Readers Write: Information Blocking: Don’t Blame the EHR

Information Blocking: Don’t Blame the EHR
By Michael Burger

Healthcare IT seems to be getting some attention in Washington these days, and not necessarily in a positive way. As a case in point, a statement which affects healthcare IT was included in an explanatory statement by the chairman of the House Committee on Appropriations regarding the house amendment to the recently passed government spending bill.

Information Blocking. The Office of the National Coordinator for Health Information Technology (ONC) to use its authority to certify only those that … do not block health information exchange. The agreement requests a detailed report from ONC … regarding the extent of the information blocking problem, including an estimate of the number of vendors or eligible hospitals or providers who block information.

This is clear evidence that Congress is frustrated by the relative lack of data exchange despite an investment of $30 billion for healthcare IT. As the explanatory statement states, “ONC should take steps to decertify products that proactively block the sharing of information because those practices frustrate congressional intent, devalue taxpayer investments in CEHRT, and make CEHRT less valuable and more burdensome for eligible hospitals and eligible providers to use.”

No question, information blocking is a significant factor in the lack of data exchange. It is appropriate for Congress to expect a return on taxpayers’ investment. What concerns me is the prevailing but erroneous perception that EHR vendors have conspired to block information.

In the nascent HIT business of 20 years ago, there was a notion of a “closed system,” where data was only accessible by those using that system. In those days, the closed system was certainly used to sell additional software by controlling the flow of data. That business model was ideal for a marketplace many years ago with few competitors and no real demand for interoperability.

However, such a strategy no longer exists in today’s HIT marketplace, if for no other reason than to meet the certification requirements for Meaningful Use (MU), EHRs must be capable of interoperability with other EHRs. A claim that a company’s EHR “doesn’t work well when you mix and match vendors” would not be a smart selling tactic, since it openly defies the very premise of MU and because there are many, many competitors.

There are fees from EHR vendors for interoperability, data extraction, and conversion from one system to another. These cover the vendor’s cost to do the work plus a profit margin. (Let us not forget that these are, in fact, for-profit businesses.) While the marginal cost of extracting the data may be small, it is not a provider’s inalienable right to have their vendor provide services for free.

One form of information blocking is called a “walled garden.” In Joel White’s recent blog post regarding Information Blocking, he says, “Information blocking [in a walled garden] occurs not because different technologies or standards prevent data transfer between EHRs, but because EHR vendors or health care providers engage in this activity as a business practice. This is not a technology problem, but a competition one.”

I disagree that EHR vendors in recent times conspire to strategically erect walled gardens, but I do see that healthcare providers routinely engage in this activity as a business practice. The following example illustrates my point.

Let’s say that there are two integrated delivery networks (IDNs) in a given market. Each IDN has acquired ambulatory practices and positioned itself to be able to offer a full spectrum of care, from pediatrics through geriatrics. Each advertises to their potential customers (patients) that they offer the highest quality, most convenient care in town. There is a competitive and profit incentive to keep patients within the network.

Now let’s say a patient is treated at IDN A and then receives treatment at IDN B. From a public health perspective, the patient’s records should flow from one to the other. But from a business perspective, there is no incentive in making it easier for a patient to go out of network and seek treatment at the other IDN. All IDNs use EHRs that are capable of exchanging clinical data in some capacity, but they do so grudgingly because of competitive concerns.

It’s appropriate for Congress to expect a return on our $30 billion healthcare IT investment. It’s refreshing to see that the authors of the spending bill understand the existence of information blocking. Let’s hope, however, that our new Congress doesn’t take the easy way out and blame EHR vendors for this phenomenon when it is really a result of competition of healthcare providers in the free market.

Michael Burger is a senior consultant with Point-of-Care Partners of Coral Springs, FL.

HIStalk Interviews Rizwan Koita, CEO, CitiusTech

Rizwan Koita is CEO of CitiusTech of Princeton, NJ.

Tell me about yourself and the company.

I have been involved with the company for nearly 10 years now, right from its inception. Prior to CitiusTech, in 1999 I founded TransWorks, a business process outsourcing company. The company was acquired in 2003 when it was about 1,800 strong.

We started CitiusTech in 2005 with a vision of being a provider of technology solutions to the healthcare space. We offer healthcare solutions and services to organizations worldwide including healthcare software vendors, hospitals, medical groups, health plans, and pharma companies. We focus on building deep healthcare domain expertise and technical knowledge. CitiusTech leverages its global workforce in a cost-effective manner to help accelerate innovation in healthcare.

CitiusTech assists its clients and partners build and implement enterprise healthcare technology solutions through its knowledge and experience in the healthcare IT landscape. We’ve grown from zero to 1,600 healthcare technology professionals over the last 10 years, making us one of the fastest-growing teams in the healthcare IT industry.

You offer an analytics product. Who’s getting traction in market and what customers are seeing real results?

Our healthcare BI and analytics solution, BI-Clinical, has been in the market for about five years, helping healthcare providers and services organizations with their analytics and reporting needs. BI-Clinical is deployed at thousands of provider locations across US and is certified against regulatory requirements like Meaningful Use, NCQA HEDIS, PQRS, etc. It offers more than 600 KPIs and quality measures out of the box, and is probably the only solution in the market to have such extensive coverage.

We are seeing significant traction in the market for BI-Clinical, primarily because of its ability to integrate clinical and financial data from different source systems and offer out-of-the box analytics capabilities for use cases like readmission management, population health, and risk-based contracts.

How are you using the $100 million investment by General Atlantic?

I believe that the healthcare space is still very nascent in terms of technology adoption and process evolution. Over the next 5-6 years, I expect this market to grow substantially, both in terms of size and complexity.

To address growing market needs, CitiusTech is making strong investments in four key areas. We are expanding our portfolio of service and solution offerings, especially in new areas like big data, mobility, and analytics. We have also established a strong data informatics group, where our in-house data scientists are helping clients mine clinical data. We are expanding geographically across the US, Europe, and Asia Pacific. In addition, CitiusTech is looking for strategic partnerships or investment opportunities in other healthcare organizations with complementary offerings

What new healthcare IT-related technologies do you think are most promising?

We are seeing tremendous innovation all across the technology landscape, in the areas of analytics, cloud computing, mobile health, and big data. The key challenge for healthcare organizations has been to effectively leverage these innovations in the context for healthcare. Say, using rapidly evolving mobile platforms while ensuring compliance to HIPAA, patient data privacy, safety, or disaster recovery.

So it’s not just the technology, but also the means by which the healthcare industry can use these new tools effectively that hold great promise for the future.

You’ve already created and sold a large company. What are the most important business lessons you’ve learned?

Focus is important. It’s easy to get involved in many initiatives, spread too thin, and lose patience. One needs to understand that any new initiative takes a lot of time to grow or show tangible results.

Secondly, it’s my belief that businesses should keep innovating to stay ahead of the curve. We live in a world where it may not be enough to just solve the customer’s problem, but we would also need to solve them at a much faster pace and at a more competitive cost than others.

More importantly, organizations should place their most valuable asset, employees, at the center of their philosophy. In a knowledge-driven economy, businesses need to place greater emphasis on capability development of their people. At CitiusTech, capability development is the biggest investment we make for growing our organization as a whole. CitiusTech has more than 600 of its engineers HL7 certified. Through our extensive internal knowledge portal called UniverCT, we help our employees constantly upgrade their healthcare domain knowledge.

You wrote two years ago that social media was a vital part of maintaining the company’s culture as hiring ramped up quickly. How do you see it being used by healthcare providers?

The power and influence of social media is gigantic. Social media today has really brought the entire world closer, and at the same time, has disrupted the traditional models of sharing information. I feel healthcare organizations need to hop on to this changing information ecosystem that is being driven less by the enterprise and more by consumers.

The new payer-provider engagement models like ACOs create significant financial upside for healthcare organizations to continue their engagement with consumers and patients outside the traditional care setting.

How would you characterize the healthcare IT market over the next five years?

The last five years have seen significant technology investments by healthcare companies, partly driven by technology innovation and also because of the healthcare reform initiatives announced by the Obama administration. In fact, for all the criticism it has received, Obamacare probably deserves more credit than it gets for accelerating healthcare technology adoption, changing payer-provider dynamics, and paving the way for better healthcare information access and efficiency.

Over the next five years, it will be interesting to see how the healthcare IT market leverages patient data to enhance clinical outcomes and optimize care delivery. I feel that with a wider use of analytics technology like big data and predictive algorithms, caregivers will be able to make significant improvements in population health, disease management, and care coordination programs.

Also, with the increasing adoption of powerful consumer devices like smartphones, tablets, and wearables, patients will start to have a greater say in the care delivery process. We are already witnessing leading mobile vendors like Apple, Google, and Samsung investing heavily in enhancing mobile devices to support tracking of patient vitals and other healthcare information.

Organizations that can effectively leverage these trends — using clinical data for analytics and engaging patients using mobile and social media — will be very successful.

Morning Headlines 1/30/15

CMS intends to modify requirements for Meaningful Use

Following months of growing pressure from industry groups, CMS announces that it will reduce the 2015 Meaningful Use reporting period for from 365-days to 90-days.

Best in KLAS & Category Leaders 2014

KLAS publishes its annual “Best in KLAS” awards, with Epic winning top spot for: Acute Care EMR, Ambulatory care for practices over 10 providers, HIE, LIS, Billing, Surgery Management, and Patient Portal. MEDITECH 6.0 wins Best in KLAS for community hospital EHRs, and Wellsoft wins best stand-alone EDIS.

This Medical Supercomputer Isn’t a Pacemaker, IBM Tells Congress

IBM has been lobbying Congress to push the newly introduced 21st Century Cures bill through to ensure that its Watson supercomputer is protected from FDA oversight.

News 1/30/15

Top News

CMS announces plans to shorten the 2015 EHR reporting period to 90 days and to change hospital reporting to be calendar year in a new rule it expects to be approved in spring 2015.

Reader Comments

From Information Dirt Road: “Re: Practice Fusion. Earlier this month they interfered with all lab results traffic during peak business hours and now are having another outage. All who work with PF are cursed by the absurd spectacle of PF being the clueless center of their own special universe.” They have a scheduled weekly maintenance window of Thursdays from 9 p.m. to 1 a.m. Pacific, which seems sensible to me. I followed the link to their EHR status page, which appears to be rarely updated.

From HIS Junkie: “Re: HX360. I thought this was supposed to get people going on a new interoperability phase of HIT, but HIMSS has created a new meeting program for it right in the middle of its conference. It’s amazing how fast HIMSS jumped on this to make another buck.” I’m not a fan of co-located conferences, but you can watch a just-posted interview with HX360 CEO Roy Smythe, MD for more on what they’re doing. The HX360 exhibit hall is included with normal HIMSS15 registration, the full track is an extra $225, and the executive sessions are invitation-only.   

From Deli Meat: “Re: electronic signature pads. Thanks for an amazing website. We are trying to reach Topaz Systems about problems with their signature pads that we use in registration with Epic. Emails are bouncing, phone calls aren’t returned, and their website seems to be down. Please assist with any insider information you may have.” The website is up for me and I got a live salesperson when I called their number, so I passed along your email address and said you needed help as a live customer.

HIStalk Announcements and Requests

I forgot to include a link to the the now-separate Dr. Jayne post in the email update, but it’s right here.

If your company sponsors HIStalk and didn’t receive our email in which we’re taking RSVPs for our HIMSS sponsor networking event and collecting information for our HIMSS guide, contact Lorre. Sometimes the information we have for contacts is incorrect or even missing entirely.

We’re still accepting applications through February 9 from real patients who want to attend the HIMSS conference with a $1,000 scholarship and registration provided. These are for non-healthcare IT folks who have a compelling patient story to tell and who want to attend the HIMSS conference and write about their experiences on HIStalk afterward. Email Lorre with your story and why you want to attend – we’ll judge on both motivation and writing ability.

This week on HIStalk Practice: Telehealth takes over the headlines, with state licensing issues and vendor compliance making the news. GE Ventures looks to HIT to the potential tune of $40 million. Community Eye Center Optometry goes with VersaSuite. Doximity offers interactive physician salary data by state. Premedex launches new chronic care management solution for physician practices. Clinicient secures $7 million. Customer satisfaction with government services reaches a new low. Google Fiber heads southeast.

This week on HIStalk Connect: Google partners with Biogen Idec in a multi-year project focused on researching multiple sclerosis. The FDA approves the first smartphone-connected continuous glucose monitors, technology that diabetics have been demanding for years. Researchers from the University of Pennsylvania find that Twitter data analytics can be used to create highly accurate maps depicting the prevalence of heart failure at the county level. 

Welcome to new HIStalk Gold Sponsor CenterX. The Madison, WI company’s next-generation e-prescribing network improves medication adherence by closing the physician-pharmacist loop. It offers enterprise medication authorization, formulary management, pharmacy benefit eligibility, and medication profiles. Doctors are notified when the prescription is picked up and flat rate pricing eliminates the per-transaction penalty that discourages communication. Physicians benefit from electronic refill requests and automated prior authorization. Only about 40 percent of patients nationally pick up their prescriptions and use them correctly, but CenterX users have up to 90 percent adherence. The company just announced that it has fully integrated its Enterprise Medication Authorization solution with Epic. Thanks to CenterX for supporting HIStalk.

Acquisitions, Funding, Business, and Stock

Lexmark turns in anemic Q4 results, but its Perceptive Software business books a solid quarter.

Sales

Penebscot Community Health Care (ME) chooses Forward Health Group’s PopulationManager and The Guideline Advantage.

St. Joseph Health (CA) selects Clinical Architecture’s Symedical for terminology management, semantic normalization, and interoperability.

People

St. Tammany Parish Hospital (LA) promotes Craig Doyle to VP/CIO.

Impact Advisors promotes Jenny McCaskey to VP.

Richard Holada (IBM) joins Truven Health Analytics as chief data and technology officer.

Announcements and Implementations

First Databank announces GA of FDB Cloud Connector, an Amazon Web Services-powered web API solution that reduces development time and IT overheard required to deliver FDB’s drug knowledge. Meditech was an early adopter, and interestingly, the company mentions that future pharmacogenomics decision support may be impractical to deliver by traditional means.

Medsphere announces OpenVista Population Health, a Windows-based enhancement developed by the Indian Health Service for its RPMS ambulatory EHR version of the VA’s VistA. The company signed a $15 million contract in 2011 to support and enhance RPMS.

Epic wins Best in KLAS 2014 for overall software suite, acute care EMR, HIE, patient accounting, patient portal, surgery management. Epic Beaker beats the best-of-breed LISs as the #1 lab system (although one might argue that Epic Care Everywhere as the #1 HIE is equally surprising). Epic also wins best physician practice vendor and several EHR/PM categories. Athenahealth wins for practice management in the two larger practice size categories (11 docs and up), while Impact Advisors takes the top spot in overall IT services and clinical implementation principal.

Government and Politics

New ONC Meaningful Use Stage 2 numbers show that 88 percent of hospitals that are MUS2 eligible have attested so far with an April 2015 due date, with 25 percent of those using the Flexibility Rule. EP attestations are much less robust, with only 15 percent of MUS2 eligible providers attesting so far with a February 28 due date and nearly half of those using the Flexibility Rule.

Privacy and Security

The psychologist who pioneered the study of facial expressions in the 1970s fears that companies will use his work to infringe on privacy. Software can measure consumer reaction to ads, but is being extended to detect shoplifters and to interrogate suspects, leading him to worry that facial expression algorithms will be used in public spaces without consent. On a positive note, the technology is being testing for measuring post-operative pain and to detect stress levels.

Technology

A New York Times editorial by a Mayo Clinic anesthesiologist warns that despite President Obama’s call for heavily funded research for precision medicine, it won’t make most people healthier. He says that genes can’t predict the most common and expensive chronic diseases, but we can already do that with simple tests, while the treatment is decidedly non-technical: eat better, exercise more, and don’t smoke. He concludes that “moonshot medical research initiatives” such as the “war on cancer” usually fail and that efforts would be better directed to studying human behavior.

Bloomberg Business says IBM has lobbied Congress for two years to pass the 21st Century Cures bill that would keep Watson-powered medical capabilities free of FDA oversight. The bill, which also includes the Software Act and addresses several health IT issues, was drafted by the House Energy & Commerce Committee, whose Democrat members just pulled their support of the bill.

AliveCor’s smartphone-powered heart monitor earns FDA approval for new algorithms that assess an ECG as normal and that warn users that interference makes the ECG unreliable. The just-introduced third generation model costs $75, creates readings from a two-finger touch, and includes an algorithm to detect atrial fibrillation.

Other

A group of health systems – including Advocate, Ascension, Atrius, Dartmouth-Hitchcock, Dignity, OSF, Partners, Providence, and SSM — and other healthcare players unite under the name Health Care Transformation Task Force in committing to put 75 percent of their business into value-based payments by 2020.

A NEJM study suggests that while the Affordable Care Act prohibits insurance companies from excluding coverage for pre-existing conditions, they may be using high drug co-pays to keep people with expensive diseases such as HIV from signing up in the first place.

The bonds of Einstein Healthcare (PA) are downgraded due to financial losses that are partly attributed to a drop in employee productivity caused by its Cerner EHR.

Massachusetts General Hospital (MA) used telemedicine virtual visits during the recent snowstorm when clinics closed.

A physician’s editorial in NEJM called “Death Takes a Weekend” ponders the age-old question of why — in this age of high-acuity admissions and fast discharges — hospital services shut down on weekends. “It seemed callous on the hospital’s part — expecting very sick patients and very worried family members to understand that the doctors’ convenience had to come first. They need the weekend off, so you’ll have to wait till Monday. Even in good hospitals, weekends had a decidedly makeshift feel, with a constant refrain of ‘I’m just cross-covering, we’re short-staffed, the person you need will be here Monday.’”

Weird News Andy researches scam online medical journals that charge authors to publish their work. A doctor tests their editorial review process by submitting an article composed of randomly generated phrases titled “Cuckoo for Cocoa Puffs?” with primary authors Pinkerton LeBrain and Orson Welles. Seventeen of 37 journals accepted it within the first two weeks and offered to publish it upon submission of a processing fee. One of the journals shares an address with a strip club. I checked out Global Science Research Journals, which publishes dozens of journals such as “Global Journal of Neurology and Neurosurgery” and “Global Journal of Pediatrics” and charges a $500 per article fee. The Nigeria-based publisher’s US office is in a Brooklyn apartment.

Another WNA find he calls “My Doctor the Car”: Mississippi’s medical board investigates an 88-year-old doctor whose practice consists only of house calls, saying they don’t like the idea that he writes prescriptions from his 2007 Camry. In the TV station video, a guy walks right up to the car window to explain his medical issues. WNA proposes a solution: he should upgrade to an RV.

Sponsor Updates

• Named as KLAS Category Leaders for 2014 are Sentry (340B management inpatient), SIS (anesthesia), Merge (cardiology hemodynamics), Zynx Health (CDS care plans), Wolters Kluwer (CDS order sets), Premier (CDS surveillance), Optum (computer-assisted coding), Strata Decision (decision support business), Emdeon (eligibility enrollment), NextGate (EMPI), Allscripts (global acute EMR, Northern America), Encore (go-live support), GetWellNetwork (interactive patient systems), Capsule (medical device integration), Nuance (medical records coding, quality management), Ingenious Med (mobile data systems), Nordic (other implementation), TeleTracking (patient flow), Iatric Systems (patient privacy monitoring), Craneware (revenue cycle charge capture), SSI Group (revenue cycle claims management), and GE Healthcare (staff/nurse scheduling, time and attendance).
• Named Best in KLAS 2014 are Merge (cardiology), ZirMed (claims and clearinghouse), Impact Advisors (overall IT services, clinical implementation principal), Wellsoft (emergency department), Streamline Health (enterprise scheduling), McKesson (ERP), Allscripts (global acute EMR), CareTech Solutions (IT outsourcing extensive), Orchestrate Healthcare (technical services).
• Logicworks publishes the eighth installment in its DevOps Automation series, entitled, “Improving the End User Experience with Amazon Web Services.”
• Orion Health earns accreditation as a HISP.
• William Seay of Lifepoint Informatics writes a new blog entitled, “Get Your Laboratory & Anatomic Pathology Results in Real-Time, When You Want, How You Want & Where You Want.”
• LifeImage’s Mike Murphy blogs about saving time, increasing referrals, and improving orthopedic patient care via medical image sharing.
• PDR will exhibit at the NACDS Regional Chain meeting in Naples, Florida on February 2-4.
• Ivenix Medical Advisor and anesthesiologist Matt Weinger, MD shares his views on infusion pump technology at the Association for the Advancement of Medical Instrumentation’s blog.
• Kathleen Aller writes about looking for meaning in mounds of data in the latest InterSystems blog.
• HealthMEDX offers insight into its full EHR implementation at Lexington Health System (KY).
• Jim Blanchet, associate management consultant at Greencastle, blogs about “The Valley of Despair” and asking yourself the right questions.
• The HCI Group offers five tips on meeting the ICD-10 implementation deadline.
• Pepper McCormick writes about the four healthcare trends that will shape 2015 in the latest Healthwise blog.
• Greythorn will exhibit at this weekend’s Geek Wire Startup Day in Seattle.
• Health IT Outcomes profiles e-MDs and its work to exchange provider data directly with the new Kansas infectious disease registry.
• DocuSign announces that over 50 million people in 188 countries now use its technology.
• The Healthfinch team offers a new blog on healthcare IT assumptions versus reality.
• Cynthia Ethier of Hayes Management Consulting offers advice on how to create an ACA front desk.
• HDS takes a look at the growing phenomenon of walk-in clinics at local malls in its latest blog.
• Ingenious Med Mobile Product Manager Brannon Gillis posts a new blog entitled, “Useful and Usable: Basic Mobile Development Philosophy in Action.”
• ICSA Labs participates in the IHE North America Connectathon today in Cleveland.
• Extension Healthcare will exhibit at the Association of California Nurse Leaders Conference in Anaheim from February 1-4.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

EPtalk by Dr. Jayne 1/29/15

The physician lounge was buzzing this morning with discussion of HHS secretary Sylvia Burwell’s newly-announced goals for the Medicare program. The plan is to move 90 percent of Medicare fee-for-service (FFS) payments to a quality-based system by 2018 and to move 50 percent of FFS payments into “value-based alternative payment models” on the same timetable.

Although we’re pretty far along with the quality-based payments, we’re nowhere near that far with alternative models (such as ACOs). When you consider the number of providers who have failed to join (or dropped out of) ACO programs, that’s a pretty audacious goal. The general tone among my colleagues is this: they’re supportive of quality, but would like to see other institutions (especially the Medicare and Medicaid bureaucracies and Healthcare.gov) held to the same standards.

I didn’t watch the State of the Union Address to hear about the President’s “Precision Medicine Initiative” but have been asked a couple of times what I think about it. Although it is very sexy, precision medicine is also very expensive. I surfed around for some quote from the Address and the Initiative purports “to give all of us access to the personalized information we need to keep ourselves and our families healthier.” It reminds me a little of end users who refuse to use the EHR because it doesn’t have one sexy feature or another. I have to talk them into using it to get the benefits it actually has rather than worry about what it doesn’t have. We need to figure out how to better encourage patients to take advantage of the general (but very effective as well as inexpensive) medicine advice we already have: eat less, move more, make healthy choices. Alas, daily exercise and delayed gratification aren’t as exciting as the idea that technology will fix all that ails us.

As a CMIO, I spend a fair amount of time listening to what physicians don’t like about our software. It’s always interesting when we perform an upgrade, and while some users like it, others consider it a “downgrade.” Sometimes the complaining is justified, but it always feels more acute when it’s a problem with the EHR rather than consumer software. I was interested to see a software firm other than Microsoft or Yahoo make a blunder recently. Intuit is under fire for realigning the features of its popular TurboTax product. Since I’ve already spent a couple of hours this week preparing all my documentation, I’m glad I saw this letter to customers that explained that the version many of us have used for years will no longer meet our needs. They’re trying to make it up to users with a $25 rebate. That’s about 50 percent of the purchase price of the version in question. Extrapolate it for what we pay for medical software and that could get interesting for a vendor who wanted to make good on a dodgy software release.

Speaking of vendors, I have a couple of physician friends who work in the vendor space. If you’ve ever wondered why they’re not spending all their time creating usable new features that physicians need and want, take a look at the test procedures they have to follow in order to get the product certified. If you’ve never seen them, let’s just say they make CMS billing regulations look like a pre-K reader.

Researchers at the University of Pennsylvania have harnessed Twitter to predict rates of coronary heart disease. Analyzing the content of tweets by county, “they found that expressions of negative emotions such as anger, stress, and fatigue in a county’s tweets were associated with higher heart disease risk.” Although there is no expectation of privacy when using Twitter, I couldn’t help but think about the documentation needed to do this kind of human studies research. Maybe Twitter should add something about it to their terms of service.

Another interesting twist on their work is the comment by one researcher that, “You’ll never get the psychological richness that comes with the infinite variables of what language people choose to use.” This is exactly what EHR-using physicians have been saying for years – that it’s impossible to get the “flavor” of the patient’s story through checkboxes and templates. I’m looking forward to the day when I can go back to dictating my notes and letting voice recognition and natural language processing do the heavy lifting of turning it into something appropriate for coding, billing, and interoperability.

The research team has experience with linguistic analysis, showing it can be as effective as questionnaires in assessing personality characteristics. I hope they’re not looking at my tweets, because given their recent infrequent nature, they would likely determine that I’ve become reclusive.

What does your Twitter history say about your personality? Email me.

Email Dr. Jayne.

Morning Headlines 1/29/15

Major Health Care Players Unite to Accelerate Transformation of US Health Care System

A large group of private health care systems and payers have formed a coalition with a goal of migrating 75 percent of their business to value-based arrangements by 2020. Called “The Health Care Transformation Task Force,” the new organization is comprised of 16 health systems, including: Ascension Health, Dignity Health, and Partners Healthcare.

Internet of Things: Privacy & Security in a Connected World

The FTC is taking flack over recommendations made in a new data security report that addresses the coming “Internet of Things.” The report calls for updates to HIPAA that would expand its consumer protection standards to apply to any consumer-facing products that capture patient health data. The report also champions the notion of data minimization, the idea that businesses should redesign their processes with the goal of capturing and retaining less data, an idea with few fans in healthcare.

Data Analytics Update: Health IT Standards Committee Meeting

During yesterday’s HIT Standards Committee meeting, ONC reported that only 15 percent of eligible professionals scheduled to attest for Stage 2 MU have done so. Further, nearly half counted among the 15 percent that have successfully attested did so by securing a hardship exemption.

Committee releases to-do list to help medical industry

A group of bipartisan lawmakers introduced a 400-page draft proposal titled  “21st Century Cures” which would cut red tape from FDA approval processes, increase access to telemedicine, and invest in research to improve the security of medical devices.

CIO Unplugged 1/28/15

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

Beyond the Summit

The follow-up exam confirmed the base camp physician’s initial diagnosis. My eyes welled as the valley echoed with a familiar roar of the medevac chopper engines making the treacherous flight to reach the high ridge.

We had barely arrived at Base Camp Plaza Argentina, a mere 4,200-meter elevation, when the fickle finger of HAPE touched my lungs. I had to abandon my bid for Aconcagua well short of the summit. The fact that I’d summited peaks higher than this base camp did not matter.

Six years ago, I’d started climbing, and since then, I’d summited 20-plus peaks. I realized mountains ago that the true prize was never in conquering the actual summit. If I really listened and reflected, each climb embodied a much deeper lesson. An epiphany. I wrote about this a few times. Kilimanjaro, Rainier and, most recently, Elbrus.

Where I’d always connected these lessons to my success in summiting, I was now perplexed by Aconcagua.

Our team had formed and stormed for a couple of days in Mendoza, Argentina. The age range spanned 30 years. Germans, Scottish, Brazilians, and North Americans. Singles, one couple, friends, and in my case, climbing partners composed this diverse team. All were surprisingly equal in abilities, well prepared, fast, and strong. And of course we had talented guides who took us places our passports could not.

Once on the trail, we traveled 8-10 miles each day. We climbed 2-3,000 feet elevations before making camp each night. One day, we even outpaced the mule team carrying half our gear. We reached Plaza Argentina swiftly and efficiently.

We set our tents on the Plaza and all of us dealt with typical altitude issues. The few hours before dinner, we rested. As I laid my head on my makeshift pillow, I heard gurgling noises when I exhaled. My experiences and training said this was a telltale sign of things not good. Our lead guide Zeb did a pulse ox. Dropping under 90 was reason for concern—I was 65! My heart rate was 80 (my normal resting heart rate is 42). Obviously, it would go up in altitude, but this was twice the norm and my breathing was already labored. I suffered a major headache and my BP was out of range.

Given my climbing résumé, we tried to fix things with drugs to accelerate acclimation. Nothing worked. My oxygen saturation stayed dangerously low. HAPE had won.

If you’ve never experienced High Altitude Pulmonary Edema, taste this. The night before my medevac chopper ride, the physical misery was indescribably frightening. Water invaded my lungs as if to drown me alive. The lack of O2 getting into my veins rendered me lethargic; every step stole my breath. I had zero energy.

After I got the final diagnosis that morning, I had to tell the team that the incoming chopper had come for me. I approached our mess tent where my companions were eating and I started bawling. I stopped and took deep, labored breaths to compose myself. I said 10 words and my emotions overwhelmed me again. I touched my heart, eyed each of them, and then left to be alone.

Frank (Tucson Medical Center CIO) helped me gather my belongings. He and I were tight, having shared many tents in the past. He’s like a brother. He provided comfort. I took what I needed to get by for the day. My bags would come down by mule later that evening.

Frank and Zeb stood with me as I waited to load the bird. I don’t bawl often, but overwhelmed with sadness and inadequacy, I convulsed. Another climbing buddy Adriane came over. A sister, we also climbed together previously and enjoyed singing. A mother and teacher, she consoled me. One by one, my team came to the helipad. We shared hugs and tears. They stood there waving as I lifted off. On the bright side, they no longer had to groan at my puns or hear me sing.

Five months prior to this climb, I ranked top 10 at the world’s highest triathlon. Four months prior, I completed my second Ironman in record time. Three months prior, I was the top 100 duathlete at the World Championships. Two months prior, I was flirting with a 90-minute half marathon. One month prior, I was traipsing around local trails, carrying a 50-pound pack or stair-climbing in my Everest boots sporting a backpack full of 50 pounds of water.

Now I could hardly move.

Not to mention all the high-end equipment I purchased. I’d given talks about the 100 percent success rates for my previous climbing teams. My pride had been at stake.

What was beyond this summit?

The flight out was amazing. To gain altitude and overcome hellacious winds, the pilot did three loops in front of Aconcagua. The beauty left me awestruck. The rest of the ride through the Andes was a sight to behold. I made the most of the experience. Chin up. God was teaching me something. Listening to Him taught me what was beyond this summit.

The chopper dropped me off at the staging area, where I waited for my belongings to arrive by mule. Most of my symptoms cleared quickly. Finally, bags in hand, I headed back to Mendoza and made the most of the next couple of days as a tourist.

What did I learn? Humility for sure. But I also took the time to actually hear God. He’d been speaking to me for a couple of years now, telling me to decelerate. Slow down in all areas of life. Pole-Pole (slow-slow) in Kilimanjaro climbing terminology.

I never listened, despite well-intentioned people telling me. Failure got my attention. I had to learn the difficult and expensive way because I’d clearly refused the easier route. So again, it was never about the mountain. It was about an epiphany beyond the summit. This time, very close and personal.

How about you? Do you have ears to hear and eyes to see the real story around your circumstances? What are the peaks and valleys in your life? It’s rarely obvious to the physical eye. You have to seek it with your heart, because your heart sees and hears what your other organs cannot.

The best news: my team went on to summit that glorious peak on January 12, 2015. At their celebration dinner back in Mendoza, they left an empty chair to honor me.

Now for some Malbec.

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.

Startup CEOs and Investors: Matthew B. Smith

Where’s the Interest in Healthcare Cybersecurity?
By Matthew B. Smith

The President’s State of the Union (SOTU) address mentioned cybersecurity concerns and might serve as a rallying cry for greater adoption in the healthcare industry. We certainly must hope the address will spark a more forceful interest in healthcare cybersecurity.

It is curious how the many non-healthcare breaches (principally banks and retailers) that have received national attention and the financial penalties to healthcare providers under HIPAA and HITECH who have suffered lost and breached patient data (though less well-publicized in the national media) have not caused the groundswell of attention to this issue. As patients assume a far greater role and informed involvement in their care, the security of their personal medical information should elevate as a concern.

However, I do expect that the older generation, as characterized by the Baby Boomers, will express a far greater concern about medical data security. The Xers and Millenials don’t seem to hold personal information in the same high regard as the oldsters and may not be as demanding about its importance. Social media seems to have not created a concern about personal information security among them. It would be a great mistake to assume that this is the standard for healthcare cybersecurity. The higher medical users (chronic and elderly) will be the drivers of this requirement as they will be in more consistent contact with the system.

It is curious that medical device, equipment, and instrumentation (DEI) manufacturers have not stepped up in unison to include cybersecurity as a component of their products. I suspect that EHR vendors and providers (especially those with foresight) who see mobile diagnostics and therapeutics as a reimbursable and cost-effective (we hope!) means of care delivery will be the motivators of this adoption. Patients as consumers will also drive this for reasons noted above. What also is desperately needed is national healthcare cybersecurity standards or certifications so that DEI makers will have an easier time incorporating these much-needed technologies to secure medical information, regardless of the source or the recipient of the medical data.

As a frontline participant in the battle for total healthcare data security, we are finding the education of the DEI makers to be the evolutionary equivalent of watching dinosaurs become extinct. The way to true healthcare data security will have to make it easy for DEI makers to adopt independent third-party data security. Too few have shown the foresight to lead in this setting, citing communications with EHRs and other issues as more pressing coupled with them not hearing a demand from their provider clients. Perhaps they are not listening very well.

National technical standards, well documented for other industries, hold the answer for our industry as the approach so the DEI folks can simply pick and choose a qualifying technology that meets the standards. The DEI folks also show a bewilderingly sad understanding of where the Affordable Healthcare Act is taking reimbursement, which we fundamentally believe will do away with the DEI capital budget and replace it with access to these products on a monitored per use/per subscription/per census day or equivalent acquisition payment mechanism with healthcare cybersecurity monitoring embedded in the payment schema.

The precedents for this movement can be seen in the historic reimbursement changes wrought when DRGs were instituted, when cancer centers were developed, and when patient advocacy services arose. All met opposition, but became new ways of conducting business in the industry. Now is the time for the insistence upon healthcare cybersecurity information technology.

Dinosaurs beware!

Matthew B. Smith is president and CEO of SecLingua of Shelton, CT.

Startup CEOs and Investors: Bruce Brandes

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

All I Needed to Know to Disrupt Healthcare I Learned from “Seinfeld”: Part I – Do The Opposite
By Bruce Brandes

In my continued efforts to learn from progressive healthcare thought leaders, I recently read Eric Topol’s new book “The Patient Will See You Now.” I was heartened to see Dr. Topol’s opening chapter illustrate his first point with an intellectual / cultural equilibrium I can appreciate … through an amusing story from “Seinfeld” about Elaine’s medical record woes. That anecdote caused me to reflect on how my favorite iconic TV show about nothing is instructive for the entrepreneurs who strive to reinvent our healthcare delivery system.

Cautionary note:  my comments in this series will assume that HIStalk readers have at least a baseline knowledge in all things “Seinfeld.” I apologize in advance to the two or three folks out there who have not seen (or heaven forbid, did not like) “Seinfeld.”

Do The Opposite

If you are relatively new to healthcare (and missed Vince Ciotti’s insightful HIStalk series on the history of healthcare IT), you may have asked yourself how Epic became so epic. Like George Costanza’s approach in landing a job with the New York Yankees, Epic did the opposite of what every other healthcare information systems vendor did.  

Most enterprise clinical systems originated as either hospital-centered extensions of patient billing systems, intended to capture just enough clinical information to get the bills out the door (SMS and HBOC) or as an expansion of a niche departmental system (Cerner and Meditech). Epic, on the other hand, began as an ambulatory system focused on winning the hearts and minds of the physicians. Those same physicians would later have significant influence over hospital decision-making. 

Rather than deploying armies of salespeople, Epic let their customers sell for them. Rather than making shortsighted decisions to placate quarterly earnings reports, Epic remained privately held. Rather than growing by multiple acquisitions, Epic expanded organically and built their own software on a common database. Epic had successfully broken down the departmental silos of laboratory, radiology, and pharmacy as well as ambulatory and inpatient records so that the health system could be unified on a singular platform.

However, the radical changes underway in our healthcare system now create an interesting parallel from Epic’s history lesson. Hospitals that are lauded for successfully unifying on a single EMR are as limited today in an Accountable Care Organization or Clinically Integrated Network as the historical single hospital was limited by the siloed departmental systems. To achieve population health, information must be openly shared across disparate systems and organizations. The sky-high costs, antiquated technology, and limited interoperability inherent in these legacy healthcare IT investments may prove to be the Waterloo for hospitals struggling for economic viability and competitive relevance in need of flexibility and agility in a value-based care world.

Emerging, disruptive companies should learn from history – and do the opposite. What might “opposite" look like from the traditional vendors with whom healthcare organizations have become accustomed? Some ideas and examples:

• Free vs. expensive (Zenefits, Practice Fusion)
• Payments aligned with benefits vs. massive capital outlays with vague ROI promises (Athenahealth)
• A better experience at a lower cost vs. causing customer dissatisfaction at higher additional costs (Theranos)
• Simple vs. complex to buy, implement, and use (Apple)
• Openly shared, interoperable data vs. closed, proprietary systems (anything built in the last few years)
• Mobile-first (information to you) vs. desktop (you go to the information) (AirStrip, Voalte)
• Cloud-based SaaS vs. installing and maintaining software (Salesforce)

But beware, big-bang industry disruptors. Over the last several decades, the healthcare IT road (except a certain one-mile stretch of Arthur Burkhardt Expressway) has been littered with major international corporations that saw gold, Jerry, GOLD, in healthcare and failed (American Express, McDonnell Douglas, Alltel, etc.). Healthcare is indeed a “bizarro” industry – almost the opposite of every industry you’ve ever encountered. 

That said, the underlying economic, technical, and clinical restrictions that have historically hindered change are lessening. New mainstream technologies that we all use in our everyday lives are resetting expectations of the tools we use in our healthcare workplace.  

Now is the time for innovative entrepreneurs to consider jumping into the healthcare pool – but make sure your target market’s water isn’t too cold in order to avoid “shrinkage” of your investment.

"My life is the complete opposite of what I want it to be. I should’ve done the complete opposite of whatever I’ve done up till now.”

Is this quote from George Costanza or a healthcare system you may know?

Bruce Brandes is managing director at Martin Ventures, serves on the board of advisors at AirStrip and Valence Health, and is entrepreneur in residence at the University of Florida’s Warrington College of Business.

Morning Headlines 1/28/15

Huron Consulting To Buy Studer Group For $325 Million

Huron Consulting acquires healthcare leadership consulting firm Studer Group for $325 million, and anticipates that the deal will close by the end of February.

Biogen hires former Children’s executive as first VP of innovation

Cambridge, MA-based Biogen Idec, the leading manufacturer of multiple sclerosis drugs, hires former Boston Children’s Hospital CIO Naomi Fried as its next VP of medical information.

$1 Billion a Year in Redundant Obamacare Programs

An OIG report investigates quality improvement initiatives undertaken by CMS and finds that there are multiple, overlapping programs currently in place which results in unnecessary costs and increased complexity. CMS spent $1.6 billion on its quality improvement efforts between 2011 and 2014.

C-Lab Engineers Developing Wearable Health Sensor for Stroke Detection

Samsung has developed a prototype headset that analyzes brainwave activity to detect early signs of stroke. The device, called the Early Detection Sensor & Algorithm Package, is still under development and will soon be upgraded to monitor cardiac data as well.

News 1/28/15

Top News

HHS Secretary Sylvia Burwell announces an ambitious plan to tie 30 percent of Medicare provider payments to alternative payment models by 2016 and 50 percent by 2018, and also to link 85 percent of Medicare fee-for-service payments to quality and value by 2016. The announcement was received positively, although with guarded enthusiasm due to the lack of details and the mixed results of early adopters.

Reader Comments

From Nihilist: “Re: BJC. Rumor is that the Epic install will be run out of a yet-unnamed holding company as a partnership with Washington University School of Medicine, which employees the academic hospital faculty. That’s why no job postings have appeared.” Unverified.

Acquisitions, Funding, Business, and Stock

Huron Consulting will acquire Pensacola, FL-based, healthcare leadership consulting firm Studer Group for $325 million. The 235-employee company was founded by former hospital CEO and author Quint Studer in 1999 and was reported to have had 2013 revenue of $67 million.

China-based Alibaba Group, one of the world’s most valuable technology companies, partners with a medical software company to develop cloud-based services for physician practice, payment systems, e-prescribing, and drug tracking.

Roper Industries reports Q4 results: revenue up 7 percent, adjusted EPS $1.85 vs. $1.65, falling short on revenue expectations but beating on earnings. Chairman, President, and CEO Brian Jellison says the company will be making at least one more Q1 acquisition that relates to its Sunquest business. He adds that Roper paid $140 million for Strata Decision Technologies, which has $30 million in annual revenue, but Roper gets an immediate $40 million in tax benefit because the company was operating as a limited liability corporation.

Sales

Eastern Idaho IPA chooses Valence Health’s vElect contract administration system to allow physicians to compare fee schedules to Medicare benchmarks in selecting and declining payer contracts.

Two hospitals in Dubai will use Oneview Healthcare’s interactive patient engagement and clinical workflow system.  

University Medical Center Health System (TX) extends its agreement with Cerner.

MedConnect chooses clinical interface terminology from Intelligent Medical Objects for its EHR.

People

Biotechnology company Biogen Idec hires Naomi Fried, PhD (Boston Children’s Hospital) as VP of medical information, innovation, and external partnerships. She was Kaiser Permanente’s VP of innovation and advanced technology from 2006 to 2009.

Announcements and Implementations

Georgia’s GRAChie HIE – founded by Cerner, GRHealth, and Navicent Health — reports increased numbers of data sources and system usage.

The DEA approves EHNAC as the sole certifier of applications for electronic prescribing of controlled substances.

The Anesthesia Quality Institute recognizes Shareable Ink’s newly released ShareQuality mobile quality capture product as Quality Clinical Data Registry ready, allowing practices to use CMS’s preferred reporting mechanism.

CoverMyMeds announces that its electronic prior authorization system has been integrated with Epic.

Decisio Health earns FDA marketing approval for its EHR-powered bedside clinical decision support and triage dashboard that was beta-tested by Memorial Hermann Hospital (TX).  

The Apple Watch will begin shipping in April.

Government and Politics

An HHS OIG report says CMS should coordinate its multiple quality improvement programs to reduce duplication of effort and to make it easier to attribute results, adding that CMS awarded Quality Improvement Organizations a new $4 billion contract just after spending $500 million to roll out two other programs.  

Privacy and Security

St. Peter’s Health Partners (NY) warns that a manager’s stolen, unencrypted cell phone contained emails with patient scheduling information for its physician practices. I think I read that iOS 8 encrypts everything on the iPhone by defauult.

Innovation and Research

Samsung engineers create a smartphone-powered early warning stroke detection headset that analyze brain waves, expressing hope that the sensors may also be useful for other brain-related conditions. The engineers add that while the prototype model is a headset, the rubber-like sensors could be attached to less-obtrusive eyeglass temples.

Technology

Logitech announces a $500 portable videoconferencing solution for medium-sized rooms, which might be interesting for remote teams and IT meetings. ConferenceCam Connect works on any device that has a USB port and includes both battery and AC power.

Other

Weird News Andy says it’s like deja vu all over again. A doctor describes his patients’ constant deja vu as being trapped in a time loop. “As he walked in, he got a feeling of deja vu. Then he had deja vu of the deja vu. He couldn’t think of anything else.”

Western Missouri Medical Center’s COO gives its Meditech-to-Cerner conversion a B+ grade, saying that continuity, integration, and data collection improved markedly, but getting data from Meditech was hard. They say they “never new when upgrades are coming” with Meditech.

Weird News Andy says it’s like deja vu all over again. A doctor describes his patients’ constant deja vu as being trapped in a time loop. “As he walked in, he got a feeling of deja vu. Then he had deja vu of the deja vu. He couldn’t think of anything else.”

Sponsor Updates

• Nordic suggests five areas that should be part of a 2015 health IT plan.
• Beacon Partners explains Business Intelligence Competency Centers and how to implement them.
• PatientSafe Solutions CNIO Cheryl Parker, PhD, RN publishes “Smartphone-Based Mobility for Nurses.”
• Besler Consulting participates today in the HFMA Florida Chapter Mid-Winter Conference and the Tri-State Winter Institute in Mississippi from January 28-30.
• Caresync CEO Travis Bond asks, “What’s it Really Going to Take to Have Personalized Medicine?” in the latest company blog.
• Brian Mitchell of CommVault, asks if “2015 is the Year of Data Dystopia?”
• Clockwise.MD is nominated as a finalist in the inaugural Georgia’s Top Startup Awards.
• AirStrip’s Alan Portela writes about “The Healthcare Dinner Party” at the company’s Mobile Health Matters blog.
• Craneware lists the “Top Five Reasons for Denials” in a new blog post.
• Awarepoint posts a new article, “The ROI in RTLS for Hospital Asset Management.”
• Divurgent writes about “The ABCs of Ambulatory EMR Training and Acceptance.”
• Clinical Architecture’s Charlie Harp writes about “The Road to Precision Medicine” in a new company blog.
• Jaffer Traish of Culbert Healthcare Solutions writes about data sharing.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Get HIStalk updates.
Contact us online.

Morning Headlines 1/27/15

Progress Towards Achieving Better Care, Smarter Spending, Healthier People

HHS Secretary Sylvia Burwell unveils a new plan, and timeline, for moving the nations healthcare providers from fee-for-service model to a value-based reimbursement model. Burwell says that by 2018, 50 percent of all Medicare payments will be made through alternative payment models.

AMA’s letter to ONC

Former ONC Deputy National Coordinator for Health IT Jacob Reider, MD pens an open response to a letter drafted by AMA last week lobbying for renewed emphasis on EHR usability and interoperability. Former National Coordinator for health IT Farzad Mostashari, MD adds his two cents in the comments section.

Revised SOFTWARE Act ‘a huge step forward’

Marsha Blackburn (R- TN) has introduced a revised draft of the SOFTWARE Act, that has received broad support thus far. The bill would limit the FDA’s authority to regulate health IT products by establishing a narrow definition for both medical software and medical device accessories.

New simplified map for Veterans Affairs

The VA unveils plans to consolidate its reporting structure so that all divisions, including the Veterans Health Administration, will report through the same channels. The new five-region structure will be in place by June and is being called “the biggest organizational change in VA history.”

Curbside Consult with Dr. Jayne 1/26/15

I know many readers are on the edge of their chairs waiting to find out the answer to the career question I pondered in last week’s Curbside Consult. I spent several days out of the office last week putting my thoughts around whether I want to join our health system’s migration to a single vendor platform or pursue other career options.

Although I enjoyed the day I spent thinking about nothing work-related, things became complicated mid-week when I received an unexpected phone call. One of my CMIO colleagues knew I was off the grid and not checking email while I weighed the situation. He wanted me to know that a draft organizational chart was circulating and it had some interesting features.

First, the physician leadership is remarkably absent. We knew that there would be consolidation in the leadership, but not to the degree represented. My colleague wanted to know if I thought there was some kind of supplemental organizational chart that would have us on it. I don’t think there is one, but seeing it confirmed the fears of some of our medical leaders who have already jumped ship.

Second, although the number of mid-level administrators was as bad as we expected, they didn’t seem to be arrayed in a way that will be effective given our history and culture. With all the work that needs to be done, we almost need two teams for each hospital or entity, one for managing the transition and conversion and one preparing the new system. Of course they would have to work closely together, but given how we’ve worked historically, I can’t imagine a team being able to focus on two things at once and not end up cutting corners in favor of one side or the other.

Third, we were surprised to see a senior leadership level that was much smaller than anticipated. I’m not sure how they think a handful of top executives will have enough bandwidth to deal with the magnitude of change we’re expecting. The “Chief Culture Officer” I hoped would materialize was nowhere to be found. It looks like, at least to some degree, that we’re going to continue to try to do things the same ways we have always done them, yet are expecting they will have different outcomes.

Depending on where the organization is thinking about plugging some of the other CMIOs, there may not even be a place for me. Those of us that came up through the ambulatory ranks have a little less status than those who are purely hospital CMIOs.

The good thing about my time off is that I was able to come up with a self-employment business plan that makes sense, at least in the short term, if I end up being downsized. I bounced it off of some smart people I know and they agreed it was viable. My clinical group is willing to let me flex my hours as much as I need. It doesn’t hurt that they just opened a sixth location and are a little short covering some of the weekend and evening shifts, which I’m happy to do.

Since we don’t even have a signed vendor contract yet, I still have some time. I have to admit I’m leaning towards staying if there ends up being a position that is a good fit. Knowing I have a fallback plan (as well as a respectable nest egg) makes it a little easier to handle the uncertainty. Regardless of how it turns out, it will be entertaining and educational to watch all the players jockey for position.

In the mean time, I can find my entertainment with the reader responses to my question from last week: If you could do anything you wanted, what would it be? So far, early retirement, gardening, and travel continue to be themes. I haven’t had a lot of people saying they’d stay in healthcare, information technology, or the wild and wacky universe we call healthcare IT. Of the clinicians who have responded, no one wants to go back to direct patient care and that’s a sad commentary about healthcare in the US.

I saw patients two days this week and was reminded how miserably our system has treated some of our patients. I was also reminded of the sacred trust our patients place in us and how things that are not a big deal to us can make us look like superheroes to others. If you’ve ever seen the look on a parent’s face when you reduce their child’s Nursemaid’s Elbow, you know what I’m talking about.

What makes you feel like a superhero? Email me.

Email Dr. Jayne.

Startup CEOs and Investors: Speculating Scribbler

Finding Those First Few Paying Clients
By Speculating Scribbler

Having been an investor in and advisor to a number of various stage healthcare startups, I have observed a common constraint that applies to nearly every startup before they enjoy early success: finding those first few paying clients. They might have created the best product in the world, a revolutionary way of doing things better or faster, or a way to fill a void that has never been filled. They might have a brilliant team of tomorrow’s Mark Zuckerbergs and Steve Jobs. Without some early clients taking a chance, however, the potential could sadly go untapped.

Startups can have some inherent advantages over the big guys. They are nimble, and if they have the right team, can adapt and adjust their product faster than a large company. They generally have no sacred cow product lines, so the “Innovator’s Dilemma” that can curse large companies that protect cash cow product lines often doesn’t apply to them.

Still, it can take a leap of faith for a hospital, health system, or physician group to engage a startup. Even as an enthusiast of startups, there are some that I would do business with in a heartbeat if I were a hospital, yet others that I would never take a chance on. The old adage that, “You don’t get fired for buying IBM” applies in healthcare, too, even today in the age of the cloud computing and mobile everything.

For those who want to give that smaller, hungry company a chance at earning your business or who need to prove to your bosses or board that you’ve done your diligence before suggesting engaging a startup, here are a few key questions to ask to cover your bases and get comfortable with the startup.

What Will This Contract Do To Your Business?

You don’t need to know how profitable they will be or what kind of revenue increase your order would do for them. It is fair, though, to understand what sequence of events scaling up to serve you might trigger. Maybe they will need to change their server structure. Maybe they will need to set up the support department they have never needed before. Perhaps they will need to double their development staff with to-be-determined resources.

Whatever the case, the key is to have the open discussion and get comfortable with their plans. A thoughtful company has thought a lot about how they would scale to accommodate your business. At a minimum, they should have growth plans and timelines that are clear and that you can get comfortable with. The red flag is if they either don’t have a plan or give you the impression they aren’t rigorous enough about the scaling question.

Am I A Sustainable Client?

You might be tempted to get an insanely good deal from the startup founder who is hungry for your business. Given the lean nature of most small companies, there should in fact be a very good value proposition for you.

Don’t overdo it, though. The best long-term answer is for you to get a deal you can feel good about and for the startup to have enough revenue flowing in to continue to improve their product and an incentive to spend the time needed to serve you with topnotch attention. Startups often forge new ground in a space that does not yet have tried-and-true pricing mechanisms, but be sure that your business deal gives the company the cash flow it needs to do a great job for you.

Are You All Doing This Full Time?

This is one of the questions I ask as an investor and that I would ask it as a potential customer as well. If you are entrusting a startup to fill a key need that you have, you should expect that the people you are talking to are “all in.” It might be a relatively small team, but it is important they are fully committed to their business.

I have observed startups run by people who are moonlighting or trying to get the company going on evenings and weekends. I admire bootstrapping and the founders just might be brilliant and could be the next big thing. If I were a hospital system or physician group, though, I would insist that I only contract with someone who is fully committed to their business. It is a lot easier to walk away from a venture and your contract if you still have a nicely-paid job to go to on Monday morning.

How Will Our Organizations Communicate?

Frankly, this kind of expectation-setting question should be done with companies of any size. You probably have experience with big guys who have 40 percent market share dropping the ball on this.

A startup sometimes does not have their customer service or account management infrastructure fully built out, so it is a good question to explore. You just want to be sure you have a clear path for communications to and from the company, whether that be escalating an issue or having regular status updates. A red flag is if the CEO dismissively says “Oh, just call me on my mobile if you need anything.” While it might be flattering to have the founder on your speed dial, it is a sign that they have not thought about how to scale up for multiple customers like you.

How Are You Protecting My Data?

I would never suggest that just by virtue of being a startup, a small company is not as good as protecting data. In fact, some of the startup firms I have worked with are doing things with data protection that could set a standard for the rest of the industry. But in the spirit of being able to tell your leadership and board that you responsibly vetted the startup, explore the topic. A well-run startup will welcome the question because it gives them a chance to show that they are a step ahead of their competitors.

Conclusion

All of your go-to large vendors were startups one day. I see first hand many startups filling niches that have gone ignored too long. You might find that engaging the right startups could be the start of a great, long-term partnership for your organization. Just ask the right questions first. The mediocre startups will demonstrate that they aren’t ready for your business, but the good ones will show you that they can do things for you that nobody else can.

The author is a healthcare angel investor, board member, and mentor to numerous startups.

Book Review: “America’s Bitter Pill”

“America’s Bitter Pill” is not a feel-good book (pun intended). It’s not a fun read except for those folks who enjoy a maddening, blow-by-blow description of how legislative sausage is made. It tries to add drama and personal vignettes to events whose outcome is already known. Steven Brill tells us the obvious – the US healthcare system is a mess, the Affordable Care Act is a Band-Aid rather than major surgery, (and in fact made things worse in some ways), and there’s no resolution in sight.

The main message is that the Obama administration realized it had no chance of pushing through comprehensive healthcare reform given the presence of a strong healthcare lobby and rabid Republican opposition, so the ACA ended up being a Frankenstein law that was watered down with so many compromises that it did little except to expand the sales of medical insurance.

Political reality forced the administration to limit ACA to addressing coverage, not cost. Hospitals, drug companies, and device manufacturers stand to make even more money under ACA, which is why their powerful lobbyists – who practically sat at the table while the ACA was being negotiated – gave their required blessing.

Creating drama from politics requires characterizing people and organizations. President Obama is portrayed as well intentioned, but a bit detached and lazy in leaving the ACA details to others. White House staffers are seen as power-hungry and anxious to get Obama’s ear. CMS is a plodding, incompetent bureaucracy that vastly overestimated its ability to launch Healthcare.gov. Former US CTO Todd Park and HHS CTO Bryan Spivak are nice, geeky guys who weren’t invited to the Healthcare.gov table until it melted down. Insurance companies are low-margin businesses that are held hostage by greedy and ever-expanding hospitals that use their consumer brand identity to force high prices; insurance companies are also an easy but undeserving political target because that’s where the healthcare rubber meets the road for most consumers.

It’s interesting to read about how much influence data geeks have. An army of government number-crunchers has to to turn vaguely worded legalese into budget impact numbers that can make or break campaign promises, i.e. are new government ACA costs taxes or is the program budget neutral? Insurance companies have their own quant people whose insurance pool models determine their financial risk over many years. The stars of the book might just be the analysts whose numbers drove big political and business decisions.

The basis of Obamacare is the Romneycare three-legged stool: (a) a competitive insurance marketplace disentangled from employers; (b) a mandate that everyone buy medical insurance to avoid the self-selection in which healthy and young people opt out of subsidizing sicker and older ones by buying insurance; and (c) massive government welfare programs to help pay the medical insurance premiums for those who can’t afford them.

You can imagine the ugly details involved in rolling out this three-legged stool as a huge, complex law that even those legislators who passed it didn’t read in its entirety.

The book makes medical device makers as bad guys who escaped significant impact other than being charged a small medical device tax that they simply passed along to their customers. Their profit margins are extraordinary, their customers are hospitals who not only buy their products at high prices but then mark them up in selling them to patients, and they have positioned their products as a beacon of American medicine.

Drug manufacturers are bad guys, too, using their political influence to prevent importation of drugs from Canada (which like every other country, has much lower prices than here), to gain extended patent protection for biosimilar products, and to kill a provision that would have allowed Medicare to negotiate drug prices rather than paying made-up market prices.

Lobbyists had their fingers in the pie at every step, including those representing odd industries such as soft drink manufacturers, tanning bed groups, and ambulance services. Every member of Congress made sure to protect any back-home businesses that would have been negatively affected, including those that should have been targeted.

The author is sympathetic to physicians. He says Congress targeted them inappropriately in 1997 in its panic over rapidly increasing Medicare spending, implementing the Sustainable Growth Rate (SGR) payment cuts that have been overridden by Congress every year since. A fix was supposed to be in the ACA, but that, too didn’t make the final bill, and neither did tort reform.

CMS is characterized as just about as inept and bureaucratic as you would expect.They were afraid that Congress would de-fund some of their “offices” in their hatred of Obamacare, so they renamed them “centers” to make them an internal expense rather than a separately budgeted “office.” That bit of political sleight of hand came back to bite them, as the newly demoted “office” that was supposed to be overseeing Healthcare.gov was outranked by CMS’s procurement groups.

The result was a plodding bid process in which the same old government contractors made promises they couldn’t keep, with CMS deciding it would run the project internally. Literally nobody knew who was in charge – the author asked a bunch of people where the buck stopped and rarely got the same answer twice. Brill says the Beltway contractors “never met a botched product, cost overrun, or missed deadline they can’t pin on someone else.”

Still, the blow-by-blow on Healthcare.gov seems to be a distracting attempt at injecting drama and maybe selling a few more copies of the book. Government software failures, cozy contractor deals, and cost overruns are the rule more than the exception. The site was quickly implemented and horrendously complex, a massive integration effort involving other government systems run by the IRS, Homeland Security, and others. It failed, but it was fixed fairly quickly. Healthcare.gov is only a tiny part of the ACA. There were no particular lessons learned except perhaps that rushed, complex legislation that requires a rushed, complex technology solution is probably a bad idea all around.

Non-profit health systems are portrayed as somewhat well-intentioned monopolists unwilling to give up huge profits and executive salaries, using their hometown pride as big employers and their vague public threats of reduced quality from reduced payments to protect their huge incomes. The author mentions the complaints of the CEO of Montefiore Medical Center, who wailed about potential ACA-caused patient harm through lower margins just as the hospital turned a $197 million profit and that same CEO took home $4 million for the year. Brill talks about the cutthroat Pittsburgh market in which UPMC and Highmark hardballed each other and got into each other’s businesses trying to dominate the market.

Brill concludes that President Obama should be admired for pushing through broad healthcare reform even though he hadn’t expressed much interest as a candidate, but says that his failure to get involved with the details of ACA’s implementation will be be his unfortunate legacy. The backroom deals with profit-making entities ensured that the ACA fell far short of true reform and in fact will probably increase corporate profits as newly insured people consume their products and services as patients.

Brill says Obamacare won’t stand as a popular Democratic program such as Medicare and Social Security since it only helped the 20 percent of Americans without an insurance and another 10 percent or so who had been fooled into buying low-quality insurance whose benefits would run out after even a short hospitalization.

The end result is that most middle-class Americans continue to struggle to pay insurance premiums and inflated medical bills, the country still can’t afford the out-of-control medical spending that makes the US globally noncompetitive, and employers and hospitals got an easy out in blaming their ensuing self-serving actions on Obamacare.

Brill makes it clear that he would have preferred a single-payer health system, but he doesn’t notice the irony that in calling out CMS as inept bureaucrats, they run the closest thing we have to a single-payer system in the form of Medicare. He should have spent more time writing about that (and the VA’s government healthcare delivery system) than in trying to create TV moments in the form of Healthcare.gov war room arguments.

For all the problems recited, the book is short on solutions. Brill proposes:

• Let the big health systems get bigger and cut out the middleman by starting their own insurance companies, as long as each major metro area has as least two big players, but cap their profits.
• Limit hospital executive salaries to 60 times the salary paid to a first-year medical resident, or about $3 million in UPMC’s case (the CEO is making $5 million now). That’s not only a generous CEO salary cap, it also ensures an unintended consequence of raising resident salaries. Why not cap CEO salaries as a percentage of operating revenue instead?
• Pay doctors for quality. Sounds good, but the devil is (as was the case with ACA) in the details, which are missing.
• Encourage health systems to run urgent care centers and other less-expensive care venues. I think ACA is already doing that.
• Create an ombudsman appeals process for patients or doctors who think care is being compromised.
• Require health system CEOs to be licensed physicians with practice experience. He doesn’t provide reasoning for this argument, but he does express disdain for corporate types that move into running health systems. He also doesn’t say much of anything about for-profit chains, including publicly traded ones.
• Require health systems to insure a given percentage of Medicaid patients at a specific discount.
• Eliminate the chargemaster and require hospitals to charge uninsured patients no more than they charge insurance companies.

Steven Brill knew little about healthcare when he wrote his Time article and this book. In that regard, he comes across as a curious layperson outraged by what he learns, but perhaps too easily swayed by people and policies that he has filed away as “good” or “bad” in his populist outrage. 

The Affordable Care Act is a political lightning road and isn’t likely to be fine tuned by intelligent Congressional deliberation, so good or bad, it’s here to stay. Most of the people involved in creating it have already left government work and the Obama administration is counting down its remaining months. Meanwhile, the healthcare cash register keeps ringing for the same companies, organizations, politicians, and people who know how to make the system work for them. That’s what makes “America’s Bitter Pill’ unsatisfying as a reader – it’s unlikely that anything will really change as a result as healthcare costs continue to bankrupt individuals, companies, and the country itself.

Morning Headlines 1/26/15

VSS exits Strata Decision Technology

Roper Industries has acquired Strata Decision Technology, a cloud-based analytics platform used by 1,000 hospitals for financial planning and reporting. Financial terms of the deal were not disclosed.

New Technology May Save Patients an Additional Visit to a Specialist

The University of Virginia Health System will pilot a remote consultation system that connects primary care providers with specialists for quick questions or second opinions on cases that otherwise would have resulted in an unnecessary referral.

How Are We Today? Study Lets Patients Help Write Medical Notes, Google Doc Style

Beth Israel Deaconess Medical Center will pilot a new program called OurNotes that will expand on the OpenNotes concept by allowing patients to access and contribute to physician notes in their EHR.

ONC Annual Meeting, February 2 – 3, 2015

ONC will host its annual meeting on February 2-3 in Washington DC. Karen DeSalvo, MD, now both the National Coordinator for health IT and the acting assistant secretary of health, will deliver the opening remarks and lead a session on ONC’s nationwide interoperability roadmap.

Monday Morning Update 1/26/15

Top News

Private equity firm Veronis Suhler Stevenson completes the sale of Strata Decision Technology to Roper Industries. Strata’s StrataJazz financial planning and analytics software is used by 1,000 hospitals. Roper’s other healthcare IT-related acquisitions include Sunquest Information Systems, SHP, and CBORD.

Reader Comments

From Kim Jong-un: “Re: HIStalk. The CMIO of a large Midwest health system told me that the IT department has blocked web access to HIStalk. Now I am wondering if HIStalk was responsible for the Sony hacking.” I like when an organization blocks access to HIStalk since that means I’m providing accurate and potentially disruptive information. It’s always been vendors doing the blocking, though. Email me your employer’s name if they’ve blocked HIStalk so I can give them a mention.

From Harold Reems: “Re: Bayhealth. Looks like they’re going Epic.” Apparently so – they’re running Epic job listings.

HIStalk Announcements and Requests

Two-thirds of respondents say that technology hasn’t significantly empowered patients. AlmostAdjusted commented that we’re getting there, but “technology has brought complexity to the patients and our patients are spastically grasping at a number of hyped solutions that for now are causing more disillusionment than empowerment,” while Mak says providers need to trust patients and put all of their information on their portal. New poll to your right or here:  will you in the next 6-12 months buy an Apple Watch, a different smart watch, or neither?

Speaking of empowering patients, I’m paying for five, $1,000 travel scholarships for real patients to attend the HIMSS conference, following through on an idea that patient advocate Regina Holliday and I had when I interviewed her last March. We’re accepting applications through February 9 and will choose the five based on their patient stories and their writing ability (since I want them to document their experience afterward). Those chosen  will wear a special tee shirt with a picture Regina painted just for that purpose (above is an example, but she’ll paint a new one specific for this project) as they attend sessions and visit the exhibit hall to represent the patient’s point of view. See Regina’s description and send entries to Lorre.

More on the patient travel scholarships: HIMSS declined to participate (like by comping their registration fees), so I could use some help. Exhibitor badges will work fine for the scholarship winners since they provide full conference access, but I only get five for my tiny HIStalk booth and I’ll use at least 2-3 of those. If anybody has extras, that would save me a bunch of money. UPDATE: Thanks to the several companies that offered to help out … CTG Health Solutions was quick to respond with an offer to provide badges to our patient representatives. Thanks to Amanda at CTG for supporting our project.

I learned a new, made-up word: “listicle,” a combination of the words “list” and “article” that refers to those lazy, click-baiting online pieces that start with a number, such as “10 EHR Vendors to Know” or “6 Cool Health Startups.” I like that it sounds like “Popsicle,’ a nutritionally devoid diversion that delivers little beyond the initial impulse to give it a quick lick (or “click” in this case).

Last Week’s Most Interesting News

• A group of medical associations urges ONC to refocus EHR certification on usability, interoperability, and safety.
• Industry groups ask that Meaningful Use and EHR certification require EHRs to accept the scanned barcodes of implanted medical devices.
• ONC hires Michael McCoy, MD to the newly created position of chief health information officer, where he will oversee interoperability efforts.
• Mayo Clinic selects Epic.
• CMS Administrator Marilyn Tavenner resigns.
• Harvard Medical School launches the Department of Biomedical Informatics, to be led by Isaac Kohane, MD, PhD.

Acquisitions, Funding, Business, and Stock

Emdeon is considering an IPO, sources say. The earnings multiples of recent sector deals suggest a valuation of $5.4 to $6.6 billion, which would create huge profits for the two private equity firms that took Emdeon private in 2011 for $3 billion.

California Healthcare Foundation invests in Seamless Medical Systems to develop and pilot patient engagement software for safety net providers and patients.

People

Nursing informatics pioneer Carol A. Romano, PhD, RN, who was chief nurse officer of the Public Health Service, is named dean of nursing school of Uniformed Services University of the Health Sciences.

Announcements and Implementations

Wolters Kluwer Health releases an eBook describing how health systems can create an antimicrobial stewardship program.

Government and Politics

ONC’s annual meeting will be held February 2-3 at the Washington Hilton. Karen DeSalvo will deliver opening remarks, describe the nationwide interoperability roadmap, lead a fireside chat with Tom Daschle and Bill Frist, and join a panel discussion with all four former National Coordinators (Brailer, Kolodner, Blumenthal, and Mostashari). The meeting will be streamed via webcast as well. It will be interesting now that HITECH is winding down if attendance at this meeting and Health Datapalooza will suffer.

Other

OpenNotes co-founder Jan Walker, RN says the next project phase, OurNotes, will allow patients to add their own notes to their electronic chart. It will be piloted at Beth Israel Deaconess, Geisinger, Harborview and Group Health in Seattle, and Heartland Health. Above is a screen shot from Joe Boyce, MD, CIO/CMIO of Heartland Health, which is using Cerner to collect information from patients (visit goals, meds, problems, care preferences) ahead of their scheduled appointments. This is brilliant – there’s no reason to waste precious appointment time collecting routine information, plus patients get flustered and forget important facts when forced to recite them on demand.

A study of New York nursing homes finds that EHR adoption increased 7.7 percent from 2012 to 2013, but HIE participation remains minimal. Those using EHRs had no specific characteristics different from those that didn’t, but HIE participation was related to being associated with a hospital and not being run as a for-profit business.

University of Virginia Health system announces that it is one of five academic medical centers that will use a $7 million CMS grant to pilot an eConsults/eReferrals model. PCPs can use Epic to send a quick question to a specialist who can then review the patient’s electronic chart to provide an answer. The goal is to free up specialists to see patients who really need a face-to-face appointment vs. PCPs looking for a curbside consult.

Weird News Andy says this story is untitleable: an Australian woman chooses a “maternal-assisted C-section” for her 10th and 11th children, meaning she removed the babies herself during the otherwise normal procedure.

Sponsor Updates

• Surgical Information Systems team members make over 50 blankets for Project Linus at its SIS Cares event.
• ZirMed announces results of the end-to-end ICD-10 testing of its customers.
• Huron Consulting releases its Healthcare CEO Forum report.
• Trey Lauderdale writes about the interconnected nature of physician messaging and alarm management in a new Voalte blog.
• Versus Technology updates the agenda for its 2015 User Group Meeting, taking place May 11-13 in Chicago.
• Verisk Health SVP of Population Health and Risk Adjustment Matt Siegel pens an article titled “Risk-Adjusted Base Payments can Support the Move to Value.”
• HHS CTO Bryan Spivak visits Validic’s Durham, NC headquarters and poses for a photo.
• Valence Health will participate in HFMA’s first Illinois Managed Care Meeting in Chicago on January 29.
• Qpid Health releases the latest podcast in its “Intrepid Healthcare” series.
• Thomas White at Phynd Technologies blogs about “Why a Single Provider Profile Matters.”
• Patientco CEO Bird Blitch blogs about “Why 2015 is the Year Providers Will Embrace Cloud Technology.”
• PatientSafe Solutions CNIO Cheryl Parker writes on the topic of supporting the cognitive workload of clinicians with mobile technology.
• Nordic releases the fourth installment of its video series on Epic’s Cupid application.
• Navicure’s Amanda Brown posts a new blog on “The New Normal for Revenue Cycle Management in 2015.”
• NVoq’s Debbi Gillotti writes a new blog post on how to “Drive Even More Value from Your EMR with SayIt 9.3.N
• TT Data’s Phil Thames provides his executive viewpoint on industry predictions for 2015.
• In a new white paper, Perceptive Software Principal Solution Architect Larry Sitka writes about vendor neutral archiving as more than just a place to store images.
• MBA HealthGroup publishes a new blog on “Security Risk Assessment – Balancing Data Protection & Efficient Workflows.”
• Medicity offers a new blog on “The 10-Year Interoperability Roadmap: How do We Get There from Here?”
• Sean Biehle writes about “Extending Patient Engagement Beyond the Point of Care” in a new MedData blog.
• MedAptus takes an Austin Powers tone in its latest blog, entitled “$375 Billion Dollars … mwwahahahahahaha.”

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

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