Monday Morning Update 7/14/14

Top News

Former health system CEO Joe Swedish, now CEO of WellPoint, says he’ll focus the company on technologies such as telemedicine, kiosks, and smartphone-based instruments (he didn’t mention the company’s partnership with IBM to develop Watson-powered applications). Swedish is also driving use of WellPoint’s databases that are populated from processing 581 million medical claims each year. It’s good to work for an insurance company – Swedish’s shares are worth $15 million and he’s paid $7.5 million per year. I remember him way back when he was CEO of Winter Park Hospital (FL).

Reader Comments

From A Concerned Customer: “Re: NantHealth. We as a customer are hearing of extensive layoffs of the iSirona people. Almost all of the account executives were let go.” Unverified.

From LISPro: “Re: Epic. I’ve heard the company has submitted to the FDA for 510k certification of their new blood bank module.” Unverified.

From Not From Me: “Re: Intermountain. The short-term choice (three or so years) would have been Epic, but we went with Cerner because of Epic’s dated technology, Cerner’s openness, and the feeling that we would be more of a partner than a customer with Cerner. The partnership is more than words. We’re working closely with Cerner and their horde of sharp, dedicated people on the implementation. We have some pieces they don’t and those are being built into the Cerner system, while some of our own development efforts have been redirected since Cerner already has that functionality. The first rollout is scheduled for December and I think it will go well due to the way the teams are working together.” Unverified.

HIStalk Announcements and Requests

Two-thirds of poll respondents have used their PCP’s patient portal in the past six months. New poll to your right: what contributed most to your present success? Young people will be interested to learn what worked for their more experienced healthcare IT peers. Click the “comments” link in the poll to elaborate further.

Thanks to the following sponsors, new and renewing, that recently supported HIStalk, HIStalk Practice, and HIStalk Connect. Click a logo for more information.

Acquisitions, Funding, Business, and Stock 

Epic says that it has 7,400 employees, 600 more than it reported in February, probably boosted by the college graduation of its latest round of hires.

QPID Health will move its offices to Federal Street in Boston to accommodate expected growth.

People

Brad Holcomb, RN (St. John’s Health System, First Consulting Group, BHL Consulting Group) died on May 14 at 47. His wife Lucretia said it would be OK for me to mention the donations page a family friend has set up for their children.

Announcements and Implementations

Valence Health announces its Further 2014 conference, September 10-12 in Chicago. It’s open to anyone and the cost is amazingly low: $500 includes registration, meals, entertainment by Second City, and two nights’ accommodations at the Drake Hotel ($400 per night on the hotel’s site for those dates.) If you’re local to Chicago, you can go for $199 without hotel. Some of the agenda is specific to customers, but a lot of it isn’t, covering value-based care, clinically integrated networks, patient engagement, and predictive risk. I would attend myself if I didn’t have a conflict , and may yet in fact, since it looks worth juggling other stuff around.

Technology

A hospital in Spain is using the Oculus Rift virtual reality gaming headset in the OR for nervous surgical patients. The immersive device provides calming scenic movies with music that minimize the patient’s perception of the OR’s noises and bright lights. Facebook must have been impressed since it bought the company for $2 billion in March even though the headset won’t be available to consumers until next year. The founder of Oculus is a 21-year-old California college dropout.

An article profiles the use by Duke Medicine (NC) of a geographic information system tied to its homegrown clinical database query tool, allowing researchers to study medical issues by neighborhood, socioeconomic indicators, and even proximity to fast food restaurants, all in real time.

Other

In England,the Health & Social Care Information Centre reports that Summary Care Records have been created for 41 million patients, with only 1.4 percent of them opting out of the program. The SCR program was intended to give off-hours providers fast access to a patient’s medications and allergies using information from practice-based EHRs. Around 5,500 practices have created SCRs for patients. SCR was until recently a floundering part of the now-defunct National Programme for IT. A British Medical Association IT committee chair called for its shutdown in early 2013, saying that while 23 million SCR records had been created, only 100 hospitals and after-hours providers were using them.

An article by former FDA Deputy Commissioner Scott Gottlieb, MD says existing policies don’t encourage researchers to develop high-priced cures for diseases that would reduce overall lifetime patient cost for chronic conditions. He suggests a system in which payers can finance their longer-term benefit through government-backed guarantees and accounting rule changes.

I found a cool heart rate app that  works sort of like a pulse oximeter – you put your finger on the phone’s rear-facing camera, the app turns on its flash so it shines through your finger, and then it measures and displays your heartbeat as a real-time graph. It seems to be quite accurate, making it useful for people who exercise or who have atrial fibrillation. The developer claims 25 million users and offers others for cardio exercise, sleep cycle analysis, biofeedback stress reduction, and blood glucose logging.

Weird News Andy sniffed out this story: a woman who received experimental treatment for paralysis eight years ago in which cells from her nose were injected into her spine grows another nose from the injection site. WNA also suggested taking the stairs in hospitals after a study finds that elevator buttons have more germs than restrooms.

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 7/11/14

HIT Policy Committee DRAFT Summary of the June 10, 2014 Virtual Meeting

During Tuesday’s HIT Policy Committee meeting, CMS reported that only 972 providers and 10 hospitals have attested for Stage 2 of Meaningful Use.

Cerner ups campus cost to $4.45B, will seek $110M TIF bump

Cerner increases the budget on its new Kansas City campus by $160 million, to $4.45 billion, and is asking the local and state government to cover $110 million of that through tax breaks.

The Experience of Young Adults on HealthCare.gov: Suggestions for Improvement

A study published in the Annals of Internal Medicine concludes that Healthcare.gov’s user interface was perceived as confusing and unintuitive by millennials.

Moody’s Assigns AA3 To Providence Health & Services Series 2014B Bonds; Outlook Stable

Moody’s gives Providence Health’s bonds a strong, stable Aa3 rating, something that is not always the case for health systems in the midst of an Epic implementation. The rating notes, “PHS has nearly completed its system-wide implementation of the Epic electronic medical record (EMR) system. Implementation has spanned many years, and has occupied a significant portion of the system’s capital budget. Outsized operating expenses related to Epic have suppressed margins but are now expected to reach a steady state going forward.”

News 7/11/14

Top News

National Coordinator Karen DeSalvo reorganizes the HIT Policy Committee. Also announced by ONC: only 972 EPs and 10 hospitals have attested to Meaningful Use Stage 2. Athenahealth users lead the EP Stage 2 attestation by far. Clearly ONC’s budget and influence are shrinking as disenchantment with the Meaningful Use program grows and providers focus on more strategic goals than lapping at Uncle’s Sam’s ever-distancing carrot.

Reader Comments

From McLayoffs: “Re: McKesson. Decimated their ranks last week, so I wouldn’t be surprised if they sold off that business. It’s not one that John Hammergren ever wanted to be in, but inherited when he took over. All non-essential implementation teams were dissolved and upgrades are rumored to be handled by national support. A lot of good people were lost last week. I’m not surprised that Siemens is calling it quits as well, with Epic dominating the market. I’m even seeing Cerner to Epic conversions now.” Unverified.

From Punch Bowl: “Re: Nuance. Acquiring Notable Solutions, Inc.” Unverified. NSI offers solutions for document capture and forms processing to a variety of industries.

From Kites Away: “Re: research question for your audience. Is strategic planning a useful exercise? Why or why not?” I will let readers weigh in. My opinion is that it’s a good exercise even though the assumptions and predictions often turn out to be wildly off. It makes people focus on the current state and to consider the array of possible future states.

HIStalk Announcements and Requests

This week on HIStalk Practice: Key takeaways from the 2015 proposed physician fee schedule. The ONC Health IT Policy Committee presents the latest round of Meaningful Use attestation numbers (and notes the vendors leading the pack). Cigna creates 100 collaborative care arrangements with large physician groups. The Accountable Care Coalition of Greater New York uses new grant money to launch a medication adherence program, while Milwaukee Health Services uses new funds to upgrade its EHR. Online consumer service providers and the DMV pilot a patient identity management program. Thanks for reading.

This week on HIStalk Connect: Dr. Travis breaks down Rock Health’s recent “Mid-Year Digital Health Funding Report.” In Europe, the $2 billion Human Brain Project is under threat of boycott from the scientific community over its hard line stance on funding out-of-scope projects. Syria is getting international support through an ICU telehealth program that is helping resolve the country’s physician shortage. AdhereTech raises a $1.25 million Series A for its connected pill bottle. 

I received two items from readers that I’m going to decline to run because I don’t think it’s fair to the companies involved, but I want to explain why. First was a healthcare IT vendor CEO who was arrested for battery, which I don’t think is fair game because it’s personal and being arrested isn’t the same as being found guilty. Second is a lawsuit brought against a company that alleges it broke its contract with an offshore development shop, which has the same problem in being just an allegation so far. I like good rumors and gossip as much (probably more) than the average person, but both of these documents name people who shouldn’t be tried on the pages of HIStalk. I’ll report the final legal decisions once they are out.

Acquisitions, Funding, Business, and Stock

Revenue cycle vendor RevSpring acquires Talksoft, which offers an automated appointment reminder service.

Allscripts acquires UK-based Oasis Medical Solutions and will implement its Oasis Patient Administration System as a single-source solution for the UK market.

USA Mobility, along with its previously acquired Amcom Software, changes its name and Nasdaq ticker symbol to Spok (pronounced “spoke”).

Oncology data analysis vendor Syapse raises $10 million in a Series B funding round. Its product integrates genomic information with the EMR to display data for decision-making, suggest treatment plans, and track outcomes.

Sales

Centegra Health System (IL) adds revenue performance improvement solutions to its existing MedAssets agreement.

Carrus Hospitals (TX) will deploy Medhost’s clinical and financial solutions via the company’s hosted Medhost Direct platform.

Memorial Sloan Kettering Cancer Center will implement Allscripts dbMotion and continue its use of Sunrise EHR.

People

Health Data Specialists promotes Chad Jones to Cerner practice director.

Harold Paz, MD (Penn State Milton S. Hershey Medical Center) is named EVP/CMO of Aetna.

George Murillo (Leidos Health) is named western area VP of Orchestrate Healthcare.

Announcements and Implementations

Awarepoint announces the availability of awareAssets V3.0 for RTLS-based asset tracking and workflow optimization.

Lexmark’s Perceptive Software launches Perceptive Cloud Share, a cloud-based content management system for video, images, and other rich media.

DSS adds real-time abnormal lab results alerts to the VA’s VistA CPRS Version 31.

Elsevier launches PolicyNavigator, a knowledge management tool for healthcare policies and procedures.

Healthcare Engagement Solutions launches the Uniphy clinician communications platform.

MediSafe releases its medication adherence app for Google’s Android Wear smartwatch technology.

Government and Politics

The HIMSS EHR Association weighs in on HHS’s proposed Meaningful Use changes, saying pretty much the same thing as other groups before it: (a) turn the proposed rule into a final rule quickly and without changes since providers are otherwise forced to make decisions blindly; (b) define the types of delays that are acceptable for not implementing 2014-certified EHRS – vendor delays, lack of provider resources, lack of local interoperability options, etc.; (c) simplify the combinations stages, objectives, and EHR certification year; (d) simplify the proposed CQMs; (e) delay MU Stage 3 to avoid the same rush and confusion that accompanied the rollout of Stage 2.

A tiny observational study published in Annals of Internal Medicine finds that the government failed in its attempt to make Healthcare.gov as easy for millennials to use as popular websites. Its recommendations: (a) allow clicking on health insurance terminology to bring up a definition; (b) make it clearer that preventive care is included in all plans offered; (c) make the dental insurance option clearer; (d) improve sorting and filtering of available plans; (e) explain the available tax credit and cost-sharing options that reduce cost; and (f) call “catastrophic” plans something else, such as “minimal” or “value.”

CMS designates non-profit Health Care Cost Institute as the first national Qualified Entity, meaning it can merge Medicare claims data with commercial payer data to provide price and quality transparency.

CMS gives Tennessee 10 days to fix its $35 million Medicaid eligibility system, saying it is preventing people from signing up for insurance on Healthcare.gov. CMS says state workers ignored requests to assign more people to the project and failed to help new users navigate its system. The state blames Northrop Grumman for missed deadlines and has paid the company only $5 million so far.

A GAO report says the VA-DoD integrated EHR (iEHR) plan met only one of six required conditions in FY2013. The VA and DoD abandoned their two-year-old plan to develop a single EHR in February 2013 due to cost and timelines, leading Congress to threaten to cut off 75 percent of the iEHR budget unless six conditions were met (define a budget, set a timeline, break out annual and total spending, define how costs would be shared, establish data standardization, and comply with government acquisition policies.) The only fully satisfied condition was creation of a cost-sharing schedule. The joint oversight group says the plan has changed to the point that the original goals no longer measure the program’s success, leading GAO to recommend holding the VA and DoD responsible for publishing accurate budgets, maintaining a deployment schedule, developing data standardization rules, and proving that they are indeed compliant with federal purchasing policies.

Other

Cerner increases the estimated cost of its new 16,000-employee campus to $4.45 billion and wants Kansas City’s tax commission to chip in an additional $110 million in tax breaks, boosting the total taxpayer support to $1.745 billion.

Quick — who’s the CEO of Microsoft? No, it’s Satya Nadella, and he plans to rejuvenate the company by moving from “devices and services” to “platforms and productivity,” emphasizing mobile-first and cloud-first.

Partners HealthCare seeks a $145 million loan to help it pay for a new building, raising its total debt to $4 billion. Part of that money was targeted for its $1.2 billion Epic implementation.

A Florida lawsuit questions whether release of information companies can charge lawyers more than patients for copies of their hospital medical records. An attorney became upset at being charged $1.00 per page by HealthPort for a client’s medical records when state law specifies $0.25 per page, but HealthPort says the lower rate only applies to patients even though it recently lost a case using that argument.

A new bond issue for Providence Health & Services (WA) gets high, stable rating, with its ratings agency noting that, “PHS has nearly completed its system-wide implementation of the Epic electronic medical record (EMR) system. Implementation has spanned many years, and has occupied a significant portion of the system’s capital budget. Outsized operating expenses related to Epic have suppressed margins but are now expected to reach a steady state going forward.”

Weird News Andy likes the idea of “virtual gastric banding” described in this article, where hypnotists convince patients they’ve had weight loss surgery, sometimes even causing them to lose weight afterward from the power of suggestion alone. Of course WNA questions the $1,500 cost in  wondering, “Can the patient then hypnotize the hypnotist to induce memories of payment?” WNA also likes a rare case in which a man suffers a blood clot in his brain after head-banging at a Motorhead concert, leading WNA to suggest renaming the band “Subdural Hematoma.”

Bizarre: city police charge a 17-year-old boy with child pornography for sending explicit photos of himself to his 15-year-old girlfriend and then ask a judge’s permission to inject him with arousal drugs in a local hospital so they can snap new pictures to compare to those he allegedly sent. I immediately thought of the “sketch artist” principal’s office scene in “Porky’s,” not safe for work or for those with a non-warped sense of humor but possibly the funniest four minutes (shot straight through with no edits) in movie history.

Sponsor Updates

• PatientSafe Solutions’ Cheryl Parker shares how informatics nurses contribute to products roadmaps through analysis, compliance, consultation, coordination, facilitation. and integration.
• Lucca Consulting Group offers post-implement feedback and testimonials.
• MedData will participate in the Annual MI Emergency Medicine Assembly July 27-30 in Mackinac Island, MI.
• A report by Imprivata and the Ponemon Institute says pager inefficiency and the inability to use text messaging costs the average hospital approximately $1.75 million per year.

EPtalk by Dr. Jayne

One of the things I enjoy least about my work in the CMIO trenches is keeping up with the ever-present stream of new rules, proposed rules, and all the supporting documents that go with them. It shouldn’t be a surprise that only a very small percentage of Eligible Providers have attested to Stage 2 Meaningful Use. As of May 1, only 50 Eligible Providers were on the books. Although the individual measures are not that difficult, keeping up with the voluminous documentation on all of them is a chore, as is preparing the documentation needed for attestation and potential audits.

CMS hasn’t disappointed in releasing its proposed rule to update the Medicare Physician Fee Schedule in 2014. I didn’t have time to read the 600-plus page rule myself, but luckily one of my vendors digests the information for its customers and sends out the highlight reel. As we always suspected, parts of MU are becoming mandatory independent of the actual MU program. Physicians billing for chronic care management would be required to use an EHR certified under 2014 criteria.

I was excited to see that Medicare is considering coverage for telemedicine services, including psychotherapy and wellness visits. I question, however, exactly how the digital prostate exam (and I don’t mean high-tech digital) or other sensitive exam maneuvers can be done via telemedicine, although I agree that a lot of the preventive counseling aspects of an annual visit don’t require a face-to-face visit if you already have a good relationship with your patient. Although those services aren’t specifically part of the Medicare “Annual Wellness Visit” paradigm, they are recommended services.

Are we setting ourselves up to have different kinds of wellness visits for patients, such as the Medicare Annual by phone, the Medicare Annual in person, the “G-Code Special” for those physical exams that have to be performed in person, and more? Patients can barely keep track of the services they need at present without having to worry how they’re delivered. And you can bet that if we try to bundle any of them into other in-person services, we won’t get paid. The Medicare Annual Wellness visit does recommend biometric assessment. I’m not sure I trust my patients to report what the scale actually says and we’re not yet in the Star Trek world of the medical tricorder. Although coverage for telemedicine sounds great in person, it just goes to show that the devil is in the details.

One of the other things I enjoy least about my work is dealing with difficult physicians. Although I’m not responsible for physician discipline per se, I do have to provide input when physicians are creating issues during implementation and training. I had mentioned a few weeks ago that we would start deploying new practices after Independence Day. This week has not disappointed for sheer magnitude of “stuff you just can’t make up.”

One of our surgeons decided to book two elective cases at the same time as his prearranged EHR training, then demanded that we train him later that evening. What do you even say to that? They weren’t emergencies. Although our trainers are happy to accommodate evening sessions when requested in advance, they can’t do it on short notice due to family and other obligations. I really think that he hopes to stall his go-live by staying untrained.

His power play failed, however, and he only ended up short-changing himself since his partner showed up and training was delivered. He’s just going to have to play catch-up because we have 22 go-lives teed up behind this cohort and there’s no room for game playing. His partner was an absolute joy to work with and decided to move his own go-live forward. I’m betting the practice dynamic is going to be pretty interesting in the coming weeks. Hopefully positive peer pressure will win the day.

One of the things I enjoy most about my work is the people I have gotten to know over the years. Although it seems like there’s a lot of movement around the industry, especially among the sales force, there’s still a sense that we’re all in this together and a willingness to help out whether you work directly together or not. I was able to meet up with a friend who used to work for one of my vendors and learn about his adventures in a different part of the industry. Another consultant I worked with early in my career turned up on a project I’m peripherally attached to. It’s definitely a small world and I’m glad to have people with whom I can commiserate. Maybe if I’m lucky though one will read the 600 pages of federal regulations and give me the Cliffs Notes version.

Will trade wine for summaries – email me.

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 7/10/14

RWJF Project Tracks Impact of Reform on Hospital Utilization

The Robert Wood Johnson Foundation announces a new surveillance program called the Hospital ACA Monitoring Project designed in collaboration with state hospital associations  to measure the impact that the Affordable Care Act has on hospital utilization.

Electronic Health Records: Fiscal Year 2013 Expenditure Plan Lacks Key Information Needed to Inform Future Funding Decisions

The DoD and VA have failed a GAO audit of their integrated EHR plans, satisfying just one of the six areas evaluated. When Congress approved the 2013 VA and DoD EHR budget requests, a provision was added preventing more than 25 percent of the funds from being distributed unless the GAO confirmed that the departments were on track with their plans.

2014 Most Wired

2014 Most Wired Hospital’s list has been published, an effort collectively undertaken by the American Hospital Association, CHIME, McKesson, AT&T, and H&HN.

Health IT from the Investor’s Chair 7/9/14

From a recent HIStalk post:

CareCloud borrows $25.5 million from a growth capital lender. I’m never cheered by a company taking on debt just like I wouldn’t be thrilled about a relative signing up for a home equity loan, but I guess it’s good news to be found credit-worthy and to have your plan for using the money vetted by someone whose objectivity is inarguable given their interest (no pun intended) in being repaid.

Investor’s Chair Thoughts

Let me present an alternative viewpoint on venture debt. Debt can be a great part of a company’s capital structure. Let’s use my favorite fictional company, eEngageLytics, as an example.

eEngageLytics has an outstanding business with high recurring revenues and a good margin profile, but needs growth capital to continue to expand, hire more sales people and finally sponsor HIStalk! In fact, with an additional $25 million, it would grow even faster than it has to date, and I have a fancy business plan to prove it!

Rather than sell more shares through a venture fundraising though, I’ll finance it through venture debt, as that can be a much more capital efficient way of funding the company. This fact remains true even if I expect to raise more equity capital in the future: the longer I wait, the more eEngageLytics will grow, and the higher the valuation will be for a subsequent equity round. Raising some debt right away allows me to kick the can down the road a bit, perhaps until after eEngageLytics is actually profitable (another major valuation inflection point).

How does the debt versus equity math work? To help us understand more clearly, let’s start by assuming that eEngageLytics would be valued at $100 million in its Series C round. That would mean that the company would have to sell 25 percent of its equity to current or new investors to raise the $25 million it needs to support its meteoric (but achievable) growth plan. Not only would an equity capital raise involve diluting current investors (who would now own a smaller slice of the eEngageLytics pie), but there would likely be other restrictions and obligations demanded by the investors (such as a board seat or two, some kind of dividend and many other “bells and whistles” inherent in a Series C preferred stock).

Now, there are, of course, other costs and complications inherent in both options:

• Like all lenders (except maybe Mom), venture lenders charge interest – but we’re currently living in a very low interest rate environment, so the CFO must model out the difference between the interest payments from debt and the dividend payments that equity investors often require. Venture debt for a quality company like eEngageLytics is running between 5-9 percent of the total amount (varying based on how much and when I actually pull down the money from the $25 million commitment – another example of the flexibility of debt financing). Let’s call it 7 percent on average, so that’s a max of $1.75 million per year.
• Also unlike Mom, debt holders always want to be paid back – often before a liquidity event, so our company must have a way to pay back out of future cash flows (a topic our lender will obviously focus on).
• Venture lenders have other ways to get paid besides the interest payments. There’s generally a warrant component, which allows them to purchase stock at a preferred rate – but it’s typically less than 1 percent, so dilution is minimal (especially in comparison to an all-equity deal).
• There’s typically various fees associated with the debt commitment, similar to closing costs for a mortgage; but, again, they are typically fairly reasonable (in this example, the likely fee would be about 1 percent of the total loan amount and some end of term fee to the lender (around 3 percent of the aggregate amount loaned.) Contrast that to the 6-7 percent ($1.5 – 1.75 million) that an investment bank would generally charge for a capital raise of this size.
• Don’t forget, however, that the availability of debt of this size is highly stage dependent. When eEngageLytics was developing its products and getting its first few customers, it was a bad credit risk and could barely get a corporate credit card – hence its need to fund through equity. Now that it needs money “only” to accelerate growth and tide itself over until profitability (or to buy hardware, or to make an attractive acquisition, etc.), it’s a far better candidate for debt.

Taking the various fees and interest payments together, eEngageLytic’s CFO can generally calculate an effective interest rate (like my mortgage broker does) and we see that, in this case, I’m paying a fully loaded interest rate of 15 percent per year, inclusive of the various fees. That’s about $3.75 million per year. Factor in the effects of compound interest and it costs current shareholders $32 million to repay the loan (assuming they borrow the full amount over the three-year term we’re using for illustrative purposes).

Let’s now flash forward a few years and assume that I’m able to sell eEngageLytics for a cool half a billion dollars (maybe a national payer like Aetna or United will step up – they’re always good for that). Had we sold 25 percent of our equity, the earlier eEngageLytics shareholders would collectively receive gross proceeds of $375 million (75 percent of $500 million). Fortunately, however, the management team are regular HIStalk readers (or get good advice from other sources) and, realizing that the amount of money they raise in no way equals how cool they are, raises the $25 million in debt rather than equity capital. Factoring out the debt repayment discussed above, and eEngageLytics shareholders in this scenario receive $468 million, a whopping $93 million more (which will allow even Inga to buy a few new pairs of shoes!).

So, bottom line, I see using debt as part of a company’s capital structure as a powerful tool to grow a business while minimizing dilution to founders, employees, and other shareholders. Here in the Bay Area (as shown on the HBO series Silicon Valley with occasionally frightening accuracy), the size of one’s capital raise is often viewed as a proxy for all sorts of things – “coolness” being just one of them. The bottom line is that entrepreneurs need to consider all the costs and benefits of different sources and types of capital, and when it’s appropriate, to use each to fund a business.

Finally, to return to Mr. HIStalk’s home equity loan analogy: assuming I’m taking out equity for a good reason (say, to renovate my kitchen, not to go on vacation), I’d rather have to pay back the loan (debt) than have to share part of my house (or proceeds when I sell it) with another party if I allow them to purchase some of my equity instead. Debt has responsibilities that equity doesn’t (such as an obligation to repay), but it typically allows the borrower more control and the opportunity to maintain their ownership. Which option makes sense depends on the situation.

Ben Rooks spent a decade as an equity analyst and six years as an investment banker. He has many friends who are venture capitalists, but he’d rather see returns go to entrepreneurs then to investors! Five years ago he formed ST Advisors to work with companies on strategic issues, only one of which is capital structure. He lives in San Francisco and absolutely loves e-mail.

Morning Headlines 7/9/14

Siemens Said to Explore Sale of Hospital IT Business

Bloomberg reports that Siemens is soliciting buyers for its health IT business unit, valued at $1.4 billion, so that it can focus on its energy and industrial units.

What Looks Like Overcharging By Your Hospital Might Not Be

A study finds that Medicare reimbursement rates at hospitals using EHRs are comparable to those still working on paper, contrary to earlier allegations suggesting that EHRs were driving up reimbursement by promoting copy and paste fraud. Critics point out that the study only analyzed inpatient records, and fails to address the original fraud allegations which were focused on ED reimbursements.

Critics worry health IT regulatory plan is already outdated

The public comments period closes on the FDASIA’s recently proposed health IT regulatory framework. The comments offered a mix of both criticism and support from various industry groups. The ONC’s policy advisory committee today moved immediately forward in a vote to endorse the framework.

Vials of Smallpox Virus Found in Unapproved Maryland Lab

Six vials of the smallpox virus, thought to be misplaced remnants from a 1950’s research lab, were found abandoned in an FDA lab in Maryland this week and are now undergoing testing to determine if they are still active. Smallpox samples are now considered so dangerous that only two labs in the world are authorized to store the pathogen, a CDC lab in Atlanta, and a VECTOR Institute lab in Russia.

News 7/9/14

Top News

Siemens AG is reportedly considering the sale of its healthcare IT unit (potentially worth over $1.4 billion) to focus on its industrial and energy businesses. The company considered selling its microbiology unit earlier this year, and is already spinning off its hearing-aids unit in an effort to give its healthcare businesses “operational independence.” A HIStalk reader familiar with these types of M&A scenarios notes that this rumbling is “sort of like rumors of McKesson selling off its IT division. They both keep losing customers, so who would want to jump on that mess? But, Siemens probably feels it’s best to sell now before it is worth less.”

Acquisitions, Funding, Business, and Stock

CliniWorks announces a strategic alliance with Pfizer in which the companies will work to develop a population health management platform that will enable large medical groups and IDNs to improve patient engagement, and deliver more efficient and effective quality healthcare in nearly real time.

Blackberry announces plans to open a healthcare services platform in India that will enable the integration of medical devices to aid in the early detection of illness. Blackberry India has several trial projects underway at local hospitals, all of which include integration with health information systems and medical equipment. A presence in India will likely serve Blackberry well, as providers there are expected to spend $1.08 billion on IT products and services in 2014. It seems likely the company will introduce those providers to the clinical operating platform from NantHealth, which it acquired a minority stake in earlier this year.

Blackberry’s interest in niche markets may just help it stand out from larger players like Samsung, which expects to post second-quarter earnings that fall $1.4 billion short of analyst expectations. The company attributes its loss to low demand in a saturated global market, and cannibalization of tablet sales by “phablet” phones. No word yet on whether a heist in Brazil affected Samsung’s earning predictions. Thieves held hundreds of factory employees hostage while they stole $36 million worth of Samsung tablets, mobile phones, and laptops.

N.C.-based Validic acquires Infometers Inc., a California-based technology company that connects remote healthcare monitoring devices to healthcare organizations. As a result, Validic has opened a Silicon Valley office and seems well on its way to achieving its goal of 300 clinical and wellness device and application integrations this year.

Following a disappointing second quarter, Royal Philips announces it will implement a new management structure within its healthcare sector, with all healthcare business groups reporting directly to Philips CEO Frans van Houten. Philips Healthcare CEO Deborah DiSanzo has decided to leave the company.

Capsule Tech announces it will open a Singapore subsidiary to support its growth in the region. Capsule Singapore will provide medical device integration implementation, technical and commercial support, pre-and post-sales assistance, and customer service.

Sales

Southern Illinois Health System expands its use of Ascend Software, selecting the company’s SmartTouch HR Imaging technology to create a paperless environment in its HR department. The 20-facility health system already uses Ascend solutions in its accounting department.

Holy Name Medical Center (NJ) selects Wolters Kluwer Health Language Workflow-Enhancing Search solutions. HNMC will use the solution to support encoding its problem lists in SNOMED-CT for Stage 2 Meaningful Use and the transition to ICD-10.

Cumberland Medical Center (TN) implements DataMotion’s Direct Secure Messaging with its Meditech EHR, resulting in successful attestation for Stage 2 Meaningful Use. The 189-bed hospital is a member of the East Tennessee Health Information Network, for which DataMotion provides Direct addresses.

People

T-System names Roger Davis (Accenture) president and CEO.

IPC The Hospitalist Company appoints Jeffrey Winter (Correctional Medical Services/Corizon Health) senior vice president of sales and marketing.

ESD names Richard Armstrong (Leidos Health) Cerner practice director.

HealthTrust appoints Kent Petty (Wellmont Health System) as CIO.

Government and Politics

FDA officials are likely starting to sift through the 158 submitted comments addressing the FDA Safety and Innovation Act draft report. Several health IT industry groups seem to have reached a consensus, citing the need for limited regulation of clinical decision support software, and a desire for the FDA to dig deeper when it comes to specifics. The EHR Association noted in its comments that “the limited number of examples of applications in each category provided in the report is not sufficient to determine the risk categories for the many existing and new applications being developed, and we urge their expansion as this proposal is finalized.” Concerns around the proposed Health IT Safety Center were also raised, though recent media coverage suggests that the ONC’s policy advisory committee has endorsed workgroup recommendations for the center.

The Health Care Cost Institute announces that CMS has certified it as a “Qualified Entity,” making it the first organization to have full access to national Medicare claims data for reporting on the costs and quality of healthcare services. The Qualified Entity program, created as part of the ACA, permits certain organizations to combine Medicare Parts A, B, and D claims data with other payer data to evaluate the performance of healthcare providers, services, and suppliers. HCCI plans to pursue a research agenda using the combined dataset containing information on over 100 million individuals.

Research and Innovation

A study finds no evidence to suggest that hospitals are systematically using EHRs to increase reimbursement. Hospitals that adopted EHRs increased billing to Medicare at a rate comparable to that of non-EHR adopters. Detractors of the study, which only looked at inpatient records, think the real billing problem is more likely to be found in EDs and outpatient clinics, which are increasingly run by hospitals.

Results from a new international study highlight four myths about the future of healthcare IT, particularly as it pertains to helping global healthcare organizations transition to all-digital environments:

• People don’t want to use digital services for healthcare – 75 percent of patient respondents expect to use digital services in the future.
• Only young people want to use digital services – Digital-service use is expected to increase across all age groups.
• Mobile health is the game changer – Awareness and process execution are in fact core drivers of digital-service adoption for patients.
• A comprehensive platform of service offerings is a prerequisite for creating value – The services that Singaporean patients request most show it’s not always necessary to start big (good news, no doubt, for Capsule Tech).

Other

Sensationalist headlines aside, The Bill & Melinda Gates Foundation is in fact backing development of wireless, implantable birth control that could be effective for up to 16 years. Massachussetts-based MicroCHIPS is working on the implant, which can be turned on and off via remote control. The device will begin pre-clinical testing in the U.S. next year, during which the company will no doubt work with the FDA to overcome hacking concerns.

The New York Times profiles Kevin Tracey, MD president and CEO of the Feinstein Institute for Medical Research for the North Shore-LIJ Health System (NY). Tracey shares his view on great leadership in the operating room: “It’s about clearly stating the purpose and asking people how they’re doing and really listening if someone needs something different that day. If the operating team can accommodate the needs of that person without deviating from the plan, that person will be a better member of the team.”

The New York Attorney General files suit against Beth Israel and St. Luke’s-Roosevelt hospitals, and Continuum Health Partners, accusing them of accepting over $1 million in Medicaid payments they were not entitled to, and had in fact received as a result of a known computer error in 2009 and 2010. (Continuum owned both hospitals prior to a recent merger with Mt. Sinai.) A Mt. Sinai representative has firmly stated it intends to argue the case “vigorously” in court.

Sponsor Updates

• HealthTronics signs a distribution agreement with HS Medical to provide HS Amica microwave ablation apparatus to providers.
• Arcadia Healthcare Solutions client Carlos Olivares, CEO of Yakima Valley Farm Workers Clinic, is named CEO Visionary of the Year.
• A.D.A.M.’s SmartCare V1.2 receives MU certification with eClinicalWorks V10.0.
• The Advisory Board Company profiles the new Medicare patient in a recent research brief, offering five ways they’re different and how to engage them.
• LifeImage’s Hamid Tabatabaie discusses transparency and OpenTable for medical imaging in a recent blog post.
• Hennepin County Medical Center (MN) details how it was able to save almost $11 million after working with Leidos Health on a revenue cycle optimization plan.
• LDM Group provides an overview of what population health management’s purpose and goals within healthcare actually are (and what they are not).
• GetWellNetwork is profiled for starting GetWell Labs to assistant fledgling health technology companies develop their software.
• Divurgent shares how pharmacists and pharmaceutical companies assist in remaining relevant as an ACO and CIN in a new white paper.
• AirWatch by VMware launches Partner University and updates its Academy Certification Program.
• BCBS of North Carolina integrates with CoverMyMeds to streamline the prior authorization process.
• Leeds Teaching Hospitals NHS Trust uses InterSystems HealthShare for its regional master patient index.
• Hayes Management Consulting explains the details of decision support extracts.
• Emdat explains the benefits of dictating documentation within the EHR in a fun, informative video.
• CareTech Solutions achieves ONC HIT 2014 Edition Modular EHR Certification from ICSA Labs for its iDoc solution.
• Western Medical Associates (WY) is live on its eClinicalWorks patient portal.
• Wolters Kluwer Health partners with Logical Images to offer VisualDX to its Lexicomp clients.
• Quintiles completes the acquisition of Encore Health Resources, which will now be known as Encore, a Quintiles Company.
• DrFirst announces in a new briefing that there are now over 28,000 pharmacies nationwide that accept electronic prescriptions for controlled substances.

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 7/8/14

Proposed policy and payment changes to the Medicare Physician Fee Schedule for Calendar Year 2015

CMS’s proposed 2015 Medicare physician fee schedule expands reimbursable telehelath services, adds language requiring 2014 Edition EHR adoption for physicians providing chronic disease management, and introduces a bonus structure to the ACO program that further incentivizes quality improvements.

‘VistA for NHS’ ready for trusts

Responding to the NHS’s call for more open source EHR solutions, General Dynamics and Medsphere team up to introduce an anglicized version of the VA’s VistA EHR in England. The team has been at work since the end of 2013 and is now prospecting for its first UK customers.

Scientists threaten to boycott €1.2bn Human Brain Project

In Europe, 130 prominent neuroscientists are threatening to boycott the $2 billion Human Brain Project funded by the European Commission because they say that the project’s scope is too narrow and limits research topics to those that support HBP’s goal of mapping the human nervous system and creating a computer model of the human brain.

ONC 2014 Edition Test Method

The ONC has updated the test procedures and test data used by vendors when seeking 2014 Edition EHR certification. The changes address automated measure calculation and automated numerator recording for measures that have percentage-based thresholds.

Curbside Consult with Dr. Jayne 7/7/14

I enjoyed some R&R over the holiday weekend. It was good to have a break from the normal routine. As an added bonus, most of our IT staff disappeared the day before the holiday, whether sanctioned or not. I had a grand total of one email after noon on Thursday and it had to do with something administrative.

I know this reprieve will be short-lived since we start implementing practices again tomorrow. At least we’ll be heading into the fray well rested.

Quite a few readers chimed in on last week’s Curbside Consult discussion of poor-quality EHR documentation. Several readers mentioned the purpose of the note as a key concept. While visit notes were traditionally for the benefit of the provider in documenting the patient’s condition, exam, and what was done, they have been co-opted by payers and regulators who equate documentation volume with value.

Notes are increasingly the purview of patients. Our health system does release visit notes directly to the patient through our patient portal. Most of our primary care physicians do a great job with patient documentation because they know the patients might actually be reading it. Our subspecialists who have been on EHR a long time also do fairly well.

The new practices are struggling more than those groups. It’s hard to tell how much they’re struggling with the actual documentation process vs. the concept of being part of an employed medical group and being told what to do.

As to who has the authority to take corrective action against “bad actors,” in our organization, it isn’t the CMIO, but rather the CMO and the president of the physician group. Both of them received formal notification of the specific concerns I found during the special project. I also included a request to authorize a more thorough and comprehensive audit by our internal Compliance department. If some of the documentation is as bad (and potentially fraudulent) as it seems, we’re going to need a better sample size and multiple independent auditors to prepare the documentation ahead of disciplinary maneuvers.

When I created my CMIO role here, I intentionally excluded physician discipline from my purview. To be successful within our culture, I needed to be seen as an advocate rather than someone who could get them in trouble. Additionally, I felt that in the case of EHR misuse, I would be seen as inherently biased towards defending the EHR and the IT group whether or not it was true.

Our leadership agreed. So far, the splitting of authority has worked. I think it will work well in this case also once we have evidence of documentation patterns across the group.

I laughed at SpoonEHR’s suggestion to create a macro “Signed but not read.” It’s unfortunately all too true. Back in the days of in-house transcription, I quit using a consultant whose letters came back “Dictated but not read, signed by transcriptionist to expedite” or some similar nonsense. If I can’t trust someone to read, edit, and sign their notes, I certainly don’t trust them to care for patients.

Reader Zafirex receives similarly ridiculous notes addressed to “Dear Dr: No Referring Doctor.” The paradox here is that the referring physician receives the referral note. Therefore, the practice at least knows how to address the envelope correctly.

I also loved Jedi Knight’s comment that, “We’ve sped up the process of sharing data without considering that the data is no longer worth sharing.” I do hope that the OpenNotes movement and the resulting opportunities for patients to read their notes will spur some providers to clean up their acts. Over the weekend, my dad asked about some information that was in his recent encounter note that didn’t make sense. I hope he calls his doctor on the carpet about it.

The idea that gives me the most hope, though, is Richie’s mention of a “Data Kidney” that can review text for “cleanliness.” In the newspaper world, that would have been the editors and proofreaders. All kinds of imagery comes to mind, including the proverbial red pencil. We’ve got grammar check in our word processing software, so why not for EHR output text?

What gives you hope that documentation will get better? Email me.

Email Dr. Jayne.

An HIT Moment with … Joe DeSantis

An HIT Moment with ... is a quick interview with someone we find interesting. Joe DeSantis is vice president of HealthShare Platforms of InterSystems of Cambridge, MA.

What interoperability benefits do healthcare organizations seek beyond just connecting systems, and what progress have they made?

First off, I think it’s important to say what we mean by interoperability. At the most tactical level, it means you can pass a clinical document from one system to another.

We think of it as something much more strategic to the organization. Sharing all health information, including financial and operational data, to achieve strategic objectives. If you have a platform that can view data as discrete elements and not simply as documents, you can support advanced analytics, decision support, rules, and other use cases. With robust connectivity, you can use your data in real time within the context of your existing workflows. And you have a foundation for creating new applications that work together and extend the capabilities of the entire system.

Our customers use our health informatics platform, called HealthShare, to achieve strategic interoperability and create an infrastructure of connected care solutions, not just to address their current challenges, but those that haven’t yet emerged. For example, North Shore-LIJ, one of the nation’s largest health systems and the largest in New York State, has harnessed strategic interoperability to improve care for its obstetrical population. This includes information sharing and care coordination among more than 100 providers, three outpatient EHRs, two inpatient EHRs, and two prenatal imaging centers. They share a coordinated record, dynamically identify members of the high-risk pool, and use alerts to notify providers of gaps in care. And, for a rapidly growing health system, North Shore-LIJ knows the platform can support its long-term needs.

On a regional or national level, strategic interoperability is essential to public health management. One statewide health information network, built on our platform, was able to reduce the time needed to report on a regional disease outbreak from several months to a few hours.

Describe the relationship between interoperability, population health management, and patient engagement.

Population health management and patient engagement are long-term goals for healthcare organizations. Both concepts are relatively new and important. They both offer the promise of helping to address the enormous issues related to chronic and lifestyle-related health problems. Neither is well defined yet.

Interoperability, or more importantly, strategic interoperability, is also a long-term goal. It differs from the others in that no one is really interested in interoperability for its own sake. They are interested in what they can do once they have it.

Population health management is about understanding the entire community served by your healthcare organization, not just the patients you have encountered. It is not a one-size-fits-all problem. There are no true off-the-shelf population health management applications. Instead, there are extensive services you can buy under the guise of a product.

The best approach to population health management, in my opinion, is to think of it as a collection of smaller, interlocking issues. The solution will be to deploy a number of focused applications, some from vendors, some custom built. These applications will need to work together and be integrated within the existing health information systems and workflows. This is why you need strategic interoperability to address this problem.

Patient engagement is about giving patients the tools to take charge of their own health. Again, strategic interoperability plays a big part. If you can provide a complete view of the patient’s information – not simply regurgitating test results from a single EHR – and if you can make services available to the patient within this context, like making appointments, education, communicating with providers, then you have something of value to offer your patient community. And coincidentally, you have a component of your population health management solution.

How is HealthShare different from other HIE, integration, and analytics solutions?

HIE, integration, and analytics products are, in general, single-issue solutions, each requiring separate management and often its own database. These solutions proliferate within organizations, ultimately contributing to information silos rather than addressing the fundamental challenges of healthcare.

HealthShare is above all a unified software platform designed for information sharing. The platform provides three important capabilities. It gives the ability to manage and store all kinds of data – relational, object, XML, unstructured – in a reliable, efficient, and interoperable manner. It provides connectivity – applications to applications, applications to users and devices, and users with communities. It provides insight, through analytics, as an embedded part of the entire platform. This gives our customers the ability to solve big problems.

One of the other key differentiators between individual solutions and a platform like ours is that once an organization adopts HealthShare, they have almost limitless growth options and multiple paths to success. They can implement a robust application module such as our Clinician Viewer. They can build out their own applications. And they can purchase HealthShare-based solutions from our many software partners.

What types of alerts are possible?

We refer to alerts as smart notifications, and again, the possibilities are nearly limitless. Because HealthShare aggregates, normalizes, and enhances all kinds of data in near real time, alerting capabilities are only bounded by your user base and your data investment.

Sometimes the simplest alerts offer the most rapid return on investment. For example, In Rhode Island, primary care doctors receive smart notifications when their patients are admitted or discharged from the hospital so they can properly manage care after discharge. They’ve measured a drop of more than 16 percent in 30-day readmissions for patients whose doctors subscribed to the alerts.

Many companies are selling analytics solutions. What factors will make specific vendors and their customers successful?

We have found that organizations that follow four important steps – capture, share, understand, and act – are more likely to achieve breakthroughs. Your organization first needs to capture health-related information. Then you have to share this information in a meaningful way among systems, applications, providers, organizations, and communities. The data, both structured and unstructured, must then be analyzed and understood.

Then you are ready to act. You can use the results to drive transformative action within your organization. For both vendors and customers, these four steps will be critical to success.

Morning Headlines 7/7/14

Fireside chat with Google co-founders, Larry Page and Sergey Brin

Google co-founders Larry Page and Sergey Brin sit down with VC legend Vinod Khosla at the annual Khosla Ventures CEO Summit. The three discuss a wide range of topics, including health IT, of which Sergey Brin says, “Generally, health is just so heavily regulated. It’s just a painful business to be in. It’s just not necessarily how I want to spend my time. Even though we do have some health projects, and we’ll be doing that to a certain extent. But I think the regulatory burden in the U.S. is so high that think it would dissuade a lot of entrepreneurs.”

Triangle hospitals go Epic with multimillion-dollar software

A Raleigh-Durham, NC paper looks back on the Epic migrations at the area’s three largest academic hospitals.

How webcams in Syria’s bombarded hospitals offer a lifeline for war victims

Physicians in the US, Canada, England, and Saudi Arabia are providing telehealth support to ICU units in war torn Syrian hospitals. 50 percent of Syria’s physicians have fled, leaving behind overcrowded ICU’s with no physicians.

Monday Morning Update 7/7/14

Top News

Google co-founders Sergey Brin and Larry Page (net worth: $31 billion each) don’t seem too excited about moving Google into healthcare (again) despite recent developments with Google Fit. Brin, responding to a question about the company’s experimental glucose-reading contact lenses, says, “Generally, health is just so heavily regulated. It’s just a painful business to be in. It’s just not necessarily how I want to spend my time. Even though we do have some health projects, and we’ll be doing that to a certain extent. But I think the regulatory burden in the US is so high that think it would dissuade a lot of entrepreneurs.” He’s probably talking specifically about FDA-approved medical devices, but that’s not clear. Page repeats his claim that data mining would save lives, although in this iteration he puts the number at 10,000 saved lives in the first year rather than the 100,000 he gave several times previously. You know healthcare is a mess when the guys who can take pictures of every street in the US and make self-driving cars can’t figure out how to crack the bureaucracy and special interests. On the other hand, their own efforts with Google Health and Google Flu Trends were pathetic, so maybe that just gives credence to the argument that it’s easy to criticize healthcare when you don’t know much about it.

Reader Comments

From Fort Apache: “Re: Dim-Sum’s comments about DoD claims processing and Epic. Kaiser is implementing Epic’s Tapestry Claims Payment System (AP Claims) throughout the country for all of their business. Epic won’t need to find a third-party partner for the DoD bid.” Verified.

From SQSUX: “Re: Riverside, IL. I spoke to the lab director — they are moving to Epic and Beaker.” Unverified. I will note the apparent trend, however, that hospitals previously wary of Beaker’s readiness seem more inclined to replace incumbent their incumbent LISs, even best-of-breed ones, with Beaker given that it carries no additional license fee, it has a theoretical integration advantage (whether that’s real depends on who you ask), and gives the hospital a single vendor to contact for support. I doubt that implementing Beaker is ever the favorite option of the lab director, but he or she is often pressured by hospital administration to justify why Beaker isn’t “good enough” given the perceived advantages outside the lab. I’d be interested in hearing from a lab director who’s made the switch and what was gained and lost from the lab’s perspective since I know the issue is coming up a lot.

From The PACS Designer: “Re: Windows 9. ‘Threshold’ is the code name for the upcoming release of Windows 9 next year. Microsoft will be bringing back a new version of the their popular Start Menu that many currently miss in their present Windows version.” The hard drive of my main computer, an Asus desktop, failed last week. I found a suitable replacement desktop PC on clearance at Office Depot for around $400 that met my minimal specs (8GB memory, 1TB hard drive, USB 3.0). It had Windows 8.1 pre-loaded with a change that bypasses the Metro tile display as its default. My suggestion is to not obsess with the Windows 8.1 changes and don’t do something silly like wipe the drive and reinstall Windows 7 just to avoid learning something slightly new when most people only barely interact with the OS anyway. Everybody knows that every other version of Windows is crap and that’s been the case since the late 1990s, but at least this latest Windows 8 kludge upgrade fixes Microsoft’s colossal blunder in trying to force a tile-based mobile interface on the vast majority of computer users who don’t have (and don’t want) a touch screen for desktop use. My only hesitation was whether to buy a laptop or a desktop and I went with the latter – even though they are a dying breed, I like having lots of USB ports without needing a hub, easy dual-monitor support, and having all the wires under the desk instead of on top of it.

HIStalk Announcements and Requests

More than half of respondents to my poll would recommend the Epic-IBM EHR package to the Department of Defense. The skeptic in me wonders if the large number of participants suggests vendor vote-urging. New poll to your right (or here): does your PCP offer a patient portal and have you used it in the past six months?

Listening: new post-grunge from South Africa-based Seether, which has been rocking a Nirvana-ish sound since 2002.

A few readers reported seeing pop-up ads (some with audio) when visiting HIStalk-related sites, to which I always suggested running an antivirus/spyware scan since it wasn’t happening for me. I tracked it down – the company that provided the hit counter that displayed at the lower right of the page (the “8 million visits since June 20, 2003” text) had slipped in some sneaky ad software in Javascript that could hijack the page, so I replaced it. The page loads faster and the hijacking problem is fixed, with the only downside being that the new stats package I installed can’t display the cumulative total on the page.

Welcome to new HIStalk and HIStalk Practice Platinum Sponsor GE Healthcare. The company offers healthcare IT products in enterprise imaging (Centricity RIS, PACS, Clinical Archive, and Centricity 360 collaboration), care delivery management (Centricity EMR and PM, Perioperative Manager, Perioperative Anesthesia, Perinatal), population health management solutions, revenue cycle management, financial risk management, EDI and claims processing, contract modeling and management, activity-based costing, and utilization management. Thanks to GE Healthcare for supporting HIStalk and HIStalk Practice.

Here’s an overview video of GE Healthcare IT that I found on YouTube. I think it’s the same one mentioned in their sponsor ad.

Acquisitions, Funding, Business, and Stock

Orion Health is considering going public with an IPO on the New Zealand Stock Exchange, with an unnamed source suggesting a value of around $440 million US.  

Sales

CaroMont Health (NC) contracts with Mercy Technology Services to implement its Epic system. MTS is the IT services division of Mercy, the 33-hospital Catholic system that is accredited as the first Epic Connect provider. The health system provides implementation, hosting, application management, consulting, and analytics. MTS also provides its model of Epic that includes its own customizations, or as it says, “Unlike Epic’s out-of-the-box base model, Mercy’s system contains years of enhancements driven by the physicians and nurses who use it.”

People 

Amy Abernethy, MD, PhD (Duke Medicine) is named CMO/SVP Oncology of oncology data technology vendor Flatiron Health, which recently raised $130 million from Google Ventures. She is also on athenahealth’s board of directors and will retain a part-time oncology role at Duke. Amy is a regular HIStalk reader and we’ve decided that an interview might be fun.  

Urgent care EMR vendor DocuTAP hires Bryan Koch (Greenway Health) as EVP of revenue cycle management.

Government and Politics

NIH awards a four-year, $43 million grant to form the NIH Undiagnosed Diseases Network, which will use genetic and clinical screening to focus on diseases that affect as few as 50 people in the entire world.

The VA signs a three-year, $162 million contract with  Accenture’s ASM Research to support VistA and develop web-based access to Vista’s CPRS patient record system.

A Washington Post analysis finds that 90 percent of the emails intercepted by the National Security Agency came from ordinary US citizens rather than suspected terrorists, some of them including medical records emailed between family members. The agency’s tools can sniff data from all voice and data networks and can extract email information from Yahoo, Microsoft, Facebook, and Google, all without requiring a probable cause warrant.

Technology

An Inc. article says that Facebook’s declining usage makes it a target for startup competitors that won’t sell the personal data of their users. According to one startup CEO, Facebook has three big problems: “The first one is privacy–you want to be able to communicate without having your communication monitored and monetized. The second is monopoly. You don’t have open competition; you have somebody who controls who wins and who loses and how much they charge for the service. There is no way a social network should be a monopoly–everybody suffers, from the vendors to the consumers. And that’s the third problem: It really stifles innovation." The article predicts replacement apps that allow users to control (and sell, if they want) their own information, declaring, “If this is the information age, then information has value. And if it has value, how come everybody has it but us?”  The parallels to healthcare data are significant.

Other

A New York Times article points out that insurance company UnitedHealth plays both sides of Medicare hospital payments as it pays hospitals less than they’d like via its Medicare Advantage plans but also charges hospitals via its Executive Health Resources subsidiary (acquired in 2010) to help them justify higher payments from Medicare.

Milwaukee Health Services (WI) receives a $190,000 city loan to upgrade its GE Healthcare EHR to earn Meaningful Use incentives. The community health center spent $3.1 million on its previous Pearl EHR from Atlanta-based Business Computer Applications, Inc., which it sued in a dispute over being locked out of its system over unpaid invoices. BCA, which did a lot of government work with CDC and NIH and sold EHR systems to prisons, was acquired in February 2014 by government contractor Acentia.

The Raleigh, NC newspaper covers local implementation of Epic at all three major systems:  UNC Healthcare, Duke University Health System, and WakeMed. It also mentions Epic-related billing problems at Cone Health and Wake Forest Baptist Medical Center, but WakeMed says its clean bill rates jumped from 80 percent to 96 percent after moving practices to Epic. Like most things in life, it’s not what you have but how you use it.

ICU telemedicine services are saving lives in war-torn Syria, where the both the government and rebel forces are accused of bombing hospitals that they claim are harboring opposing forces. The US-based Syrian American Medical Society (SAMS) started a telemedicine program last year to alleviate a shortage of doctors to care for ICU patients, most of them civilians injured by randomly dropped barrel bombs. Doctors from Canada, England, the US, and Saudi Arabia use Skype and webcams to oversee ICU patients and offer suggestions during surgeries. Syria previously had one of the Middle East’s best healthcare systems but has lost half of its doctors. Another 460 healthcare professionals have been killed in 156 hospital attacks, 90 percent of them carried out by government forces.

The Federation of State Medical Boards issues a telemedicine-focused model state policy that would make it easier for doctors to obtain licenses in multiple states. Expedited licensure would be available for certified specialists with no history of disciplinary problems. The patient’s location at the time of the encounter would determine which state’s medical regulations would apply. FSMB subject matter Alexis Gilroy, JD mentioned this change when I interviewed her in May. This is a great and potentially quickly implemented alternative to national licensure, allowing doctors to practice in multiple states (telemedicine, referrals from other locations) without having to apply for licensure state by state.

Weird News Andy calls out the sad story of a veteran who died waiting for an ambulance while he was inside a VA hospital. The man collapsed in the cafeteria of the Albuquerque VA hospital, but hospital policy required him to be transported by ambulance to its ED, just 500 yards from where he went down. Employees called 911 and performed CPR in the cafeteria during the 15-20 minute wait for the ambulance. The hospital is reviewing its policy, but despite the negative press, it’s pretty much standard in every hospital I’ve worked in. You can’t have ED people leaving the building (and their patients) to sprint down the sidewalk with a gurney. The article didn’t say whether those performing CPR were clinicians with code cart support, and if so, the outcome was probably predetermined regardless of location.

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 7/3/14

Big cyber hack of health records is ‘only a matter of time’

A Politico report interviews IT security experts who fear that health IT is primed for a massive cyberattack on par with the recent headline grabbing attacks on Target and Yahoo. Experts say that medical records are worth far more on the black market than credit card data, and the infastructure protecting the data is far more vulnerable  to attack.

Veterans Affairs Selects ASM Research to Modernize Electronic Health Records

Accenture signs a three-year $162 million VA contract to support and enhance VistA. Accenture will provide workflow analysis, software development, implementation, and end-user training. The project will address interoperability and data security, and will provide an enhanced web-based user interface to the Computerized Patient Record System used by VA clinicians.

Executive Insights on Healthcare Technology Safety, 2014 Report

The Association for the Advancement of Medical Instrumentation has teamed up with the ECRI institute to publish a healthcare technology safety report. The 2014 edition, its inaugural report, focuses on alarm systems, Luer connectors, cybersecurity, batteries, and recalls.

Morning Headlines 7/2/14

 Billionaire With Achy Knees Cashing In on Health Data

Bloomberg profiles InterSystems and its owner Terry Ragon, whose net worth has soared to $3.1 billion since starting the company.

NextGen Healthcare and Mirth Launch Enterprise Interoperability Platform

Quality Systems Inc., parent company to both NextGen and Mirth, announces a new interoperability offering that allows NextGen customers to leverage Mirth’s interoperability platform to meet Stage 2 MU data exchange requirements.

Tale of two health care websites: Minnesota presses on; Maryland moves on

Minnesota health leaders say they will stand by its problematic health insurance exchange website despite calls for its replacement and reports that only 26 of 73 site functions are working. Deloitte has been contracted to repair the troubled site.

Medical Cost Trend: Behind the Numbers 2015

PwC forecasts a 0.3 percent increase in healthcare spending for 2015, citing EHR investments and the overall economic recovery as drivers. The report goes on to say that value-based reimbursement models and integrated care delivery networks appear to be helping contain the cost inflation.

News 7/2/14

Top News

Bloomberg profiles InterSystems founder and owner Terry Ragon, net worth $3.1 billion, and the connections he has with other early healthcare IT companies such as eScription and IDX.

Reader Comments

From Illinois Blago: “Re: Riverside in IL. Moving from McKesson to Epic.” Unverified.

From GhostofEclipsys: “Re: Allscripts. In an effort to reduce costs as sales continue to wane, the company is considering outsourcing its client education and training group this fall. This has not worked well for other HIT companies and is an often quoted reason for not selecting a vendor during RFP. Clients want training by experts from inside the four walls who have critical relationships with engineering, not the B-team outsourcer. The Allscripts education team has won several awards for client education nationally.” Unverified.

From Block and Tackle: “Re: Self Regional Healthcare. Has had three days of Allscripts Enterprise downtime due to a known issue involving a patch. I’m curious if readers have had similar experiences with Allscripts Enterprise.” Unverified.

From Nasty Parts: “Phytel laid off a large number of people today. Rumor has it that the primary VC wants their $40M investment back and that Premier backed out of a deal to buy Phytel. I hear Phytel wants $225M and Premier wants to only pay $165M. So, today’s layoffs are to help the company get to a more profitable number that can justify the larger purchase price.” Unverified.

From Furydelabongo: “Re: athenahealth. The Belfast, ME office is bringing in a local primary care practice, Searsport Family Medicine,  to serve as the clinic practice for their employees as well as be a test site for new functionality.” Unverified.

DoD EHR Update from Dim-Sum

DHMSM status and latest rumors in the halls of bedlam, located “just to the right” of K Street. Sorry about he delay, I have been rather busy.

• June marked the date where the DHMSM vendors will finally peruse a more comprehensive assessment of what each and every vendor will have to endeavor.
• Great job Captain W and your respective team – The REAL RFP will be dropped September 2014.
• One can only hope that your DHMSM team’s work will allay the fears and will fuel the excitement of those that are crazy brave and yet confident to move forward with this unique EHR experience
• Rumors are ringing about the Womack ousting. In all sincerity, I believe that all three impact solution teams could improve safety across the DoD HIT environment, be it Cerner, Siemens/athena, or Epic (have yet to decide if Allscripts can compete with their sub-mundane acute solution). Good news, DoD, all of these solutions will improve workflows, enable true integration and interoperability, and will be focused on clinician adoption. In the immortal words of the DoD, “There is no such thing as too much training?” COTS love to train the trainer (for a nominal fee) and perhaps that mentality will be a bright spot in a bleak environment.
• Six site visits by DoD to Epic sites, one gratis for McKesson, Meditech, and Cerner. I guess Siemens/athena and Allscripts missed the boat?
• Can anyone explain how with two media submissions (one article, one announcement) the DHMSM solution price went from $5.5B to $11B? Perhaps it is the Watson effect?
• In that same way of thinking, I believe that the first decade in a half of amateur DoD HIT design cost tax payers a trillion dollars give or take a half a billion!
• Claims rumors abound. Wondering how much of the claims processing debacle including collections will be handled by one of the big three. This is an essential component, and since ABACUS is having FISMA issues, I figured that maybe Mr. Miller will see value in pushing claims in the DHMSM deal – more than revenue cycle, so sorry, Epic, you will have to actually find a third-party system (feel the fear!)
• Industry Day – interesting, not as interesting as the RFP team read. Telehealth, asset tracking, real enterprise scheduling, military styled healthcare logistics (COTS, this is more of a challenge than most realize – hope there are some real discussions to understand what it means to be a functional ERP+ system).
• Cerner, you are not ranked in the top five to install your own system. Good thing you have Accenture to pick up the slack – Leidos “as is” is your key to victory – Theme “transition, transition, transition”
• Siemens, be happy athena is a very competitive ambulatory care solution. Teamed with your SOA your co-hosting maturity in acute and ambulatory settings make a lot of sense. I believe it might be appropriate for Tibco to lend a hand in the technology story that is truly a differentiation for the Lockheed team.
• BTW, Lockheed, I could have sworn you had more than a part-time employee working your public relations program – is it difficult to state your intentions? CSC passed you as though you were riding a moped on the autobahn.
• Allscripts, CSC, and HP — what a combination. You only need a population health solution and have to press the fact that Eclipsys is not archaic – good luck with that. Great announcement, short, succinct, and made people scratch their head.
• McKesson is rumored to be in deep negotiations with themselves – so far no progress.
• Cerner is the closest COTS to try to emulate what Epic has done, stating proudly that they are a monolithic solution, built on a myriad of frameworks they are competitive and can hold their own (however, I do not like the ambulatory solution, but the RFP will not have a weighted value assessment on features and functions, merely a check box that allows a team to state “YES we CAN"). Cerner should also utilize the Oracle story as they did in Utah for a win.
• Accenture “good on you” for the Henry Schein relationship. If my teeth were falling out of my mouth, the first and most exciting dental EHR solution I would want managing my episode of care would be Dentrix!
• GE Healthcare is missing in action. Perhaps an upcoming announcement will be made about their acquisition by SAIC? OK, maybe that is pure rumor 🙂
• VistA – we all know your solution is awesome, everyone loves it, adoption in a monopoly environment is 110 percent. However, do you really think after the debacle that is VA, informatics should try to be proliferated across the DoD? Methinks NO.
• NOTE: After several “as is” and “to be” meetings, the EHR vendors real fears have more to do with two things: (a) Legacy solutions that were so poorly designed and the manner in which they were integrated requires duct tape and glue – can any vendor that programmed the old solutions actually stand behind their solution?  Did anyone within 50 miles of the beltway ever read anything about HIT standards? (b)How does a real EHR maintain parallel operations with a variety of poorly designed systems? These two thoughts are constantly on the minds of the EHR vendors – it haunts their dreams!
• There is a sobering thought I had with a colleague over a cigar — that Leidos (SAIC in general) and Grumman should not be allowed to bid as a member of any team, but instead be enlisted as enablers to access the “stuff” they created. Perhaps they should be relegated to provide 100 percent support for all transitions, migrations, parallel synchronization, and conversions for the new EHR solution team. This time using real standards, ones that people can understand, would be refreshing. In essence they should act as Switzerland so they can actually do something that emits value over the next 5-7 years associated with rollout. Think of it as penance.

Webinars

July 2 (Wednesday) noon ET. The CIO’s Role in Consumer Health. Sponsored by HIStalk. Presenter: David Chou, CIO, University Of Mississippi Medical Center. We are moving towards an era where the consumer is searching for value. Healthcare is finally catching up with other industries and this is forcing health care providers and health plans to rethink their "business model" as consumers test new decision-making skills and demand higher quality and better value. Technology can provide value in this space as we move towards a digital healthcare.

Sales

Arkansas Methodist Medical Center (AR) chooses T-System’s ED documentation and coding solutions.

Children’s of Alabama extends its contract for Allscripts Sunrise and adds dbMotion, Sunrise Ambulatory Care, and Sunrise Emergency Care.

People

Voalte promotes Trey Lauderdale to CEO and appoints a new board of directors: Tom Johnson (Global Imaging Systems), Nico Arcino (Kaiser Permanente), William Gish (Cerner Corporation), Isobel Harris (PeopleFluent), Jeffrey Lozon (Revera), Michael Marvin (MapInfo). 

SRS names Scott Ciccarelli (GE Healthcare) as CEO. He replaces Evan Steele, who will become senior advisor.

AirStrip promotes Matt Patterson, MD to president and hires Nancy Pratt, RN, MSN (St. Joseph Health) as COO.

Robin Raiford, RN-BC (The Advisory Board Company) died on June 26 at 62. The visitation and service will be held Wednesday, July 2 in Springfield, VA. Details and guest book are here.

Announcements and Implementations

PatientKeeper adds a rules engine to its charge capture solution that allows billers and coders to manage code edits.

QSI subsidiaries NextGen and Mirth announce NextGen Share, a Health Information Service Provider (HISP) that will connect NextGen and non-NextGen EHR users via Direct.

Albany Area Primary Health Care (GA) goes live on Forward Health Group’s PopulationManager and The Guideline Advantage.

Innovation and Research

Researchers develop the capability to create blood vessels using a 3D printer and then growing cells around them, leading to the possibility of “printing” a full organ.

Other

An Ars Technica article written by an early Google Glass Explorer  says Android Wear smart watches make Google Glass obsolete. Reasons: (a) Google is developing more technology for Android Wear than for Glass; (b) Glass will always look weird and raise suspicions that the wearer is secretly recording them; (c) Google disabled live video streaming on Glass because it didn’t work well; (d) Glass doesn’t fold, so it takes up a lot of room wherever you place it other than on your face; (e) it’s easier to look at a watch than upward to Glass; (f) Android Wear watches cost $200 vs. Glass at $1,500 and do more; (g) Android Wear is being run by Google’s powerful Android team while Glass is a skunkworks project that hasn’t even exited beta; (h) Android Wear is faster and less buggy; and (i) Google has no plans to add augmented reality or facial recognition to Glass to make it something more than just a computer built into a pair of glasses.

Weird News Andy wonders “retail or wholesale” when an ED patient is charged with walking out with $300 worth of medical supplies that included bed sheets, 47 latex gloves, a bloody syringe, oxygen tubing, washcloths, alcohol wipes, lubricant, and pulse oximeters. WNA concludes, “The list price on a pulse oximeter on Amazon is $199. A single aspirin might be a hospital charge of $25. Seems like the perp might have gotten off cheap.”

Sponsor Updates

• Aventura releases the latest in its “This is Aventura” video series, seasonally appropriate in being set to the “1812 Overture.”
• EDCO Health Information Solutions publishes an article, “Solve Patient Indexing Errors Once and for All.”
• Liaison Healthcare will offer its EMR-Link laboratory and radiology integration solution to members of GNYHA Services.
• Beacon Partners offers an article, “Four Key Components for Building a Sustainable mHealth Strategy” and publishes a blog post “Are You Ready for Change? Four Questions to Ask Before Launching a Healthcare IT Project.”
• Truven Health Analytics reports that 300 hospitals have integrated Micromedex patient education and clinical decision support with their EMRs so far in 2014.
• QPID CEO Mike Doyle will participate in the “Big Data and Decision Making” panel at the Connected Health Symposium 2014 October 23-24 in Boston.
• ADP AdvancedMD introduces integrated fax with a short video clip.
• ICSA Labs certified products from First Databank, Iatric Systems, Juniper Networks, Orion Health, Quest Diagnostics and The Advisory Board Company in June.
• Health Catalyst explains the anatomy of healthcare delivery model in a recently published white paper.
• Maury Regional Medical Center (TN) selects Nuance services for its medical transcription needs.

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 7/1/14

 Medical Boards Draft Plan to Ease Path to Out-of-State and Online Treatment

State medical board from across the country have unveiled draft legislation that will ease licensure restrictions that are currently preventing doctors from treating patients that live in other states, a change that proponents of telehealth have been lobbying for for some time.

American Medical Association and the Medical Group Management Association Letter to CMS

AMA and MGMA send a joint letter to CMS administrator Marilyn Tavenner asking for a 30-day extension to the MU Stage 2 hardship exception application deadline, which is currently set for July 1. ONC recently proposed changes relaxing EHR certification standards for the 2014 attestation period, but those changes have not been finalized. The changes would allow providers to use 2011 certified products and 2013 criteria for the 2014 period. Providers are asking that the hardship application deadline be extended so that they can wait to see if these changes are approved and finalized before applying for a hardship exception.

Digital Health Funding: Midyear Review 2014

Rock Health notes, via its mid-year digital health funding report, that digital health startup funding has reached $2.3 billion for the year, already surpassing the total funding levels seen at the close of 2013.

Curbside Consult with Dr. Jayne 6/30/14

I spent most of this weekend doing a special project. Our coding and compliance officers approached me about how some of our providers’ notes look in EHR. They had seen some notes that were “really awful” and naturally assumed that something was going on with the EHR to cause them to be that way.

Our ambulatory vendor offers checkbox-style documentation templates, so I figured the complaints were about how their documentation was being output now that we’re dealing with SNOMED and other factors.

I asked my team to pull a sampling of notes from each of our specialties so that I could look at them myself. We’ve seen issues where the behind-the-scenes verbiage engine generates some subject/verb disagreements. Additionally, when a large number of positive and negative symptoms are documented, sometimes that can get a little strange.

Since our analysts are not clinical, I know that I can’t exclusively use their review to identify good vs. bad notes. Sometimes the documentation might be technically accurate, but would actually be something a receiving physician would laugh at.

We have a lot of subspecialists who do a lot of procedures, so I had the team pull a variety of those notes as well. They’ve been problematic in the past, especially when multiple procedures are documented. Most of those issues have been easy fixes. Still, considering the variety of specialties and all the different kinds of documentation, I had well over 100 visit notes to review.

By the time I was done, I could barely contain my aggravation. The largest subset of “awful” notes came from our providers who are heavy users of voice recognition. Some of the notes were downright incoherent. The problem however wasn’t with the technology – it was with subspecialists dictating sheer nonsense that normal humans (even those with medical degrees) would have difficulty comprehending.

The next subset of bad notes came from providers who have created their own documentation macros. The idea of providers having their own saved text blocks is generally a good one. We all know that there are some parts of the note that are the same over and over again: “regular rate and rhythm, no murmurs, rubs, or gallops, lungs clear to auscultation bilaterally, abdomen soft non-tender and non-distended with normal active bowel sounds.” From years of dictation it just rolls off the tongue, so it would make sense to save it as a block for EHR.

The problem comes when providers save text that either doesn’t make sense or has gender-specific findings that winds up being reused on the opposite gender. The point of saved text is to be able to quickly add documentation with little work. Some of our providers take the idea of efficiency too far, with so many acronyms and abbreviations it’s impossible to figure out what is going on with the patient.

Even with the subject/verb disagreement and some of the typical template issues, the group that most heavily uses check-box powered documentation did the best. They were easy to sort out due to the way the history blocks format and I was surprised at how much clearer their notes were compared to those done via other methods. Those that used the templates, however, had a much higher propensity to document Review of Systems items that I’m sure they didn’t actually perform.

For your amusement, I’ll share some of the highlights:

• General surgeon sees a patient to remove a skin cyst. She documents a gynecological review of systems with seven negative elements. I confirmed that it wasn’t from a paper form the patient completed and staff keyed in. She also documented the procedure as “EXC TR-EXT B9+MARG 2.1-3cm.” What does that even mean? I could extrapolate “benign” and “margins” from that, but it makes no sense for the type of cyst excised.
• The same surgeon documented a 21(!) point male urinary review of systems for a similar visit. The procedure document was the same except it was 0.6-1cm. At least she’s consistent. And apparently thorough, since she documented that she examined all 12 cranial nerves and the cyst was on the shin.
• Orthopedic surgeon documents a physical exam that includes a normal fundoscopic exam. I’d pretty much bank that the last time an orthopedic surgeon touched the instrument needed to look at the back of the eye, it was in medical school.
• Chief complaint of “bx results” which was saved to a provider custom list. Could we not have spared the extra characters to have it read “biopsy results” so that when the patient receives the note on our patient portal it makes sense?
• Not capitalizing the names of other physicians on the team. Nothing says “thanks for the referral” like addressing the letter to “dear dr jayne.”
• A “follow up back pain” visit with a (no kidding) 91-point review of systems including “changes in shape/size of moles” and “breast lumps.” I can’t wait until that one gets pulled for a CMS audit.
• Detailed discussions of radiologic studies pulled into the note from other practices. I guess in addition to being “one patient, one chart” the EHR also lets us time travel because the same CD with the MRI results that the patient hand-carried from shoulder surgeon was simultaneously imported to the orthopedic consultant’s May visit note and also to the nephrologist’s note with a date stamp two months prior to the visit.

I could go on, but it would just make me frustrated and likely make you angry. More than anything, it just makes me sad, especially since the providers electronically signed all of them and indicated that they were read and reviewed.

You might ask who had the best documentation. Hands-down the most coherent, thorough, and clearly non-padded were the notes done by one cardiology group using a mix of voice recognition for the history and plan and template documentation for the physical exam and review of systems. I didn’t identify any gratuitous documentation and the notes were high quality. It probably takes them longer to document since they’re speaking most of the note vs. clicking. However, their documentation was so pretty I wish I could clone them. But CMS says cloning is bad, right?

Got documentation problems? Email me.

Email Dr. Jayne.