CEO Jonathan Bush in a bubble?

Fortune profiles Jonathan Bush, CEO of athenahealth, and his More Disruption Please program. He explains, “The plan is we’re going to create and curate the health care Internet.”

News 12/31/14

Top News

CSC will pay $190 million and will restate previous years’ financial statements to settle a variety of SEC fraud charges that includes its participation in the UK’s NPfIT program. That’s a minor amount compared to the $2.75 billion the company already wrote off for its work on the failed NPfIT project. CSC will change its 2011 balance sheet to reflect a $1.16 billion impairment charge.

Reader Comments

From Brandom: “Re: Barnes Jewish Christian. Rumor is it they will be installing Epic.” Unverified, but I ran a reader’s rumor saying the same thing on December 5. Often the earliest confirmation is a health system’s posting of a ton of open Epic positions, but BJC doesn’t have any of those on its recruitment site.

HIStalk Announcements and Requests

I have to disclose a brilliant idea I heard in listening to the rehearsal of the Versus webinar I mention below, which I honestly think is the most interesting webinar I’ve ever watched. John Olmstead of Community Munster captivated me all the way through on the hospital’s use of ED technology, but he really grabbed me at the end when he suggested technology tools he needs. His holy grail is a way-finding, GPS-type app that patients and visitors can use on their own devices to locate themselves precisely on a hospital floor plan, then receive directions to get them to a desired location. Example: I’m in room 4401 with my mom and I want to go to the cafeteria, then to the financial counselor, then to the gift shop, and then back to 4401, so give me turn-by-turn directions like I get with my car GPS. His take is interesting: patients will become so attached to hospitals that offer this app that they won’t consider going elsewhere, where they’ll go back to stumbling around lost or trying to follow decades-old red vs. green lines on the floor that lead to confusing elevators. Hospitals are always a poorly conceived patchwork of added-on construction that went up quickly as funding allowed, so visitors spend a lot of time wandering and wasting the time of employees who have to assist them. Turning that universally embarrassing situation into a competitive advantage is brilliant.

What’s really bugging me lately (it always has, but even more so now): companies that make portions of their name incorrectly upper or lower case, defying all of the civilized rules of spelling just because someone in marketing who’s never run a business has decided that being flagrantly incorrect is a desperate way to distinguish a company from its competitors. I’ve always refused to recognize all-caps vendor names like Meditech, Medseek, and Medhost, but I’ve also decided that I’m also no longer letting Athenahealth slide with the oh-so-cute small “a” at the beginning of the company’s name. Names in America start with a capitalized letter and then have all lower case letters following, so now I have to decide what to do with the many cutesy company names that stick capitalized letters midstream (even providers like Partners HealthCare mistakenly think that’s cool). I’ll even concede that HIStalk should really be Histalk if that will convince other companies to value conformity to accepted rules over marketing nonsense.

Webinars

January 13 (Tuesday) 1:00 ET. “The Bug Stops Here: How Our Hospital Used its EHR and RTLS Systems to Contain a Deadly New Virus.” Sponsored by Versus Technology. Presenter: John Olmstead, RN, MBA, FACHE, director of surgical and emergency services, The Community Hospital, Munster, Indiana. Community Hospital was the first US hospital to treat a patient with MERS (Middle East Respiratory Syndrome). It used clinical data from its EHR and staff contact information from a real-time locating system to provide on-site CDC staff with the information they needed to contain the virus and to study how it spreads. Employees who were identified as being exposed were quickly tested, avoiding a hospital shutdown.

Acquisitions, Funding, Business, and Stock

Fortune describes Athenahealth’s “More Disruption Please” conference as “the Animal House of corporate gatherings,” with the company’s 387-acre Maine resort hosting drinking games and an after-party cabin for investors and corporate hangers-on led by CEO Jonathan Bush, described as a “hyperactive, no-filter goofball of a chief executive.” The article contrasts the party atmosphere to skeptical investors who believe that Athenahealth shares are massively overvalued, especially since the company just announced that revenue growth has slowed as it continues to lose money. Bush says those naysayers don’t understand the company’s business model and will miss the building of a Salesforce-like technology company that will “create and curate the healthcare Internet.” Hedge fund manager and ATHN short-seller David Einhorn isn’t buying it (literally), saying, “They’re a niche provider way out on the periphery with a tiny market share. I don’t see how they’re going to become a backbone of anything.” My take is that Athenahealth would have been an obscure, offshore-powered medical paper pusher without the cult of Bush’s personality; investors had better hope he sticks around and keeps his mojo since that’s the only way shares can continue to trade independently of tepid company performance as a self-proclaimed Internet high flyer. The money gods would lose interest quickly if recommending or owning ATHN stock no longer paid the dues for being a member of JB’s frenetic fraternity.

Athenahealth shares (in blue above) did OK in the past year, falling a bit short of the Nasdaq’s 15.6 percent gain but 25 percent off their March 2014 highs. The company is valued at $5.6 billion on annual revenue of $711 million and a negative operating margin. Jonathan Bush hold shares worth $46 million.

The Forbes article on Athenahealth mentions that the company’s $1.1 million investment in Castlight Health was worth $75 million at the end of Q1, allowing Athenahealth to buy a private plane it calls “the Castlight jet.” At least Athenahealth ended up with something more high flying than CSLT shares — above is the CSLT price chart since its March IPO (blue, down 71 percent) vs. the Dow (up 12 percent).

Cincinnati-based revenue cycle management firm The Consult Inc. (TCI) will acquire RCM software and services vendor Physician Management Information Services of Denver.

Specialty EMR vendor Modernizing Medicine acquires Aesyntix Health, which offers dermatology practice RCM, inventory management, and group purchasing services.  

Sales

The federal government awards Accenture a five-year, $563 million contract to continue the work it started on Healthcare.gov after CGI Federal was fired.

Medical practice performance management company GloStream chooses DrFirst’s EPCS Gold 2.0 controlled drug e-prescribing system to comply with New York’s I-STOP mandatory e-prescribing requirement.

People

Tom Palermo, a 41-year-old senior software engineer at The Johns Hopkins Hospital (MD), was killed in a bicycling accident Saturday. Memorial Mass will be celebrated Saturday in Towson, MD.

Announcements and Implementations

Lafayette General Medical Center (LA) donates a telemedicine station to a local elementary school, allowing ill students to be evaluated by a physician without leaving school.

Government and Politics

An ONC-commissioned report studying HIEs in six states finds that they commonly offer care summary exchange, lab results reporting and exchange, public health reporting, and ADT messaging, but otherwise their technologies and strategies vary. Lessons learned include setting attainable short-term goals to maintain stakeholder interest, recognizing that big health systems can be either supporters or competitors of grant-funded HIEs, and data standards are often voluntary but need to be standardized to achieve real interoperability. Five of the six states plan to charge subscription fees but haven’t set rates (the sixth HIE already shut down). The study found that Direct is still a confounder, with HIEs originally seeing it as a competing model but are now looking at Direct as an easier workaround to problems they found with query-based services, but Direct is still poorly integrated with EHRS (usually requiring providers to log in to a separate portal) since it wasn’t required of vendors until Meaningful Use Stage 2 and they’ve been slow to incorporate it. Wyoming’s HIE gets a special mention for shutting down immediately once its federal grant money ran out. The issue of sustainability is nicely summarized by this statement: “In the short term, grantees are trying to identify use cases that align with the market” (i.e., we built it and they didn’t come before the government money ran out, so it’s like being the owner of a tattoo shop when the local military base closes).

Technology

Iltifat Husain, MD names his best medical apps for 2014:

• ASCVD Risk Estimator (#1)
• JAMA Network Medical Image Challenge
• Medscape MedPulse
• UMEM Pearls
• Multiple Sclerosis @Point of Care
• PreopEval14
• Pediatric Quick Reference
• Eye Emergency Manual
• Blood Donor by American Red Cross
• CDC Vaccine Schedules
• Family Practice Notebook
• Change Talk: Childhood Obesity and Motivational Interviewing

A German hacker replicates a politician’s biometric thumbprint using only a press conference photo and off-the-shelf software. The politician, ironically, was speaking at a hacker’s convention. The hacker, who’s apparently not a fan of biometric security, says he assumes that politicians will start wearing gloves when speaking in public.

Siemens has been caught countless times over at least 100 years for bribing people to earn government bids, so this is hardly news: Israel’s securities regulator arrests six electric company employees for accepting $20 million in Siemens bribes related to a power station turbine bid.

Other

Geisinger Health System CEO Glenn Steele, Jr., MD, PhD, who is retiring next year, comments on physician complaints about health IT in a Modern Healthcare interview:

Here’s my Jonathan Gruber statement: This is an issue of stupidity. If people believe that you can put IT in, continue working the same way you did before IT, and not get inefficiency, we are talking double-digit IQs here. What everybody’s learned over the last 15 to 20 years is if you put IT in, whether it’s hospital-based or ambulatory, you have to look at the entire workflow and use the IT implementation as an excuse for re-engineering your workflow from beginning to end. If you don’t do that, it’s going to create havoc. You’ve got to look at your patient-care processes from beginning to end and say, “How are we going to do it differently? How is this going to make it better?”

On the benefits of health IT, we couldn’t do point-of-service care innovation without having near real-time data fed back to us. You’ve got to have data both from the insurer side and the provider side to predict which patients or cohorts of patients are most likely to need the highest-intensity vigilance. If you don’t have feedback in a timely fashion, it’s not going to work.

The president and CEO of Campbell Soup Company says she’s a fan of the quantified self movement, in which people will “[take] charge of their well-being through the use of data and digital sensors, wearable health bands, and smartphone apps that can track and quantify everything from their heart rate, blood pressure, and sleep quality to steps walked and calories consumed. The word ‘quantify’ is what’s really important because people will use the personal data and feedback from these devices to make healthier lifestyle choices and adjust the way they eat, exercise, work and rest.”

I’m not interested enough to look up the details, but somehow Cerner and Allscripts are both involved in a patent dispute with RLIS, which apparently took a stab at the EMR market in the late 1990s but then folded. I mentioned a reader’s report of the lawsuit in mid-2012, so apparently it’s still churning its way through the court system.

CDC declares the 2014-15 flu season as an epidemic, with 22 states reporting significant influenza-like activity vs. 13 last week. Flu vaccine doesn’t seem to be working well against this year’s strain.

This is sad: a hospital Santa of 30 years hangs up her red and white suit, saying the drug test, background check, fingerprinting, and HIPAA requirements make it too much trouble to give young inpatients their December dose of Christmas cheer. At least a new Santa is happy to take over the suit, which the former Santa donated.

Only in America, home of too many lawyers trying to drum up work and too many righteously indignant people convinced that everything that happens to them is an egregious injustice wrought by deep-pockets defendants: the family of  a woman killed when a driver allegedly high on nitrous oxide rear-ends her as she slows for a traffic light sues: (a) the driver, which makes sense; (b) Toyota, because the family claimed the victim’s car was defective; (c) the driver’s sister, a doctor the family claimed helped the woman get drugs; (d) the towing company who released the driver’s car to her; and (e) a local ambulance company, who the family says caused the crash by responding to an accident with flashing lights on, causing cars to pull over right before the crash.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

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Morning Headlines 12/30/14

Accenture wins $563M contract to continue with HealthCare.gov

Accenture signs a $563 million five-year contract extension with HHS to manage and continue developing healthcare.gov.

ICD-10 Testing Results and DMEPOS Competitive Bidding Registration Reminder

CMS reports that during its November ICD-10 open testing period more than 500 providers, suppliers, billing companies, and clearinghouses submitted test claims, resulting in a 76 percent claim acceptance rate. The test checked that claims had a valid diagnosis code, ICD-10 companion qualifier code, national provider identifier, and date of service, and returned an automated acceptance notification when all criteria were met.

Startup Health Insights Annual Report 2014: The Year Digital Health Broke Out

Startup Health reports that $6.5 billion in startup funding flowed into the digital health sector during 2014, a 125 percent increase over 2013.

The National Patient-Centered Clinical Research Network: Clinical Data Research Networks (CDRN)—Phase II

PCORI will award $87 million to establish 13 clinical data research networks and $26 million to establish 22 patient-powered research networks as part of the second phase of its PCORnet project.

Curbside Consult with Dr. Jayne 12/29/14

Whenever something happens with our EHR that physicians don’t immediately like, there is bound to be grumbling. Sometimes it doesn’t even have anything truly to do with the EHR, such as a change in requirements for Patient-Centered Medical Home recognition or with Joint Commission accreditation.

Physicians and clinical staff would have had to comply in the paper world, but they don’t see it that way. They seem to perceive such mandates as uniquely burdensome and EHR related despite our attempts to educate.

We’re going through one of those periods now. Our accountable care team has decided that we need to collect certain information in a specific way that doesn’t fit very well with some of our workflows. That’s the problem in an organization like ours – each hospital has its own CMIO, but we don’t have one over-arching person who can cut through the noise and make decisions that fully take into account the limitations of our various systems and vendors. The accountable care team has good intentions, but I doubt half of them have even seen the workflow of some of our clinical systems.

On the ambulatory side, we’re trying to make it as smooth as possible, even using some programming sleight of hand to get the data into the right format without clinicians having to enter it twice. The problem of non-clinicians dictating data that clinical staff must document certainly isn’t new. It goes back to the creation of ICD codes and E&M coding requirements. Anyone who has ever had to formally diagnose a patient with “Bone and Mineral Disease, NOS” rather than osteopenia simply to get it billed will know what I’m talking about.

In some ways, Meaningful Use has helped with this, allowing us to use SNOMED codes to capture that level of clinical granularity. We do still have to translate them into billing codes, however, resulting in parallel diagnosis lists in the chart. That can have issues as well.

When we first started using SNOMED, we found out there were issues with some of our mappings to ICD-9. As long as the data flowed from SNOMED to ICD, we were fine. But if clinicians tried to pull diagnoses off the billing list and convert them to SNOMED, detail was frequently lost.

Physicians immediately jumped on this as a patient safety issue. The financial team jumped on it because the loss of specificity could lead to decreased reimbursement. Those two forces combined made it easy to get access to resources to fix the problem quickly. One of our most vocal EHR haters used it as a reason to again call for discontinuing use of the EHR because of its many safety flaws.

We hear that chorus all the time. Although there are many valid points about EHR design and patient safety, there are also numerous points where EHR makes our work safer as well as more efficient.

I was thinking about this last night as I worked in the ER. There is a great deal of attention to EHR-related patient safety and people are always crying out for regulation. How much attention is there to financially-driven patient safety risks?

One of the patients I treated was a prime example of what happens as more and more of our decisions are financially driven. The patient was a young woman who came in because she couldn’t reach the on-call nurse covering her case. That’s the first point of failure – that physicians are no longer taking their own call because it’s more cost effective (and burnout reducing) to have a nurse cover your call.

Unfortunately, she has four different specialists involved in her care and didn’t actually have a problem that we could address in the ER. Her condition is complex and still partially undiagnosed. Her visit was more about coming to us as the place of last resort. She thought that if we tried to call her specialists, we’d have some magical ability to get her some answers.

If she had come into the medical system when I was a student, she would have been admitted to the hospital until the full workup was complete and we had a plan of care. Each of her specialists would have seen her daily and seen each other in the halls and at the nursing station. However, it’s cheaper to care for people as outpatients, so money was saved by sending her home. Unfortunately, her care was fragmented by this decision – the second point of failure.

During the course of her care, she developed a serious infection that required weeks of intravenous antibiotics. Her insurance company has a policy that patients under Medicare age be “trained” to administer their own infusions at home to save on the cost of the home health nurse. There is no regulation in my state about this practice, which gives payers the ability to make these determinations.

Apparently the patient either didn’t understand or didn’t receive the information that the antibiotic packets had to be kept refrigerated. When she went to the infectious disease physician’s office each week to have her IV line and dressing checked, it didn’t come up there, either. This resulted in the patient infusing 21 days of non-effective medication, which likely contributed to the recurrence of her infection, which was why she was in the ER — she was worried about whether it was extending.

Failure point number three is assuming that just because it’s statistically likely to be OK to allow a patient to administer their own IV antibiotics, that doesn’t make a clinical treatment plan applicable to all patients.

For each person demanding regulation of EHRs, where is the demand for regulation of situations like this? She did determine five days ago (after talking to the on-call nurse about her IV line) that the medication had to be refrigerated and a new supply was sent out, but the infection isn’t looking any better, which was why she was trying to reach her physician in the first place.

In talking to her, I struggled to figure out the best person to call. The infectious disease specialist was out of the country. His primary nurse had gone into labor and was being covered by a nurse who initially told the patient to call the surgeon and then didn’t return subsequent pages. The surgeon was also out of the country, but the patient didn’t think he was the right person to call since he wasn’t involved in the antibiotics. The primary care physician hadn’t seen her in six months. The other specialist involved is a plastic surgeon, who wouldn’t be of much assistance in this situation.

Failure point number four is lack of ownership of this patient and her complex situation, again in part due to cost-cutting maneuvers. Physicians just aren’t likely to spend hours playing phone tag with various specialists when that time isn’t reimbursed and payments are being cut.

I had the charge nurse put out a couple of pages to different specialists involved in her care, figuring there was an equal chance that whoever called back wouldn’t know anything about her, so might as well cast a broad net. In the mean time, I went back in and looked at the patient’s medication that she had brought with her. Sure enough, nowhere on the labeling did it indicate that it was to be refrigerated. It was from a compounding pharmacy contracted by an infusion company contracted by the insurance company. Many cooks in the kitchen always make for a questionable dish.

Ultimately one of the infectious disease nurses called back and we made a plan for the patient. Since she was clinically stable, fever-free, and had no new symptoms, she was stable to go home and the nurse would see her first thing the next morning. I reassured the patient and explained that our goal in the ER is to take care of any critical issues and make sure that patients are stable and that follow-up has been arranged. I chose my words carefully. Usually I say something about making sure any life-threatening conditions have been addressed. In this situation, there are still multiple factors that may threaten her health (and ultimately her life), but they were completely beyond my scope.

I’ve been thinking about her all day today and wondering how things turned out this morning. That’s the problem with putting a family physician in the ER. I always wonder about the follow up since continuity of care is one of the reasons I wanted to be a physician in the first place.

I’ve also been thinking about the ways that the system failed this patient. I can’t help but draw a parallel to all of the people out there who think that more technology is going to solve all the problems and that regulating the technology is the answer. Dealing with technology is just the tip of the iceberg in healthcare. This case is a prime example of everything out there that also needs to be addressed.

To the people who demand broad regulation of health information technology by the FDA as the solution to patient safety problems, I’ll get on board with that at about the same time the FDA gets oversight of compounding pharmacies, home infusion agencies, and payer executives squeezing the maximum profit out of the system. Based on the 50 patients I saw yesterday, they’re a much greater threat to patient safety than my EHR.

Email Dr. Jayne.

Readers Write: The Eve of War

The Eve of War
By John Gomez

Steve Lewis arrived at his office at 7:03 a.m., draining the last remains of his grande mocha as he finished chewing on his blueberry scone. These were his last few minutes of peace before the day started. He did all he could to savor them as his laptop booted. He began the login to his corporate network.

Username:
Password:

WHAT THE HECK?

There on the screen in front of him was an image a red skeleton and the words “Hacked by #GOP.”

Steve pressed Escape, F1, ALT-TAB, CTRL-ALT-DELETE. Nothing. The skeleton just starred back at him. Power off. No luck — the skeleton remained. He closed the laptop and opened it. The skeleton was still there.

The sudden ringing of the phone made Steve jump. He noticed that every line on his phone was lit up with inbound calls. He randomly choose one and answered, “Sony Pictures network support, Steve speaking …”

Steve would handle hundreds of calls that morning, as would his colleagues. Everyone reported that their computer bore the image of a skeleton. Within minutes, word had spread across the corporation of the computer attack.

Managers scrambled to calm employees and asked them to remain, though many decided to take immediate time off as they didn’t feel safe. If you were to have asked Steve’s colleagues that morning, not one of them would have said, “I feel safe and secure.” 

In the coming days, Sony Pictures executives would make a gutsy choice and agree to the demands of the company’s attackers. Meanwhile, several hundred miles away, members of the Department of Defense Cyber Command were spending their time analyzing cybermunitions and strategies to provide the President of the United States with options in the event he ordered cyberattack on North Korea.

As the dawn of 2015 appears on the horizon, the United States is poised to engage in the first cyberwar in the history of mankind. If there is any irony to all of this, it would be that it all reads very much like a Tom Clancy script. Unfortunately, all of the events and the situation we find ourselves in as the year comes to an end are all too real.

The attacks on Sony Pictures by North Korea are interesting. Studying what happened is critical to protecting our own infrastructure and systems. The key takeaways are that although the attacks were not sophisticated or highly technical, the strategy by those who executed the attack was advanced.

We now know that Sony was being probed and scanned for months, with the sole purpose being to gather massive amounts of intelligence that could be used to formulate escalating attack strategies. We also know that as a result of this intelligence gathering, the attackers were able to carefully and selectively control the attacks and the resulting damage.

We should also keep in mind that since the attacks themselves were not highly advanced, it does show that the use of proactive security hardening measures could have helped Sony minimize or defend against the attacks.

What do we do now? We as an industry and nation have never had to prepare for a cyberwar. The battle is now all of ours. The actions we take in the coming days and weeks will be critical to how we navigate and survive whatever may occur on the cyberfront.

The top three targets for cyberterrorism and warfare are finance, utilities, and healthcare. Attacking any of those areas creates extreme consequence to the citizens. Of the three, the most damaging would be healthcare. The worst case would be affecting patient outcomes in some form or manner. In my eyes, this could be done.

My prescription is as follows.

Top-Down Education

Educate the C-suite and board of directors to provide clarity in terms of what occurred and the reality of the attack types and strategy. Clarify the resources and support needed to harden systems.

Little Things Matter

The technically simple attacks on Sony were effective because Sony didn’t do the little things: using old technology like Windows XP; not enforcing security policies or policies, and giving in to the screaming user or privileged executive while compromising the overall welfare of the organization.

Holistic Approach

Fight as a team. Cyberattacks aren’t about singling out one system. They involve finding a vulnerability anywhere and exploiting that for all it’s worth. If someone can exploit security cameras to gather compromising information that leads to greater exploits, they win. Think of the entire organization, physical and digital, as a single entity and then consider the possible risks and threats. What if someone shut down the proximity readers? What if they disabled the elevators? What if biometric devices or medical devices running Linux were infected with malware?

Monthly War Games

This is a fun way to build a security-minded culture. Once a month, gather the security team (which should represent the physical and digital world) and start proposing attacks and how the organization would respond or defend. Invite someone from outside.

Fire The Professionals

Organizations rely on those who help them feel good by saying all the right things – clean-cut consultants with cool pedigrees and fancy offices. Those might be the right people to review financials, but for security, look for crazy, go-for-broke, “been there, done that” people. The ones who make you a little scared when you meet them that maybe they bugged your office while you stepped out for a minute. When it comes to testing systems and infrastructure, be liberal with the rules of engagement and highly selective in who to engage. Get someone who makes everybody uncomfortable but who can also provide guidance.

Admit You Need Help

For most people, cybersecurity is not something they do day and night. Even a dedicated team won’t see everything outsiders see because they are exposed only to a single organization. Consider getting help from people who do this every second of the day, regardless of if the help entails remote monitoring, managed services, surprise attacks on a subscription basis, or delivering quarterly educational workshops. The SEAL teams of cybersecurity exist.

Education Matters

Cybersecurity education is as critical as that for infection control and privacy. It could be that last line of defense before becoming the next Sony, Target, Kmart, Staples, or Sands Casino. Also consider providing ongoing education for the in-house technologists.

Integrate Business Associates

Don’t let business associates do whatever they want. Set standards and insist that they be followed. Minimize shared data with them, enforce strong passwords, require surprise security assessments, and get the board and C-suite to understand that they are the weakest link.

The Technology Vendor Exposure

Hardware or software doesn’t matter — most vendors do not design or engineer secure systems. Not because they don’t want to, but they overlook things when trying to get hundreds of features to market and dealing with client issues and priorities. Not to mention many of today’s HIT systems were designed and developed decades ago, well before the words “buffer overflow”, “SQL injection,” or “cyberwarfare” were known. Push vendors hard to demonstrate how they are designing and developing highly secure systems that keep customers and patients safe and secure.

Security Service Level Agreement:

Do this is nothing else – it will make sure the other stuff gets done. Set a clear and aggressive Security Service Level Agreement (SSLA). This should be a critical success factor that holds the CIO, CISO, COO, and CEO accountable. Defining what is part of the SSLA should be a joint venture between the C-suite and the board, but it should clearly dictate the level of security to be maintained and how it will be measured.

These aren’t earth-shattering suggestions. However, had someone from Sony read this last year, they would have said, “We already do this,” yet Sony may very well end up being a case study for cybersecurity (and depending what happens in the coming days, a key part of our history lessons for centuries to come).

The bottom line is that HIT is an insecure industry that has not done enough to pull forward and become the standard of cybersecurity that everyone outside the industry expects (and thinks we are already doing).

Now is the time to set a standard, fight back, and take things to a new level. Sony provides an opportunity to educate the board, create a partnership with the CEO, reexamine trusted partnerships, and push vendors to step up their game. Let’s hope that Sony is more than enough to be a call to action for our industry.

John Gomez is CEO of Sensato of Asbury Park, NJ.

Readers Write: EHR Vendors: Barriers to Interoperability

EHR Vendors: Barriers to Interoperability
By King Coal

As patients and taxpayers, I encourage everyone to contact your Congressional members about this topic. Mention that the barriers to EHR interoperability are not just technical — they are contractual as well.

EHR vendors that enjoy the benefit of our tax dollars under the HITECH Act are preventing interoperability — and innovation around the edges of their EHR products by third-party developers — by placing limitations and threats in their contracts with clients. The vendors who are engaged in this antitrust behavior can point to their technology and say, "See? We can share data. We follow data sharing technical standards. Quit criticizing us."

But when you look at these vendors’ contracts, the license fees associated with interoperability are cost prohibitive. In addition, the interoperability clauses are surrounded by onerous contractual obstacles that are veiled to protect the vendors’ intellectual property, but are actually ensuring the vendors’ continued monopoly and preventing innovation around their products.

This behavior on the part of some EHR vendors is strikingly ironic given the enormous success of open source, easily accessible APIs that benefit interoperability. The more open products are from a software architecture perspective, the more value that accretes to a product’s intellectual property. Open, transparent APIs create a larger dependence and ecosystem around products, not less.

Several years ago, I sponsored a meeting with senior executives from three large EHR vendors, lobbying them to open their APIs and migrate their software engineering architecture from tightly coupled, difficult to modify and upgrade, message-oriented architectures to loosely coupled, flexible, services-oriented architectures with open, published APIs so that my development teams could write innovative products around the edges of these EHR products. 

I will never forget the response from one of those EHR vendor’s senior executives: “We see ourselves as more than a database vendor.” Meaning, of course, “Our closed APIs are a market advantage.” 

Bill Gates and Microsoft used to think the same thing about Windows, Office, and Internet Explorer. You can see how that worked out for them when you compare what’s happened with the openness of Android, iOS, the browser market, and office suite products. Salesforce.com is the supreme example of business success based upon an open API and open culture.

A colleague described his thoughts in an email:

Current interoperability standards selected by the ONC and required by MU-S2 do not contain an adequate amount of data/data types to support the quality measurement requirements of the same MU-S2 program. This gap in data is what enables the EHR suppliers to continue the veil of interoperability while still protecting their proprietary intellectual property, serving the interests of the owners of these companies with little regard to what may be best for care, providers, patients, or consumers.

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.

I’m not sure what if anything Congress can do at this point to fix the ills of Meaningful Use Stage 1, which rewarded existing vendors with billions of dollars in tax money to maintain those vendors’ closed and proprietary APIs. Decertification by ONC will become a bureaucratic mess, but I appreciate the symbolic stance taken by Congress around decertification nonetheless.

One thing that must happen—and maybe our legal courts are the only option for this—the contractual threats and barriers in EHR vendor contracts that stand in the way of interoperability and innovation must be removed.

Interoperability and innovation in healthcare IT are suffering, both technically and contractually, by old-fashioned, old-school thinking on the part of EHR vendors. As a consequence, our healthcare system and patient care are suffering, too. ​

Readers Write: What Physicians Want From Their Medical Software

What Physicians Want From Their Medical Software
By Charles Settles

Physicians looking for medical software have many options. With hundreds of healthcare IT vendors and bloated feature sets, making a decision can be difficult. Especially when purchasing a system for the first time.

Many physicians are skeptical of vendor claims (especially regarding workflow efficiency) and healthcare IT in general. Additionally, learning a new system can be a daunting task for busy providers who have spent years managing patient encounters with paper charts. Some providers are opting out of healthcare IT entirely and are accepting reimbursement reductions or taking early retirement in order to avoid electronic health records and other systems.

Conventional wisdom (and the marketing material from vendors) would lead healthcare IT buyers to believe that Meaningful Use incentives are the number one reason to buy medical software. Based on responses we’ve received, fewer than 10 percent of physicians care whether or not their electronic health records system is certified for Meaningful Use. The latest data from CMS would seem to confirm this; less than 1.5 percent of physicians and organizations that attested for Stage 1 of the program have successfully attested for Stage 2.

The biggest factor for most physicians is effective document management. This should come as no surprise. It is difficult to achieve the goal of a paperless office without such tools. Despite requirements for health information exchange, interoperability between medical systems remains difficult. Many providers still use fax machines to coordinate care and share notes. An electronic health records system with built-in fax capabilities allows providers to bypass this. Additionally, the role- and user-based access capabilities provided by these systems keep health information secure in a HIPAA-compliant manner.

The second-most requested feature for medical software is template-based progress notes and orders. Despite concerns with upcoding or indecipherable template-based notes, most physicians want to be able to use customized templates to save time during encounters. One otolaryngologist said he performed “the same three procedures for over 90 percent of patients.” Using a template makes the most sense for providers who find themselves in a similar situation. Primary care providers were the only specialists to show an aversion to template-based notes, which makes sense, as a primary care provider is likely to deliver a much wider variety of care than a specialist.

Other features are less of a surprise: a patient portal, e-prescribing, and tablet or mobile-based access round out the top five most-requested features by providers using our service. Also, despite security and uptime concerns with cloud-delivered systems, it’s worth noting that fewer than 15 percent of providers asked for medical software that could be installed on their own server; 56 percent of providers requested cloud-based software; and the rest had no preference.

Despite the trend of providers opting out of the Meaningful Use Incentive Program, the market for electronic health records and other medical software systems remains significant. With estimates of healthcare IT adoption rates rising above 80 percent, many of these purchasers are replacing an existing system. This could explain some of the feature preferences, especially the significant preference for strong electronic document management capabilities.

Charles Settles is a product analyst at TechnologyAdvice.

Morning Headlines 12/29/14

Cerner Corp (CERN): $65.71

Cerner stock closes at $65.71 Friday, an all time high for the company.

Disneyland trip, Beyonce tickets were ‘inappropriate gifts’ to official, judge rules

The government upholds a VA decision to fire the former director of the Phoenix VA Health System,  not because of the wait-time scandal that was discovered at her facility, but because she accepted “inappropriate gifts,” including an 8-night family vacation to Disneyland for herself and six of her family members, from a consulting firm whose core business is helping vendors secure lucrative government contracts from the VA.

Why It’s So Hard to Fix Medicare Fraud

The Wall Street Journal analyzes Medicare fraud detection, explaining that the problem is complicated by the fact that 45,000 new providers enroll in Medicare every month and CMS does not have the resources to verify that every one is legitimate.

Jeb Bush quits hospital chain before possible White House run

Jeb Bush resigns from his position on the board of directors at Tenet Healthcare in preparation for a widely-speculated run in the 2016 presidential elections. Tenet is a for-profit health system that has publically attributed strong financial gains to the rollout of Obamacare, legislation that Bush formally opposes.

Monday Morning Update 12/29/14

Top News

Cerner shares hit a 52-week high last week, closing Friday at $65.71 and valuing the company at $22 billion. The end-of-year rise sounds impressive until you examine the one-year share price graph that shows CERN shares rising 18.2 percent (blue) vs. the Nasdaq’s 15.6 percent (red), so it barely beat the Nasdaq composite index. 

Reader Comments

From Pango: “Re:  vendor employee provider experience. My company developed a rounding program where our software developers, project managers, product managers, and QA team members spent time observing a clinician in hospital departments. It was valuable because it provided insights into workflows and usability that we could not have understood other than by on-site observation. The programs were in place at several client hospitals and we maintained an active rotation of our team members who wished to participate.”

From Patti Melt: “Re: Epic. I just spent all day interfacing it to other systems. Since Neal Patterson says it can’t be done, should I buy a lottery ticket?”

From Urban Cowboy: “Re: Madison airport. If Epic is trying to eliminate consultant advertising within 50 miles of Verona, someone should tell the airport since it’s about all they have. With fewer implementations, they need all the help they can get.” Someone mentioned previously that perhaps the airport wasn’t within Epic’s rumored no-fly-ads zone since it’s a long cab ride, but Google Maps says it’s only 21.9 miles.

HIStalk Announcements and Requests

News is predictably (and thankfully) skimpy, so the biggest takeaway from this post is that you haven’t missed anything over the post-Christmas weekend.

Dave Miller, CIO of Optimum Healthcare IT and formerly CIO of University of Arkansas for Medical Sciences, sent out an email suggesting Christmas donations to the Salvation Army, recounting how as a child the organization got his family of seven through their temporarily homelessness. Bitdefender wouldn’t let me bring up Dave’s fundraising campaign page at OnlineRedKettle.org because of a phishing warning, but I matched Dave’s $250 donation online in honor of HIStalk’s readers. Salvation Army is my #1 overall charity choice, with DonorsChoose.org running a close second.

I’m ecstatic to report that three-quarters of respondents to my poll say they’re happier now than they were a year ago. New poll to your right or here: what is your overall impression of HIMSS? Click the poll’s “comments” link after voting to explain.

Last Week’s Most Interesting News

• The executive director of the Connecticut Health Policy Project observes that the state’s now-defunct HIE oversight organization spent $4.3 million in federal grant money without accomplishing anything.
• Pennsylvania’s HIE organization asks the state for $4.7 million to keep it running now that its ONC grants have expired and its efforts to bring paying organizations online and to solicit charitable donations have failed.
• The FDA announces plans to require drug manufacturers to publish prescribing information for professionals electronically on an FDA-maintained website, eliminating the paper versions.
• HTC Global Services acquires CareTech Solutions.
• Boston Children’s Hospital (MA) pays $40,000 to settle state charges over the theft of an unencrypted laptop, while Northwestern Memorial Healthcare Group notifies 3,000 people that their information has been exposed by the theft of an unencrypted laptop from an employee’s car.

People

Oneview Healthcare names Samir Batra (CareInSync) as VP of patient engagement.

Announcements and Implementations

TEDMED is offering a $1,000 discount for registrations completed by December 31 for next fall’s event, dropping the cost of the refundable, transferrable delegate pass to $3,950. This year’s event was split between San Francisco and Washington, DC and connected by video. No way I’m paying thousands of dollars to watch a big screen meeting from the other side of the country, but to each his own. The only names I immediately recognized from last year’s speaker list were swimmer Diana Nyad and Theranos CEO Elizabeth Holmes, neither of which would cause my hand to move toward my wallet.

Government and Politics

Jeb Bush will resign from the board of for-profit hospital operator Tenet Healthcare as he explores a 2016 Presidential run. He made $300,000 from that gig last year. Tenet is worth $5 billion, with CEO Trevor Fetter holding shares worth $42 million.

A Wall Street Journal report says that Medicare is hard to fix because the agency doesn’t want to restrict care, adding that new providers aren’t vetted and inspectors never visit provider locations to see if they are real. The article points out that 45,000 new providers sign up to deliver Medicare services every month and CMS doesn’t have the resources to vet them.

Technology

My most-used iPhone app is the outstanding, 99-cent MotionX GPS Drive navigation system. I just noticed that the company offers the also-99 cent MotionX 24/7, which includes a sleep tracker, step counter, heart rate monitor, and wake-up alarm, all integrated with Apple Health. I didn’t realize until I looked up their site that the company’s emphasis is on and quantified self rather than GPS navigation. It holds dozens of patents and licenses its technology to wearables vendors such as Nike. MotionX’s CEO and co-founder is Philippe Kahn, who invented the phone camera, founded the powerhouse 1980s software vendor Borland (Turbo Pascal, Quattro, TopSpeed/Clarion, dBase, Delphi, and Paradox), and earned simultaneous master’s degrees in mathematics and classical flute. I’m installing MotionX 24/7 now and will report back, but I can already see that it’s as well designed as I expected.

Since I mentioned my most-used iPhone app, here’s another highly used one on the phone, desktop, and laptop: the LastPass password manager and single sign-on utility, which allows me to log on to a single Web page and have instant auto log-in to everything I use online (and to easily and centrally maintain complex and mandatory-change passwords) from any device. It’s free for personal desktop use, or an extra $12 per year to run it from mobile devices.

This should annoy everyone smart enough to use their phone as a personal hotspot instead of paying $15 for crappy hotel Internet access: Marriott and its hotel lobbying group ask the FCC for permission to block tethering, using the extraordinarily stupid and self-serving excuse that guests might use their personal Wi-Fi connections to attack the hotel’s network, steal information from other online guests, or slow down the hotel’s Wi-Fi (all of which are arguments hotels should make for NOT using their own in-house networks, other than the fact that they profit handsomely from it). Microsoft and Google are urging the FCC to deny Marriott’s lame idea. Somehow cheap roadside hotels can offer free parking, Internet, and breakfast but the snootier, big-city ones milk their business travelers hard. Marriott’s Springhill Suites is still my favorite chain, though.

Other

The board of Massena Memorial Hospital (NY) approves spending $49,000 for a Medhost upgrade and $29,000 for a Meditech/LSS purchase. The CEO explained that the Medhost upgrade is required for complying with New York’s I-STOP mandatory electronic prescribing law, adding, “The last thing we want to do is end up sideways with the state and DEA. That would be extremely unpleasant.” 

Eric Topol, MD tweeted this graphic of his medical smartphone concept from his new book, “The Patient Will See You Now.” Amazon’s “look inside” preview contains generous sections of the book’s content – it looks good.

This YouTube video of Derby the dog running for the first time after being fitted for 3D-printed prosthetics has received 6.8 million views for its producer, 3D Systems. The company, based in Rock Hill, SC , is traded on the New York Stock Exchange and is valued at almost $4 billion even after shares dropped 64 percent in the past year.

The children of “American Top 40” host Casey Kasem, who died of dementia last June at 82, will share his hospital records with his widow, who is suing the hospital that cared for him. Kasem’s widow is the former Jean Thompson, who played Nick Tortelli’s curvaceous wife Loretta (with the “I Dream of Jeannie” hairdo) on “Cheers.”

The federal government upholds the firing of the head of the Phoenix VA, not because of the wait times scandal that erupted there, but because she accepted gifts from a consultant that included a family trip to Disneyland and Beyonce concert tickets.

‘Tis the season for intolerant lunatics: American Airlines removes a disruptive La Guardia passenger who was loudly berating the flight attendants and crew who had wished him “Merry Christmas.” The man, who wouldn’t calm down, said nobody should ever say Merry Christmas because not everyone celebrates it. His fellow passengers cheered when he was escorted off the plane.
 

UPMC’s Magee –Women’s Hospital (PA) gives keepsake Christmas stockings and caps knitted by volunteers to the parents of newborns who are in the hospital over the holiday.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

Morning Headlines 12/24/14

AMN Healthcare Acquires Avantas

AMN Healthcare, a healthcare-focused staffing firm, acquires Avantas, which builds data analytics tools for optimizing staffing and scheduling.

Medicine Is About to Get Personal

TIME reports on direct-primary care provider Qliance Health, and their efforts to provide direct to consumer primary care for a flat monthly fee, and without involving insurance.

Health IT In Connecticut – Learning From Mistakes

A director from HITE-CT, Connecticut’s quasi-public organization tasked with building its health information exchange, explains that the organization was dissolved after “wasting $4.3 million in federal grants and four years, without accomplishing anything.”

Pennsylvania eHealth Partnership Authority Annual Report to the Governor and General Assembly

The organization responsible for Pennsylvania’s HIE reports that despite very lean staffing, finding a business model capable of delivering financial sustainability remains its biggest challenge.

News 12/24/14

Top News

Healthcare workforce services vendor AMN Healthcare acquires Avantas, saying its clients need staffing forecasting analytics.

Reader Comments

From Sonoran Dog: “Re: Maricopa Integrated Health System. Veiled rumors from administration suggest it will have to shut down in July 2015 due to lack of funds after receiving a large bond in the November elections. Any truth to the rumors? A lot of us medical personnel are working hard to comply with every cost-cutting feature we can come up with to help.” Voters overwhelmingly approved a $935 million bond to upgrade the facilities of the 515-bed public health system that includes Maricopa Medical Center, the Arizona Burn Center, and the Level One trauma center. The CEOs of the four largest private hospitals in Phoenix (Abrazo, Banner, Dignity, and Scottsdale Lincoln) say the huge construction expense is unnecessary given the sufficient bed capacity already in place (theirs, of course.) Readers comments are welcome. Surely there’s little chance of MIHS shutting down given public support, but some sort of public-private partnership with the those other Phoenix systems would make sense.

From Czarina: “Re: vendor-provider contact. What do HIStalk readers suggest for giving vendor employees exposure to the clinical workflow and technical challenges that providers face? We want every one of our people to get out in the field, but just taking a hospital tour doesn’t seem to have much value. We’re considering encouraging volunteering, attending a local or national conference, or taking a clinician to lunch.” I should note that this isn’t a huge company, so their employees won’t overwhelm the local health systems. Ideas? I’ll be honest that in my health system IT experience, I wouldn’t see the benefit to my department in having vendor people underfoot so they could learn on my dime, so I would be somewhat resistant to committing. I like the idea of setting up a volunteer program specific to the IT department if the hospital is willing to support it – our desk-bound IT department people learned a lot just going out with the field services techs or sitting with the help desk people.

From HITPro: “Re: cyberdefense training system. Can’t mimic real-world health system security because it is virtually non-existent.” CyberCity, created to train federal government employees to defend against cyberattacks, had to artificially boost the security capabilities of its prototype hospital because it otherwise would have been “too trivial to hack.”

HIStalk Announcements and Requests

I’ll probably slack off a bit over the next week by posting less frequently. Merry Christmas, Happy Hanukkah, and Habara Gani (and if you don’t celebrate any of these holidays, those of us who do thank you in advance for respectfully tolerating that fact).

Acquisitions, Funding, Business, and Stock

Provider secure messaging app vendor GroupMD renames itself Flow Health, or at least that’s what I infer from the maddeningly vague company blog post announcing a change without really describing it. I probably shouldn’t be surprised given that Flow Health’s “About Us” page on its we’re-so-hip, scroll-happy website doesn’t list its founders, physical location, or history.

Sales

Porter Medical Center (VT) chooses Summit Healthcare’s data exchange platform to meet Meaningful Use Stage 2 Direct messaging requirements.

People

 

Explorys hires Greg Yarrington (Truven Health Analytics) as VP of operations and Patrick Wells (Deloitte) as VP of solutions.

Home medical equipment manufacturer Invacare appoints Cleveland Clinic CIO Martin Harris, MD as interim board chair following the retirement of Mal Mixon. The publicly traded Ohio-based company has 5,200 employees and a market value of $533 million, with Harris holding shares worth $327,000. The company’s share price has dropped 28 percent in the past year.

J. Robert Beyster, PhD, founder of SAIC and Leidos, died Monday at 90. He left his job working on nuclear submarines for Westinghouse in 1969 and founded SAIC at age 45.

Announcements and Implementations

The Cal INDEX HIE connects to Blue Shield of California via Orion Health.

India’s state of Telangana rolls out the country’s first healthcare app.

Sagacious Consultants announces an Epic report-writing annual subscription that provides a fixed number of hours each month with discounts of up to $50 per hour.

Government and Politics

The executive director of the Connecticut Health Policy Project says the now-defunct state HIE oversight organization (Health Information Technology Exchange of Connecticut, or HITE-CT) was shut down “after wasting $4.3 million in federal grants and four years without accomplishing anything.” She references a state auditor’s report that concluded that the organization was slow to react, couldn’t figure out how to fund itself, and failed to renegotiate a bad vendor contract it had signed with Axway and GE Healthcare. At its peak expense year of 2013, the organization paid $343,000 in salaries. Auditors also noted that some of the 20 members of its board often missed meetings, vacant board positions weren’t filled, and with zero revenue the organization couldn’t pay the paltry matching funds required by the federal government ($1 for each $10 in federal grant money received). The editorial’s author is correct: the only accomplishment of the group was to squander federal money.

Acting HHS Assistant Secretary Karen DeSalvo, MD writes a Huffington Post blog post welcoming home the US Public Health Service officers who returned from fighting Ebola in Liberia this past Saturday.

The FDA issues a proposed rule that would require drug manufacturers to provide prescribing information for professionals in electronic form, which would then be posted on an FDA reference site. Paper versions would no longer be allowed since they can’t be updated with new information, but manufacturers would be required to staff a telephone service that would send paper copies on request.

Privacy and Security

Mercy Medical Center  (CA) announces that a third-party transcription vendor unintentionally opened up its server to the Internet for several weeks, making the physician notes of 620 oncology patients visible in web searches. The hospital has apparently fired the responsible contractor.

The Michigan appeals court dismisses a privacy brought by 159 people whose medical records were unintentionally made available online by a contractor for Henry Ford Health System (MI). The three-judge panel ruled that an invasion of privacy claim isn’t valid unless the plaintiff’s actions are intentional.

Other

Time magazine profiles Qliance, a Washington-based nationally expanding concierge primary care practice that has lowered its cost to the point that it covers entire businesses (Expedia and Comcast) and even Medicaid groups for a flat monthly per-patient fee based on age. Billionaire investors include Amazon’s Jeff Bezos and Michael Dell. I really like this snip:

At the tangled heart of this dysfunction is Medicare, which by its sheer size sets the standards for insurance reimbursements. Specialists dominate the panel that sets its payment rates. Thus the system values surgeries, scans and other procedures more than it values checkups and management of existing conditions. West, a primary-care doc, explains it this way: “If I put in an hour with a patient, I will be reimbursed for one exam–the same payment I would get for seeing that patient for 11 minutes. Meanwhile, an ophthalmologist might perform three cataract surgeries in that same hour, and each surgery might be reimbursed at twice the rate of my exam. So that doctor is making six times as much money.”

And if the eye patient has questions after the surgery about her medicine or her recovery, the specialist’s office is likely to suggest that she consult with her primary caregiver. After all, neither doctor gets reimbursed for answering questions on the phone, so the chore is often traded like a hot potato. “We say primary care is critical to a healthier future,” West says, “but in every way we show value, it is at the lowest level.”

Doctors without Borders is using donated advertising on free medical imaging social network Figure 1 (“Instagram for doctors”) to recruit Ebola volunteers. The app automatically detects faces in submitted photos and blocks them for privacy and allows users to manually block other identifying features. Images are also moderated before posting to make sure they have been de-identified. The Toronto-based company has raised $6 million in funding and was founded by (a) a professor and writer with a JD and Columbia MBA; (b) an internist who describes himself as having an “above-average sense of humor and below-average physical fitness”; and (c) an iOS app developer.

A Harvard Business Review article called “The Antidote to Fragmented Health Care” contains as  one of its recommendations universal EHRs. It doesn’t define exactly what that means, but references the VA’s VistA, Kaiser’s HealthConnect, and the OpenNotes initiative. Looking back at all the money (taxpayer and otherwise) spent on EHRs and HIEs, maybe the better and cheaper alternative would have been to buy or create a nationalized EHR. Or, as I proposed years ago, mandate use of a standardize EHR database structure with rule-defined fields and let vendors compete based on the user interfaces and add-on capabilities they sell beyond the basic database-populating parts of the EHR.

Trustees of Regional Medical Center (SC) approve an extra $500,000 to implement Cerner’s document imaging system, with its president explaining that the hospital had underestimated the number of departments that would use the system and the volume of documents to be converted.

The annual report of the Pennsylvania eHealth Partnership Authority says its biggest challenge is funding (duh) after its ONC grant ran out earlier this year, when it asked for $1.85 million in state support. Now it wants $4.7 million for the next fiscal year, explaining that it failed to generate the charitable donations it expected, user fees that were supposed to start kicking in earlier in 2014 won’t start until mid-2015, and even then those fees “will not reach levels that contribute significantly to Authority sustainability until most HIOs are onboarded to the P3N in 2016.” Translation: we don’t don’t know how to run a business, every one of our plans and projections were wrong and have been scrapped, and it’s highly doubtful anyone will ever pay us for the services we may eventually offer. Therefore, taxpayers should provide a never-ending flow of money so a poorly conceived, ever-changing, and incompetently executed idea can be pushed onto a market that doesn’t want it.

An apparently serious study finds that the 30-day mortality rate of high-risk heart failure and cardiac arrest patients admitted to teaching hospitals is lower when cardiologists leave to attend national conferences. I remember reading years ago that death rates dropped when hospitals were closed due to strikes.

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Sponsor Updates

• Greenway Health releases version 3.1 of PrimeMOBILE.
• EDCO Health Information Solutions posts two new case studies involving its Solarity medical records scanning and indexing solution.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

Morning Headlines 12/23/14

Supreme Court to Hear Arguments in Big Health Care Case on March 4

The Supreme Court will hear King v Burwell on March 4. The case argues that the Obama administration overstepped its authority by providing federal subsidies to Healthcare.gov users when the ACA’s language only authorized subsidy payments for insurance acquired through state-run exchanges.

89 ACOs will join Medicare Shared Savings Program in January

CMS announces that 89 new ACOs will join the Shared Savings Program effective January 1, 2015.

Accretive Health Provides Updated Timeline for Completion of Restatement

Accretive Health, a Chicago-based revenue cycle management company, will file its long overdue 2012 and 2013 year-end financial statements next week. The company will also publish restated 2011 statements.

Electronic Distribution of Prescribing Information for Human Prescription Drugs, Including Biological Products

A proposed rule by the FDA will require that pharmaceutical companies replace the paper-based prescription drug handouts written for doctors with electronic ones that can be updated in real-time.

Curbside Consult with Dr. Jayne 12/22/14

As the year closes out, my hospital’s employed physician group continues to acquire physician practices under the guise of building its accountable care network. At this stage in the game, however, the strong independent practices have either grown to a point where acquisition isn’t a viable option or have banded together as part of IPA groups and aren’t interested in being employed. For the rest, however, it seems there’s no practice too questionable for us to purchase.

I was out of the office last month when the operations leaders did due diligence on a small pediatric practice. I had heard that there were some “interesting” things noted on the site visit, but leadership was bent on purchasing it anyway. The physician is close to retirement and they figure they can just plug a new physician (straight out of residency) in July and absorb the patient volume as the owner steps away into the sunset. In the mean time, my team’s job is to get the EHR live, transform care delivery to bring them up to MU-ready standards, and deal with all the fallout.

I went to the office on Friday for an initial workflow review. One of the implementation team members is fairly new, and although skilled with EHR, has never converted a practice from paper. The team lead who was supposed to be running this one ended up having her first grandbaby arrive, so I stepped in to cover the day of shadowing.

We have a checklist of things to review and we also shadow office staff as they go through their daily activities. Ultimately we’ll create current state workflow maps and use those to derive a future state. We’ll take that back out to the practice and validate it with the physician and office manager, put together a Team Operating Agreement, and then schedule them for implementation.

Often there is a fair amount of clean-up that has to be done with the workflows and addressing that is within the purview of our implementation team. Our operations staff initially fought us on this, but finally conceded that practice roles and responsibilities, patient flow, and EHR workflow are so intertwined that they can’t be addressed separately (especially if you’re trying to bring practices live on a rapid cycle). They also didn’t have the resources to adequately handle process improvement, so it was an easy “poach” when I decided it needed to live on my team.

My initial impression from the waiting room was a good one – freshly remodeled, new furniture, adequate space, and a cool salt water fish tank that the patients were enjoying. The receptionists were friendly and using computers proficiently. The exam rooms were large, with plenty of space to add a computer workstation and not lose the room needed to park strollers and the extra family members who often come to visits with new babies. I liked the way the layout clearly separated the “on stage” patient care areas from the “off stage” staff work areas, which not only helps control clutter, but reduces risk of patients overhearing phone conversations.

Once I stepped into the staff area, a veritable house of horrors awaited me. I wasn’t sure whether they over-spent on the furnishings and remodel and tried to make it up by skimping on the rest of the office or whether they just didn’t care. The back half of the office was just dirty. From the stained butcher block table in the staff lunch room to the piles of trash bags by the back door, I couldn’t believe what I was seeing. They knew we were coming, and if this is how they present the office for an assessment, I couldn’t imagine what it would look like if we showed up unannounced.

The counters and workspaces were crowded, with open drinks and snacks in the lab area, food crumbs in the keyboard of the computer they use to access the state immunization registry, and trash on the floor. Really, trash on the floor. Not the “oops, I dropped the cap to that needle while I was drawing up that injection” kind of trash, but the “I just don’t care and can’t be bothered to walk to the can because it’s on the other side of the room” kind of piles.

The cabinets and walls were covered with so many “don’t forget to do this” or “X insurance requires that” notes and stickies that you couldn’t even see the walls. More than two-thirds of them were obscured and some of them had been there for years based on the dates.

We started the assessment and quickly determined that no staff member had been there more than a year. Most had been there less than six months and two were new that week. That’s a red flag, as was the presence of the owner’s son as office manager.

In the positive column, we knew all the clinical staff would be at least minimally tech savvy because they were using their smart phones constantly, even when work piled up and patients were waiting.

We went through our usual questions about training and on-boarding, how work is divided, patient flow, and so on. I also asked about the remodel of the front half of the office (14 months ago) and how long the son had been managing the practice (18 months).

The timing of the son’s arrival and its association with staff tenure was suspicious, as was the timing of the remodel. Pediatric practices are not exactly centers of profit, especially small solo ones. They’re a labor of love for most physicians, and if not run right, can be more chaotic than other specialties. I wasn’t sure whether the son had been brought in to try to remediate a problem or whether he was the cause. Unfortunately, the latter was confirmed when we had a chance to sit down with the physician later in the day.

I haven’t heard such a sad story in a long time. The owner’s son had gone to college with the goal of being pre-med and eventually taking over the practice. His grades weren’t good enough to get into med school, so Dad financed an MBA at a for-profit university and hired him to manage the office instead. With no understanding of medical practice management or the realities of office cash flow, he embarked on an aggressive campaign to improve the office’s appearance.

Driving them further into debt, he terminated the seasoned staff because they were costly and he assumed they were replaceable. The office spun further and further out of control and for love of family the owner didn’t want to reach out to a consultant or anyone else who could help. Ultimately, they felt they needed to sell to remain viable. He saw the purchase by the medical group as a way to continue doing what he loves and apparently wasn’t aware of the plan to add a physician to the practice in six months.

Having been in this business as long as I have, none of this should be surprising. Still, every time I hear one of these stories, it shocks my sensibilities. First, that there are physicians in this day and age of regulatory complexity that still think a practice can be family run without specific training and administrative support by someone who actually knows what they are doing. Second, that the son was still in the practice even though we had acquired it. Usually we have a pretty good track record of buying out those kinds of situations when we take over. And third, that my own employer actually thought acquiring this practice was a good idea.

Looking at reimbursement rates for general pediatrics, we won’t break even for a decade. It may be the right thing for the community, though, and I hope they acknowledge this and react accordingly when the negative financial statements start documenting what our guts already know. In the past, they haven’t been sensitive to the realities of acquiring damaged goods. Their knee-jerk reaction will likely be to push the physician out, replace him with a younger model, close the office proper, and move the “practice” (aka patient base) to an on-campus office.

In the midst of all this chaos, we’re supposed to deploy EHR and have happy satisfied end users without expending more resources than are budgeted. Good thing the OSHA, CLIA, HR, and regulatory remediation won’t come out of my budget.

We’re going to do our best with this practice. Although I’m not terribly hopeful, we’re in it to win it. As for our operational leadership, however, I’d like to throttle them.

Does your employer make business decisions that leave you shaking your head? Email me.

Email Dr. Jayne.