News 5/28/14

Top News

An MGMA survey of large (median of 10 FTE physicians), mostly independent physician practices finds that 62 percent are struggling to identify patients whose insurance came from an Affordable Care Act exchange and to verify their eligibility or obtain plan details. Most practices also say that patients who got their insurance via an ACA exchange are more likely to have high deductibles and don’t understand that fact. Half of the practices say they can’t provide services to ACA exchange patients because their practice is out of network.

Reader Comments

From Trinity: “Re: Meditech READY Certification Status. How many firms will be named to this list? What’s the upside for Meditech clients and the consulting firms?” Certainly READY Is one of the more contrived acronyms ever: rapid adoption, evidence based, advanced workflows, dedicated team, and your success. Apparently it’s an Epic-like certification that allows consulting firms to implement Meditech 6.x. The company says its purpose is to drive a big bang go-live and its implementation team members “will become workflow experts armed with a more global view of how the solutions work together and will be trained to collaborate with one another when the software is delivered to the customer.” The key components are (a) more application consultant time at the client site instead of having the customer travel to Meditech; (b) project leadership and physician training by Navin, Haffty & Associates; (c) delivery of standard system content; and (d) a course for hospital clinical leaders to address process improvement.

From Jockamo: “Re: Meaningful Use Stage 2. The attached document is from the administrator of a multi-specialty group.” The unnamed practice administrator urges everyone to tell CMS that MU Stage 2 is unreasonable via the comment period for the proposed changes. The main concerns: (a) 50 percent of patients must provide email addresses to meet the requirement that they have portal access; (b) orders must be initiated electronically directly by the clinician instead of dictated, written, or verbally issued to a clerical support person; (c) data entry timeliness is unworkable given that patients are to be given an electronic summary of care within one day; (d) summaries of care must be sent or received with each transfer out or in.

HIStalk Announcements and Requests

Listening: Portland-based Heatmiser, which in its five years of existence that ended in 1996 begat Elliot Smith (who died in 2003 at 34.)

Acquisitions, Funding, Business, and Stock

Risk scoring vendor Apixio raises $13.5 million in a Series C investment round.

PatientPay receives a $2.5 million investment from San Francisco-based Mosaik Partners.

Wisconsin-based payment analytics vendor Aver Informatics raises $8.5 million.

Cerner’s board approves a $100 million share buy-back, raising the total from the original $213 million repurchase program approved in December 2013.

Atlanta-based insurance software vendor Ebix acquires “ask a doctor” service vendor Healthcare Magic for $6 million and will roll it into its A.D.A.M. Health division.  

People

Helayne O’Keiff (IBM) joins Beacon Partners as senior regional director for the South.

Sean Nolan (Microsoft) will leave the company and his role with HealthVault.

August Calhoun, PhD (Dell) joins Truven Health Analytics as SVP/GM of the company’s Provider Solutions business.

Announcements and Implementations

AirStrip will incorporate PeriGen’s enhanced context and decision support tools for obstetrics into AirStrip One.

Government and Politics

From The Onion.

A Vermont Information Technology Leaders RFP indicates that the company will spend $175,000 on awareness advertising campaigns for the public and for providers as it prepares to launch the Vermont HIE, which is about to exit beta testing. VHIE drew controversy a few weeks ago when it announced that any provider will be able to look at any patient’s information, which the CEO says was done to reduce the number of forms patients would need to sign.

Innovation and Research

An engineer develops a $300 smart spoon that stabilizes up to 70 percent of a person’s hand tremor, allowing people with those conditions to eat without help. More attachments are coming.

Other

The Columbus, OH newspaper profiles Columbus-based CoverMyMeds and the prior authorization process.

AtlantiCare (NJ) will merge with Geisinger Health System (PA), with both organizations citing value-based care as their motivation. 

The VA hospital in Denver reports that two laptops containing respiratory testing information on 239 patients have been stolen from its pulmonary lab.

in England, NHS says the operating cost of its new e-Referral service will be 80 percent less than that of the $600 million Choose and Book system it replaces.

Also in England, the government opens bids for its Integrated Digital Care Technology Fund, which will provide up to $400 million in matching funds over the next three years to projects that create open source data sharing tools.

Sponsor Updates

• Technology leasing provider Winthrop Resources achieves its second “Peer Reviewed by HFMA” designation.
• The e-MDs 2014 user conference is scheduled for June 5-7 at the AT&T Executive Education and Conference Center in Austin, TX.
• TriZetto (Gateway EDI) offers four things to prepare for ICD-10 after attending WEDI’s ICD-10 Summit.
• Glytec receives FDA approval to add pediatric insulin dosing to its Glucommander.
• Greenway Health is recognized by Black Book Rankings as a Top EHR Vendor for ambulatory settings.
• Culbert Healthcare Solutions offers proactive steps in transition to value-based physician compensation.
• Liaison Technologies adds template-based mapping to its Contivo Data Integration Suite.
• Capsule’s Karen Lund discusses the importance of nurses understanding the ‘big picture.”
• Beacon Partners discusses the good and bad aspects of the recently proposed CMS rule that would defer MU Stage 2 until 2015.
• Phoebe Putney Health System is live on the Summit Healthcare Summit Care Exchange platform communicating with RelayHealth.
• CoverMyMeds’ CEO Matt Scantland shares the processes behind the company’s success with a local publication.
• McKesson will be the headline sponsor for the 5th Annual Health IT Leadership Summit November 20 in Atlanta.
• Newark Community Health Centers (NJ) will implement Forward Health Group’s PopulationManager for its seven clinics.

Contacts

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

More news: HIStalk Practice, HIStalk Connect. 

Get HIStalk updates.
Contact us online.

HIStalk Interviews Dave Dyell, SVP, NantHealth

Dave Dyell is SVP of product development of NantHealth of Culver City, CA.

NantHealth exhibited at the HIMSS conference, but nobody I talked to could figure out exactly what the company is selling even after talking to the people in the booth. What is being sold today? 

The solutions fall primarily into two sections today. One of those is connectivity, the older iSirona set of products, but taking them beyond the traditional “in the house” variety that iSirona has focused on. Focusing primarily more on telehealth.

There were other assets that were available as part of NantHealth that we’ve brought to that connectivity suite. Medication adherence — it’s a solution called the GlowCap and the GlowPack that we can place into a home that allows to track whether or not a patient is actually taking their medication when they’re supposed to. That is live today in multiple organizations.

We currently also have a product we call the HBox, which is just going GA right now, which is allowed to go into the home and be able to communicate to virtually any medical device that a patient may have in the home. This could be an off-the-shelf glucometer, your scale, blood pressure cuff, things of that nature that would bring that data back and send it to the cloud.

The second part of the solution set is what we call interoperability. This is the ability to go in and partner with an ACO organization to provide the technology platform. That is our Clinical Operating System that we launched at HIMSS, which allows us to then connect to all of those systems that a particular physician’s practice may be running. The ACO is going to be needing to be able to interact with the data about that patient, obviously connecting to the hospital systems.

Any typical hospital can have 80 to 100 different systems. We can pull data from all of those silos, as well as then the insurance companies, and bring in all the historical claims data and other information from maybe even pharma. Any of the claims data that would be related to any of the healthcare around that patient.

I wasn’t clear when the announcement was made about the Clinical Operating System. I understand that there’s like 80 acquisitions involved and suddenly declaring those to be a Clinical Operating System seems like a bit of a stretch from an interoperability standpoint.

The Clinical Operating System actually came from a single organization previously known as Net.Orange. It was built from the ground up to be a Clinical Operating System. That was the original vision that that team had for that particular product.

You’re looking at seven-plus years of development that’s gone into that particular platform, building each and every one of those individual connectors over time. All of them tied to an implementation. That’s the key –going into an organization and actually performing that integration rather than just building an off-the-shelf connector to it.

I must have missed that point with the announcement. Tell me again, what exactly is the Clinical Operating System and what is its heritage?

It was designed from the ground up to be based on bringing supply chain principles to healthcare. Dr. Rangadass and his team came from the old i2 space in supply chain management. Obviously i2 had a breadth into healthcare as well. One of the things that frustrated them was the waste that happens in healthcare. 

When they started looking at building the next generation of platforms, they wanted to build something that could literally sit on top of all these different systems, gather the data, and then bring it to the front. In the case of applications, that would look at things that we call Value Monitor, which would help you see how you’re comparing to your peers.

A lot of the typical trending applications that we’ve all seen in healthcare and worked around for a while — their real goal was to see, can we build a data model and a set of services that essentially, if you wanted to build any healthcare application on, we would have those basic services. That’s what they set out to do. That’s why we call it an operating system, because they’ve literally built a service that can do just about anything you would possibly want to do in healthcare if you were trying to build a clinical application.

There are customers live on this now?

There are. US Oncology is one of those customers that’s been using the platform for 5+ years. They’ve got all of their physicians on it.

But they’re not really a hospital and you’re targeting this to hospitals. Are there hospitals live?

St. John’s Health System in Los Angeles.

That’s the only one?

It is, yes.

When you’re describing this to a hospital that might be a prospect, what is it that you tell them they could do and what capabilities they need to run this on top of their existing systems?

The biggest traction we’re getting right now in the conversations with hospitals is of course around population health management. Everybody’s trying to figure out what is population health management. There’s a lot of buzz, a lot of noise. But one thing is for certain – everyone  is trying to identify that platform that they’re going to use to pull all of this data together.

They all understand they need the data. They know there’s data locked in their EMR. They know there’s data locked in their other independent systems. They know there’s data locked in the multiple physician EMRs that are out there. How do they bring all data together into a single platform, that if they’re going to form some type of accountable fee structure, that they can use that data to care for that population? That’s normally where the conversation starts. 

Once everybody understands the full depth and breadth of the Clinical Operating System, they immediately see the value. They immediately see where this is different than anything they’ve seen before. Where we can bring together that data unlike anything else that’s ever been done before. Then you add to it the rest of the things that belong in the NantHealth family. You start talking about genomic data, you start talking about proteomic data, and you bring that science in and add that to that clinical component. It’s not like any platform you’ll ever find out there.

Are all these acquired companies still operating independently under their own names or is the plan to roll them all up into a super-product?

Unknown to the market is that this didn’t start like a light switch on January 1. Dr. Soon-Shiong has been an investor in iSirona for over five years. He’s been an investor in many of these companies for years. This has always been something we talked about. It’s always been something that we started to plan for and operationalize around, even from a perspective of technology choices we’ve made in our applications. 

We’ve had most of our things interoperable over the years to be prepared for this. I personally spent most of 2013 and parts of 2012 taking other assets that he had invested in that were no longer surviving as a market go-forward company and bringing those in and integrating them into iSirona in the background, being ready to launch on January 1. The launch of NanthHealth was January 1.

As of January 1, we are a single operating company. We are going to market with a single sales force, single message, single company. There won’t be an iSirona any more. There won’t be in Net.Orange. There won’t be any of these individual companies any more. They will only be NantHealth. The market is going to sit back and wait to see whether we can pull off or not but it has already actually been in place for a large number of years.

What’s the effort required and what are the steps that are required to turn a bunch of piecemeal investments into something integrated?

We’re a little over 350 employees right now as a company. We have 280+ hospitals that are using some aspect of our technology. Most of that is the iSirona stuff, but still, there are others that are using different pieces of the rest of the portfolio.

We’ve got over 50 percent of the different US Oncology practices that are currently using our decision support engine. That came in from a company called Eviti that’s a part of the portfolio. There are a very large number of practices and companies and revenue that are coming in the door today. 

As far as putting it all together and making it that single cohesive story, again, we believe we did that in preparation for the launch at HIMSS. We are out in the market with that single message.

You had 180 or so employees at iSirona. I didn’t appreciate what a big chunk it is of NantHealth.

We are, yes.

Dr. Soon-Shiong has a far-reaching vision on personalized medicine and genomics. What are the steps required to take NantHealth to meet that vision?

We already have the genomic, the proteomic technology. What needs to be done now is taking that data and being able to map it in a meaningful way into the rest of the care process.

If you’re a case manager who’s looking at a care plan and walking your way through that on a member of your population that you’re trying to manage, and all of a sudden a physician orders a gene mapping and you get those results back, what do you do with that data? How do you map that wisdom that’s going to come back from the science into the overall decision support workflows that are going to be around traditional population health management to make it different? 

We like to say it this way within NantHealth. What’s that one piece of data, that if we could get in front of a caregiver, would make for a significantly better outcome? That’s really what drives us all — trying to find that one piece of data, that one other piece of data that I could put in front of a physician, put in front of a caregiver, put in front of a scientist for that matter, that would give that patient a much better outcome.

BlackBerry seems to be on its last legs. Why did it suddenly get interested in healthcare and what will it co-develop with NantHealth?

That’s an interesting perspective, because one of the largest portions of the market that BlackBerry owned was healthcare. I don’t think I’ve walked into a hospital in 15 years that hadn’t had some form of BlackBerry technology there. The BlackBerry enterprise server is installed in hundreds of hospitals, if not thousands across the country, because of its secure messaging and because of HIPAA concerns and those things. People have been using BlackBerry for years.

They use BlackBerry devices, but this is actually developing healthcare-specific technologies and not just saying they’re going to park BlackBerry in a hospital.

It is, but that’s to me why it’s a natural foray for them. They’ve already go this large infrastructure. They’ve got a large customer base that’s already in healthcare that’s using one of their devices. 

What they saw obviously with NantHealth is on our connectivity side again. Connectivity everywhere, regardless of where you are. We think the smartphone is another logical place to provide some of that connectivity. Not everybody’s going to want an Hbox in their home. A lot of us that are more tech-savvy are going to want our smartphone to be that. 

Having the Nantoid with BlackBerry is going to be a really interesting play for us to be able to provide a device that’s optimized for that connectivity, optimized for image display, those types of things.

The NantHealth offering isn’t exclusive to BlackBerry, right?

No, of course not.

So their contribution is just to optimize it for BlackBerry?

Correct.

What are the milestones the market will see in the next few years from NantHealth?

I think what you’re going to see over the next few years is some significant growth within the telehealth side of the business as we continue to expand the connectivity-everywhere approach. You’re also going to see on the interoperability side us expand much more heavily into population health. We have some releases and stuff that will be coming out soon and new customers on that end where the Clinical Operating System is being used as the basis for multiple population health deals. These are again primarily focused around ACOs at this particular point.

Wearing your iSirona hat, what did you think of the FDA’s report and the topic of medical device integration with EHRs?

What’s interesting is if you look at the majority of the market, at least for the more mature companies, everybody’s already there anyway. Cerner produces medical devices. Siemens produces medical devices. GE produces medical devices. Maybe an Epic on the outside, but they’re got laboratory systems, many of which are already regulated. 

I’m not sure why any of them would be concerned about this from an overall ruling perspective. Most of them already have some type of quality management system and build their software under that ruling anyway. I was a little bit shocked that the FDA didn’t take it a little bit further than they did considering that reality.

I think there’s this misperception in the market that somehow software vendors don’t follow quality processes. But for the most part, they do, especially if you’re going to be an international company. For the rest of the world, if you’re not building your clinical software especially under a quality management system of some sort, whether you’re fully ISO certified or not, just having a quality management system is so important in trying to market to the rest of the world. If you’re going to be an international company at all, you have to be able to show that you do actually use quality within your development practices.

What about the status of alerting and alarming? What’s being worked on to try to make that smarter?

We obviously follow that space pretty closely because of the fact that we connect to so many medical devices now. A lot of those vendors in that space look to us for the data. We got our own alerting and alarming package cleared last year that we call Magellan. We started to bring that to market around HIMSS as well. We’ve launched that and we should be seeing some press releases on that coming out soon. It’s a space that we believe in, obviously, and one that we’re going to continue to invest in.

Do you see a point where there won’t be a third-party product in between the medical devices and the EMRs to help negotiate the conversation so that it makes sense to the clinicians?

I really don’t. You’re right – HL7 and other types of integration standards that have tried to standardize the industry, what we found is is that until customers demand that interoperability, there always ends up being somebody in the middle. 

I’ve been in healthcare long enough to remember when HL7 was in its infancy and when products like Cloverleaf and at that time DataGate and the old Healthlink product were all just coming to market. Every one of them, everybody thought would last a few years and then HL7 would have that broad market adoption and nobody would need integration tools any more. EAI was going to be a short-term thing. Those engines are still going strong today. 

In the mean time, companies like Orion, companies like InterSystems have come out and completely stolen market share away as those products have died in some cases, especially in the case of the eGate thing after they sold it off to Sun and Oracle. You really see that everybody believes these integration technologies will only be around for a little while, but they end up staying because even once the standard’s adopted, the standard doesn’t necessarily always fit every situation. So no, I don’t see middleware, if you would, going away any time soon to help broker that conversation.

Morning Headlines 5/27/14

Veterans Allowed More Care at Non-VA Facilities Amid Criticism of Agency

Following weeks of turmoil over the length of time veterans are waiting to get VA appointments, the VA unveils a new program that will allow some veterans to skip the waiting line altogether and seek routine care at non-VA facilities.

Insurers Once on the Fence Plan to Join Health Exchanges in ’15

The successful 2014 enrollment period for Healthcare.gov, which drew eight million subscribers, has sparked the interest of insurers. Several major payers that had stayed away from the marketplace thus far, including Cigna and UnitedHealth Group, have indicated that they will sell plans over the exchanges next year, while others like Harvard Pilgrim, are announcing that they will expand their current presence on the marketplaces to include new plans and coverage in new states.

Curbside Consult with Dr. Jayne 5/26/14

Several readers emailed about last week’s EPtalk, where I shared my frustration with CMS and the constantly-changing game of Meaningful Use.

Dear Dr. Jayne,

I’m sorry for how you feel about CMS and long for days of old when $5 got you a doctor visit at home. I’m 76 and have been on Medicare for over a decade. From a patient viewpoint, it beats big payers hands down. One little card with a red, white, and blue stripe gets you everything from any healthcare system, any physician, no referrals, no one ever asks a question, and, if you have a gap insurer, you almost never pay a nickel. As I recall, CMS gave every doctor $44,000 to buy an EMR and every hospital a lot more. I’m sure over $50 billion was given to providers and now CMS wants something in return. Sounds reasonable to me and almost rare that the government can’t be accused of a giveaway.

I think a lot of MU requirements are off target as to need and value. Most EMRs are off the mark in architecture, workflow, and value. So, we have the equivalent of a 1.0 standoff, but at least it is a start. Hopefully by 2.0 both the MU and EMR will have both evolved to a better place. This will take at least a decade and the practice of medicine and the technological advancements during this period will make the current systems look like stone age work.

Don’t give up on Medicare and CMS; make it better. The alternatives are much less attractive.

Sincerely,
Spirit of ‘76

Dear Seventy-Sixer,

Speaking as an Eligible Provider, I can confidently state that CMS hasn’t “given” us anything. It’s true that up to $44,000 each was available to eligible providers over a multi-year period. For most providers in my community, however, it cost far more than $44,000 to dot the “I” and cross the “T” of each Meaningful Use requirement. Even in the first iteration of Stage 1, providers had to meet 22 objectives (several of which have multiple subcomponents). For many physicians, this meant overhauling practice operations. Unfortunately, I’ve seen a lot of box-checking at the expense of clinical quality. When providers go to file their attestation, it’s all or none in nature, which creates a great deal of stress on caregivers and staff.

I’m glad you have had such a positive experience with Medicare. Patients in my community aren’t as fortunate, as many physicians have stopped accepting Medicare assignment or are limiting the number of Medicare patients they see. CMS has many coverage and medical necessity rules and my patients are spending a lot more out of pocket than some of them think is fair. We’re still in a recession and quite a few patients have been forced to drop their supplement plans or have chosen barebones coverage that they don’t like. Those who have gone on Medicare Advantage plans hate the narrow networks and further limitations, but like the cost.

Speaking of cost, going back to what it costs to implement an EHR. Looking at HealthIT.gov for numbers, they list the five-year total cost of ownership (estimated average) as $48,000 for an in-office system and $58,000 in a software as a service model. That doesn’t include practice losses during implementation or ongoing loss of efficiency, the need to add additional staff to manage all the metrics, or hiring contractors and attending classes just to make sure one understands all the maze of rules.

I agree with you that necessary change will take a decade. Unfortunately, CMS only gave providers half that time to accomplish ever-changing (and sometimes obscure) goals involving elements beyond their control before the penalties kick in. I hope there are some primary care providers left when the dust settles. I’m seeing my peers retire in droves and there aren’t enough new hires to fill the gaps, increasing patient wait times.

Sincerely,
Jayne

Dear Jayne,

What do I think? Well, I’m glad you asked. I have just spent about four hours reading, digesting, and summarizing in a document I can share internally what this could mean. Then again, it might not mean any of what I have summarized. Theoretically depends on public comments.

This has been such a frustrating process for everyone. I work with providers and healthcare organizations. There was so much confusion with the 2014 CEHRT requirement already. This will undoubtedly make it so much worse. For some EPs, it could be a life preserver – several vendors aren’t CEHRT yet. Maybe the 62-year-old provider I met with last week (whose EHR vendor wants him to sign a 10-year contract for their patient portal) will be able to delay and shop some more. Perhaps another client I work with won’t be forced to purchase a CQM module and sign a three-year contract by June 1 or be faced with missing MU Stage 2 this year because the vendor won’t have them upgraded in time.

Waiting the 60 days for public comment, however, will be like trying to fly stand-by the Wednesday before Thanksgiving. If you get the flight, all will be well and you’ll spend the day smiling and toasting your good fortunes. If you don’t, you had better be scrambling to figure out how to thaw a turkey overnight. MU and a turkey – it’s a good analogy!

Sincerely,
Apple Pie Fan

Dear Pie Fan,

Thanks for writing. Your thoughts reflect those of many people I’ve spoken with this week. The potential delay doesn’t mean anything if it doesn’t go through. If you wait for the final rule and you didn’t guess right about its content, you’re going to be caught short. In the mean time, everyone has to push forward as if there will be no delay.

I really like your turkey analogy. In contrast to CMS, however, Butterball has a turkey hotline you can call for actual answers.

Sincerely,
Jayne

I’m not sure how many readers we will have given the Memorial Day observance. I hope you were able to spend time with loved ones and took the opportunity to remember those in the armed forces that made the ultimate sacrifice. If you’re wondering about today’s picture, it’s courtesy of Smithsonian.com and was taken at the site of the Battle of the Somme. There are several other haunting images that show the scars that remain even after 100 years.

Email Dr. Jayne.

Morning Headlines 5/26/14

At Cerner’s annual meeting, executives express confidence

At a shareholder meeting in Kansas City, Cerner CEO Neal Patterson reports that, since 2010, the company has doubled its contract win rate. He reported that he is optimistic about the company’s interoperability initiatives and its population health consulting services.

Thaw resigns as Athens Regional CEO

Athens Regional Health System (GA) CEO James Thaw has resigned following a difficult Cerner implementation. The news comes after an internal letter critical of the new system was leaked to the media. The letter was written by physician leadership at Athens, and cites "medication errors … orders being lost or overlooked … (emergency department) patients leaving after long waits; and of an inpatient who wasn’t seen by a physician for (five) days."

Report reveals America’s top companies for pay and benefits

Epic is named the #5 company in America for companies with the best pay and benefits, falling behind Cosco, and other tech giants like Google, Facebook, and Adobe.

Why I Blew the Whistle on the V.A.

Sam Foote, MD, the whistleblower responsible for alerting authorities to the Phoenix VA waitlist improprieties writes an Op-Ed piece for the New York Times saying that he knew veterans were dying while waiting for appointments, and so he sent a letter to the VA about the secret waitlist in October 2013, and again in February 2014 but nothing was done, which is why he decided to go public.

Monday Morning Update 5/26/14

Top News

Cerner CEO Neal Patterson tells shareholders that the company is transitioning from a healthcare IT company to a healthcare company, echoing sentiments expressed in the company’s most recent earnings call. Cerner executives say the company will dominate areas that include aggregating information across providers, reducing healthcare costs, improving outcomes, and providing consulting services related to population health management.

Reader Comments

From Katherine Kroessler, MD: “Re: EMRs and Meaningful Use. The burden is overwhelming for small practices. More physicians will become employees and use systems where someone else crunches the numbers. My small practice’s EMR is fine for MU, but it has increased our overhead and staffing and thus has decreased physician income. We have some electronic lab/DI data and others come on paper. Docs fax paper referrals and we fax back paper consults because our systems don’t talk to each other. Information gets put in folders to be scanned and has to be tracked down when the patient is in the room. However, if you are in a large contained system, all of that works seamlessly. The government should have created an incentive for IT vendors to use the same interface requirements so their systems could talk to each other. Doctors are being reduced to clerks and spend more of their valuable time clicking boxes and coding unless they are part of a large infrastructure that automates that for you. I just hope that new doctors will know how to think about patients and not just how to copy and paste notes. Listening to our patients is our most important skill because, at least in neurology, 90 percent of the time the diagnosis comes from the history. Doctors will become employees of large systems and their thought processes and workups will be governed by those systems. Let’s hope the systems get it right because the MDs phasing out of medicine will all be Medicare patients soon enough.”

HIStalk Announcements and Requests

Eighty percent of respondents think ONC should certify EHRs only if they offer external program access (APIs) for interoperability. New poll to your right: is the Meaningful Use Stage 2 slowdown good or bad?

Announcements and Implementations

KLAS announces that it is developing a myKLAS mobile app.

Epic is named the #5 best company for employee pay and benefits in a Glassdoor review of employee surveys. It’s probably the one company on the list whose name the average American wouldn’t recognize.

Government and Politics

The White House says HHS has passed a cybersecurity assessment that was required by a presidential order, saying its voluntary efforts are sufficient to address cyber risk.

Oregon Governor John Kitzhaber said he fired the director of Oregon Health Authority in March effective immediately over the Cover Oregon health insurance exchange debacle that will end up costing nearly $300 million, but the local paper discovers that he’s still on full-time status and getting paid $14,425 per month, at least until July when his vacation pay runs out. Federal investigators issued several subpoenas last week to people at both the health authority and the insurance exchange, apparent interested in finding out whether state officials lied to CMS about the project’s status to get more federal money.  

CMS announces the second round winners of its Health Care Innovation Awards. Among them: $15.9 million to the American College of Cardiology Foundation for  the SMARTcare provider feedback and decision support tools for reduction of inappropriate procedures; $7 million to the Association of American Medical Colleges for an electronic consult and referral model in five academic medical centers; and $10 million to UCSF for a monitoring system for dementia patients.

Sam Foote, MD, the retired Phoenix VA doctor who turned wait list whistleblower, says in a New York Times opinion piece that he doesn’t think the current VA investigation will be effective because it’s being performed by Veterans Integrated Service Network office workers who will just ask employees a few questions, while he would rather see an anonymous electronic provider survey. He also says the VA’s VistA system is excellent and second to none in transferring information from one VA facility to another. He concludes by saying that any negative findings will be pushed back because it’s an election year.

Innovation and Research

Researchers at Stanford University develop an externally rechargeable embedded implant it calls an “electroceutical” that may be able to cure specific medical conditions using radio energy.

Other

The CEO of Athens Regional Health System (GA) resigns after problems with its Cerner implementation. A dozen doctors sent a letter to administration complaining about lost orders, medication errors, ED patients leaving AMA after long waits, and an inpatient who wasn’t seen for five days. They also complain that the implementation timeline is too aggressive and the users aren’t ready. The doctors claim that Cerner problems have caused several doctors to drop their hospital privileges and others to send patients to a competing hospital. The health systems foundation VP said in a letter to donors and volunteers, “The last three weeks have been very challenging for our physicians, nurses, and staff … parts of the system are working well while others are not.”

HIMSS congratulates some new EMRAM Stage 6 organizations.

Medical educators say that doctors are losing the ability to diagnose based on a physical examination, instead relying on sophisticated tests. One says he has seen cases where “technology, unguided by bedside skills, took physicians down a path where tests begot tests and where, at the end, there was usually a surgeon and often a lawyer. Sometimes even an undertaker.” Medical schools are going back to basics, teaching students, for example, to use a stethoscope instead of an EKG. A former NEJM editor weighs in after his experience as a patient at Mass General: “Doctors now spend more time with their computers than at the bedside,” with electronic medical records containing only short descriptions of how he felt and looked, but with “copious reports of the data from tests and monitoring devices” that generated few documented conversations. A professor and doctor tells the story of a resident desperately clicking through a febrile patient’s EHR looking for a cause when a short walk to the patient’s room would have made it obvious that his IV site was inflamed. Another says foreign doctors are more competent clinically than their American counterparts because they are either trained to rely less on technology or don’t have much of it available.

Saw screenshots of @VanderbiltU home-grown Electronic Medical Record today. Looks more impressive than Epic/Cerner.

— Pallav Sharda (@Pallavsharda) May 23, 2014

Someone asked me the other day if Vanderbilt was still using WizOrder. I assume so, even though McKesson’s commercialized version of it under the Horizon nameplate is being put slowly out to pasture.  Apparently this physician informaticist was impressed.

The Houma, LA paper profiles Objective Medical Systems, started by a group of cardiologists to create a specialty-specific EHR. It captures the output from medical devices, presents a combined view of test information, and can recommend research papers relevant to the patient’s condition.

Weird News Andy says we should fight illness with fist-bumps instead of handshakes according to a JAMA article that urges creating “handshake-free zones” to reduce the spread of pathogens. The article says shaking someone’s hand could eventually become as much of a social taboo as smoking.

Photo: Pete Marovich/EPA

Monday is Memorial Day, set aside to honor the one million US Armed Forces members who died while serving. Thanks to them, you are free to decide that you won’t fly the flag, visit a military cemetery, or think about those who made the ultimate sacrifice on your behalf. That’s not to say it wouldn’t be nice for you to do those things voluntarily on Monday. 

Book Report
Where Does It Hurt?

Where Does It Hurt? is an entertaining, punchy potpourri of ideas, just what you would expect from athenahealth’s Jonathan Bush and his professional co-author. The book is breezy and fun, with self-effacing humor and first-person stories about Bush’s experience with the healthcare system as a paramedic, a failed consultant, a failed birthing center operator, and now the successful co-founder of a pretty big back-office services and software provider.

Bush works his readers into righteous indignation by pointing out the fairly obvious things that are wrong with our broken and massively expensive healthcare system. Most of his anecdotal everyman ire is aimed at hospitals, which should be interesting since their fat and happy leadership (in his mind) are the prospects that will drive athenahealth’s planned growth into health systems. (He probably shouldn’t hand out copies of the book as part of the company’s pitch to hospital prospects.) 

Where Does It Hurt? delivers on its title, with nicely summarized and fun-to-read examples the maddeningly illogical healthcare system. Consumers rather than healthcare insiders are the target audience for the recitation of issues covered in far more specific and analytical detail elsewhere. As you would expect, Bush travels in circles different from the rest of us, so when he wants to learn something (and share it with readers), he has access to the CEOs and politicians who will tell him first hand.

Where it fails to deliver is on its subtitle: “An Entrepreneur’s Guide to Fixing Health Care.” The book is long on criticizing the system in its 241 pages, but short on offering new ideas about how fix it. He doesn’t fall short on “the vision thing,” but perhaps he could have been more prescriptive, especially given the barriers of government meddling, the political power of organizations profiting handsomely from the status quo, and the disconnect between those receiving services and those who pay for them, all of which have sucked the energy out of most of the good ideas that have floated around.

Early on, Bush declares that “healthcare is the new oil” in urging entrepreneurs to create profitable businesses that target monolithic, protective hospitals and the massive chunk of healthcare spending they consume. He provides fascinating examples such as Steward Health Care and Florida Woman Care, relayed mostly as conversations between himself and the CEO of those companies, and how they found easily picked low-hanging fruit in the inefficiency of their lumbering big-hospital competitors that weren’t adding much value in providing routine services.  He suggests that the idea of the Affordable Care Act had promise, but most of what it could have accomplished was neutered by special interest lobbyists into being little more than insurance for a lot more people instead of really reforming anything.

The “what should we do about it” message isn’t as clearly presented. After reading the book, I went back through it twice (it’s not all that big) to manually pick out what seem to be its main suggestions since it’s a bit all over the place.

• The industry should train lower-level people to perform routine tasks, just like the military does in turning an 18-year-old with poor academic achievement into a weapons operator by breaking everything down into simple steps. He wondered in his New Orleans EMT days why there weren’t a swarm of $9 per hour EMTs like himself providing services in the community rather than just hauling patients with routine problems to the ED (in the cab-u-lance, as he refers to it.) He sees retail clinics as a model that works for up to 70 percent of the patients who would otherwise be sitting in the expensive ED’s waiting room.
• Hospitals, especially academic medical centers, should transform into focused factories that offer fixed-priced services for specific, complex treatments in which they have developed notable expertise, leaving routine services to less-expensive providers. Hospitals fund their high-overhead operations by drastically marking up basic tests and procedures without adding any value and that money could be better spent elsewhere.
• Big hospitals should overcome their geographic constraints by employing telemedicine and providing air transportation for patients who need their specific treatments.
• Community hospitals shouldn’t get a free pass to make a lot of money just because they erect impressive buildings, staff EDs, hire a lot of people, and instill community pride. He says they should be reconfigured into providing emergency and high-acuity services and be paid accordingly since inpatient bed demand is already dropping significantly. He observes that hospitals are fighting to keep control of their fiefdoms, buying each other and medical practices to snuff out potential competitors that might undercut them in bidding for insurance company contracts.
• State-specific limitations on provider licensing and insurance sales should be eliminated, as should artificial provider limits such as certificates of need.
• Doctors should realize the power they have and band together rather than selling their practices to hospitals.
• The government should loosen up anti-kickback laws so that providers can pay each other for information, such as contributing data. (Bush adds an interesting note that doctors selling their practices to hospitals is the ultimate kickback given the increase in business hospitals get from their referrals.)
• The government should eliminate the requirement that only providers can run ACOs, opening up the market to entrepreneurs.
• Insurance companies should offer tailored packages instead of the one-size-fits-all type. They should also offer barebones plans for those who don’t need extensive coverage.
• The government should encourage new entrepreneurial insurance companies by backing their risk as it does mortgages through Fannie Mae.
• Patients should be financially engaged in the healthcare decisions they make, should learn from each other, and should demand data.
• Providers should manage populations and offer health management rather than just healthcare services, such as coaching, classes, and exercise.
• Epic is part of the problem because it was designed to do what big academic medical centers want – protect their near-monopolies. Its high price ensures that most independent practices can’t afford it, giving Epic’s big customers the leverage to tell those practices to use their Epic system (at a discount) or risk being left out, giving those hospitals more control of the market and the data needed to protect it.
• Entrepreneurs shouldn’t try to sell software to those big hospitals because the changes they will demand will reflect their inefficiency, turning the entrepreneur’s fresh approach into the same old systems everybody else is selling.
• Data is the key to figuring out which treatments are effective.

I enjoyed the book and recommend it for those not expecting magic answers. It contains a lot more observations of problems than solutions, and healthcare insiders won’t learn very much from the admittedly interesting presentation of what’s wrong with healthcare. If I got my $11.99 worth (Kindle edition) it would probably be because it’s entertaining to hear Bush’s take on what those of us in healthcare see every day as being part of that expensive system that needs to be overhauled. You can hear a lot of Jonathan Bush’s ideas for free by watching business TV shows, so there’s no reason to sit impatiently waiting for the sequel.

Contacts

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

More news: HIStalk Practice, HIStalk Connect. 

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Readers Write: Narrow Networks: Blessing, Curse, Should You Care?

Narrow Networks: Blessing, Curse, Should You Care?
By Shawn Wagoner

Narrow networks = blessing. In its recommendations to improve the government’s ACO programs, the American Hospital Association is urging CMS to “create some financial incentive on the part of the beneficiary to choose to stay ‘in network’ so that their care can be coordinated.”

Narrow networks = curse. In Seattle and New Hampshire, healthcare organizations are taking legal action to prevent health plans from developing narrow networks.

Narrow networks = real. Regardless of where an organization falls on the blessing vs. curse spectrum, narrow networks are back and gaining momentum. McKinsey research finds that 70 percent of the plans sold on the individual exchanges created as part of the ACA are what they categorize as narrow and ultra-narrow hospital networks. There is also serious traction among the private sector companies that help finance health insurance for their employees. As evidence, a commercial health plan in Minneapolis now has roughly 30,000 members enrolled in private exchanges and over half of those enrolled have chosen a narrow network benefit product constructed around one of four available ACOs.

Former ONC Chief Dr. David Blumenthal recently wrote about narrow networks, suggesting that “by guaranteeing their chosen caregivers a certain volume of business, health plans acquire the leverage to negotiate better prices in future contracts.” The private exchange example from Minneapolis suggests that providers also agree to higher quality and patient experience standards in addition to the price concessions. In theory, these narrow networks have the potential to benefit all stakeholders:

• Health plans pay lower prices to providers and can package those lower prices into lower cost and higher quality benefit products to attract consumers and members.
• Consumers pay lower premiums to the health plans for higher-quality care.
• Providers are assured that the members will use their services when the need arises. Additionally, more people than before will use their services because the lower-priced narrow network benefit products attracts new patients.

Chances are that most organizations have a strategic plan that includes some form of a narrow network, whether a clinically integrated network, an ACO, or in many cases, both. Given their strategic importance and operational complexities, now is the time to start thinking about how to operate a narrow network effectively.

Recall the advent of high-deductible health plans a decade ago and how quickly patient responsibility grew as a percentage of revenue and the amount of process and technological change required in response. Likewise, narrow networks bring forth new yet similar challenges that will require a great deal of process change and technological advancement. Here are some thoughts to help assess the readiness of an organization:

Challenge #1: Patient transitions require improved coordination to track patient status in order to deliver on the higher quality standards and realize the financial benefit by ensuring patients are transitioned to in network providers.

Operational considerations:

1. Can pertinent portions of chart notes be shared among all in-network providers?
2. Does an automated workflow exist to book follow-on appointments for in network providers, both employed and affiliated?

Challenge #2: Narrow networks typically incent patients to stay in network for care by making it more expensive for them to have treatment with an out of network provider.

Operational considerations:

1. Is a system in place to respond to patient inquiries for whether a given provider or facility is in their network?
2. Can providers easily determine who is in and out of network when they are recommending follow-on care?

Challenge #3: Patients who choose narrow network products are cost conscious and expect their clinicians to be as well.

Operational considerations:

1. Are clinical protocols broadly adopted that address the appropriateness of care so that patients are not faced with medical bills for unnecessary care?
2. Are workup requirements established so that patients do not arrive at an appointment to find out key steps were not completed and therefore additional appointments are necessary before coming back?

Challenge #4: Patients have traded broad access via a wide open network of every provider and facility for a limited access option. However, limited access only refers to the number of physicians and facilities, not the ability to be seen in a timely manner.

Operational considerations:

1. Are the individuals who handle inbound requests able to quickly view availability for all services within the narrow network to ensure the patient can get a timely appointment?
2. Is this the time to start allowing patients themselves to book their own appointment online?

By no means is this an exhaustive list, but it should help quickly determine how prepared an organization is to support a narrow network strategy.

Shawn Wagoner is president of Proximare Health of Savannah, GA.

Readers Write: ATA Conference Recap: My Impressions of the Show

ATA Conference Recap: My Impressions of the Show
By Norman Volsky

After attending and walking the exhibit hall of the 19th Annual American Telemedicine Conference in Baltimore Monday and Tuesday, I walked away with several conclusions (besides Baltimore having the world’s most delicious crab cakes.)

• Telemedicine is a very exciting space. This market has the potential to help hospitals, patients, employers, and health plans reduce cost. There are also solutions out there which simultaneously improve quality and outcomes. This is a market that is poised for some tremendous growth.
• The telehealth / telemedicine / telepresence (these all have different definitions) space could become commoditized very soon if it hasn’t already. There were a ton of companies that sold mobile carts, each with their own differentiators. Some were focused on providing their services at the lowest cost while others focused on quality and value. Either way, this market seems to be moving in the same direction that HIE and more recently EMR have gone in the past couple of years towards consolidation and commoditization.

• Telemedicine is geared towards multiple customers. There were some companies like Healthspot and American Well that were showing off kiosks or pods designed for the retail sector including pharmacies, large corporate headquarters, and supermarkets as well as hospitals. American Well had solutions geared towards a tablet and smartphone that were impressive. This is a market that could have some significant growth.
• Remote patient monitoring software companies are poised for growth. Some focus on home health, while others focus on post-acute and more broadly, the entire continuum of care. The companies that collect data from wearable devices are particularly cool. Many of these companies have patient engagement capabilities, secure texting, and outbound or proactive phone calls to patients to make sure they are following their care plans. This segment of HIT helps hospitals qualify for Meaningful Use by reducing readmissions. ACOs and health plans are leveraging these types of software systems to reduce cost, risk, and readmissions (the holy HIT trinity). The majority of these companies are focused on high-risk populations which include chronic care patients, the elderly, and patients who have had a recent major operation or episode. Others are focused on wellness for population management. I was particularly impressed with the exhibits of CareVia, AMC Health, Ideal Life, and Tactio Health.
• Unique software caught my eye. Specific companies that caught my eye had unique offerings such as iMDsoft (clinical information systems software geared towards perioperative and critical care) and MediSprout (a telemedicine platform that runs entirely on tablets and leverages existing HIT apps.)
• Smaller vendors need additional funding. I asked a lot of companies about their revenue model and some of them didn’t have great answers. There was also some ambiguity as to who the economic buyer would be (patients, hospitals, payers, etc.) Many companies threw out buzzwords like population health management and care coordination, but it seemed to me that they need to better articulate why these types of solutions are important to providers and health plans. If these companies can show how their solutions connect to the larger healthcare picture, they would have a better chance of obtaining the funding they require.
• This is a very sheltered segment of the industry. The majority of the booths I went to had no knowledge of HIStalk. Most were unfamiliar with the site and many of these companies did not have a vast knowledge of the software world. At least half of the exhibiting companies were hardware focused, for example mobile carts with videoconference capabilities customized for healthcare.
• The telemedicine segment should become more in tune with how their products and solutions fit within the broader healthcare IT market. With the previous conclusions in mind, these companies would be wise to keep abreast of blogs like HIStalk. They need to understand where hospitals are spending their money and what types of products and solutions will get the attention of hospital C-Level executives. With a better understanding of their competition for dollars, they would be more successful in articulating the right message to potential buyers. I also believe that partnering with some pure software companies could give them a more comprehensive and marketable offering to sell.

Overall, telemedicine is an area of healthcare that will have incredible growth over the next several years. There is a lot of competition in the telemedicine and remote patient monitoring segments and there will undoubtedly be some winners and losers. However, once the dust settles and consolidation occurs, the healthcare space will be better off. The ability to have doctor visits remotely and be able to monitor patients while they are at home is powerful. With this technology, hospitals and health plans will be able to reduce cost, risk and readmissions and, most importantly, save lives.

In conclusion, I feel this market is too siloed and needs a better understanding and exposure to the rest of the healthcare IT market. My advice for companies in this space would be to attend next year’s HIMSS conference in Chicago. I think doing so would be an eye-opening experience that would be extremely beneficial to this market’s inevitable growth. The better companies in this space understand how they fit into the bigger picture of healthcare, the better chance they will have to make it in both the short and long term.

Norman Volsky is director of mobile healthcare IT practice for Direct Recruiters, Inc. of Solon, OH.

HIStalk Interviews Bruce Bethancourt, MD, Chief Medical Officer, St. Vincent Medical Group

Bruce Bethancourt, MD is chief medical officer of St. Vincent Medical Group of Indianapolis, IN.

What are the biggest challenges for the medical group?

The biggest challenge is that with the Affordable Care Act, not so much now but in the near future, so many more people that will have access to care. We really don’t have an increase in provider base. We need to move — and we’re in the process at St. Vincent’s in moving — from a traditional model of “one physician, one patient at a time” to more team-based care. 

Moving to the patient-centered medical home model, where it’s team-based as opposed to one-on-one, is a challenge. In the long run, once we’re there, we’ll be able to provide the right care at the right time and at the right place.

How are you positioned in terms of electronic medical records?

I think we’re OK. We’re moving from one EMR to athenaclinicals, which will be a huge advantage for us in the near future. Athena’s ability to track things and to improve gaps in care will be a big advantage for us as soon as we get fully implemented. We’re about 50/50 right now.

What technologies do you see as being either necessary or promising for how you see the care model changing?

Many of us thought that the EMR was going to be the end-all. It would provide all the analytics that we need. I don’t think there’s any one product out there, as far as EMR goes, that provides what we really need.

What we need, there are a couple of things. One is predictive analytics. There are several products out there. Milliman MedInsight is one. The Advisory Board Company’s Crimson is another. Optum is another since they and Humedica came together.

What we need to know is not just the patients we know that are at higher risk, but those patients that are out there that are the second line to be high risk. The example I use frequently is a 75-year-old woman who has an eighth-grade education, who has COPD and smokes, who doesn’t really like going to her doctor, doesn’t get a flu shot, gets pneumonia, is on a ventilator for a month, and then is discharged to a SNF and dies six weeks later.

If we could just reach out to that person, if we had the analytics to find that person and bring them in to the fold, so to speak, before she reaches the tipping point … that’s going to be critical when we’re at risk for all these patients.

The other, much like Acupera that we’re piloting, helps physicians close the gaps in care. That’s the big problem. There have  been several studies that show that if a primary care physician with an average patient population or panel size of about 2,400 were to provide all of the evidence-based predictive health and all the evidence-based treatment of chronic disease, it would take that physician 17.5 hours a day just to meet those needs, not counting all the acute problems when they come in. 

We really need those analytics to figure out which patient hasn’t had the appropriate preventive health — mammography, colonoscopy, etc. The Acupera model we’re piloting picks up those gaps in care. It doesn’t have to rely on the physician to remember or to even order. The staff can order for the physician and close all those gaps in appropriate care.

Will you put the same resources towards those patients who are still fee-for-service as you do for those who aren’t?

Yes. It’s the right thing to do. If you look at it, the ones that are fee-for-service that we’re closing gaps in care are actually bringing revenue into the system.

Even though you can save money on the patients you’re at risk for, you can make money on fee-for-service patients by being more aggressive about their ongoing needs?

Exactly.

What are the building blocks of getting from a purely fee-for-service, volume-based practice to a more at-risk model?

It’s what we’re going to right now. You can’t just develop a complete team-based care and have open access and non-traditional hours in that physician’s hours to the nth degree and be able to meet the bottom line.

We’re asking our physicians to grow their panels. As we see their panel grow from the 50th to the 75th percentile, we’re implementing an advanced practice provider into that practice. We may even have to split some of our larger practices up because there’s not enough room in the office that they’re in. We’re going to have to, in some cases, open up the access so we can have team-based care, but it’s a gradual process. You just can’t do it overnight.

People talk a lot about patient engagement. Are patients are pushing you to engage differently with them and are you considering any technologies that would help you do that?

We really are in an era of convenience. There was a study last summer where they contacted patients that, when they had an immediate need, would not even call the physician. They went to Walgreens or they went to CVS and they went to some retail provider because it’s convenient. Patients want to be able to get in in a very convenient manner. They didn’t even want to wait on the telephone to find out if they could see the doctor. They didn’t bother — they went directly. 

We need to have the ability to have open access, but still be able to meet patients where they are and meet the bottom line. It’s a balance between having enough open access, doing it gradually, and getting the patients where they need to be. 

One of the things we’re working on right now is a call center, so that when a patient calls, the call is answered immediately. If they can’t see their physician, at least get them in to a member of the team. A two-way call center is very appropriate.

The other thing is in dealing with predictive analytics and closing the gaps in care. If we have the two-way call center, so that not only calls are coming in, but calls are also going out to find those patients that are missing those gaps in care, whether it be mammography or a colonoscopy or they have to have their hemoglobin A1C checked in six months. We can reach out to them and bring them in. It’s going to take the predictive analytics also with an appropriate call center to do that.

Will you run the call center in-house or will you outsource it?

We’ll run it in-house. What we envision is really not even hiring more personnel. We’ll take the person that’s in the office right now answering the calls and put them into a call center.

Are patients approaching you about being able to see their medical records or the OpenNotes project?

For Meaningful Use, patients can have a summary of care within 72 hours. To be honest, we really haven’t seen a lot of demand for that yet. We’ll have it there when it’s ready.

What are physicians looking for when you recruit them?

Most of them in today’s world are looking for a work-life balance, specifically the younger doctors. They want to be employed. They’re not into working 50 or 60 hours as we did when I was coming up the ranks. They’re looking at a 40-hour week and they want that. They want the electronic medical record. They’re looking for a work-life balance.

What will be the group’s biggest challenges and opportunities in the next few years?

Where we become fully at risk, we may reach the pinnacle of where we want it to be. That is, that it isn’t about how many patients we churn or see to be compensated or reimbursed for our services, but physicians and providers will be compensated on a population of patients. They will be responsible for that patient from birth to death, from preventive health to acute illnesses to end of life. 

For example, if you have a panel size of 5,000 and your patient satisfaction scores are excellent, your readmission scores are low, and your quality metrics are in the 90th percentile, you may be compensated X-squared dollars. If you have 3,000 patients and your patient satisfaction scores are low and your quality is low, you’re going to get X-squared minus Y-squared dollars. It will really be about how well you’re taking care of your panel of patients. To be honest, I look forward to that.

In order to do that, it’s going to take the appropriate EMR, but it’s going to take predictive analytics to take care of all those patients. If you think about it, we have not increased the number of physicians substantially at all since 1997, since the Balanced Budget Act. It just recently increased the size of the medical schools, but we really don’t have the appropriate physician workforce to manage 40 million newly insured citizens of the United States. We’ve got to have team-based care. We’ve got to take care of the population. It’s going to take appropriate analytics to do that.

Morning Headlines 5/23/14

Health Site Under Fire, Nevada Alters Path

Nevada will shut down its problematic health insurance exchange and sever ties with Xerox, the contractor responsible for its development. Nevada will rely on Healthcare.gov for next year’s enrollment period and then will evaluate whether it wants to spend more money developing a new state level exchange for the following year.

Finding the Missing Link for Big Biomedical Data

Harvard physicians publish a JAMA article suggesting that big data could accurately discern a picture of individual patient health if it were technically possible, and socially acceptable, to combine disparate data sources, such as EHR data, claims data, census data, social media data, and credit card transaction data, at the individual patient level.

U.S. Senate Drives a Stake Through Heart of Patent Reform

Senator Patrick Leahy (D-VT) withdraws the widely supported Innovation Act, a much-needed patent reform bill, because of concerns that the bill went to far in removing patent protections and would end up hurting the businesses and academic research centers that rely on patents to protect genuine discoveries.

AHRQ: 2014 Hospital Survey on Patient Safety Culture

AHRQ surveys 653 US hospitals and finds that 81 percent report strong teamwork at the unit level, but 53 percent reported that important patient safety information was not always conveyed when patients were transferred to new units or during shift change. Only 55 percent reported that their hospital’s had adequate staff to deliver quality care. Small hospitals (6-24 beds) scored higher on the survey than large hospitals (400+ beds)

News 5/23/14

Top News

Nevada fires health insurance exchange contractor Xerox and announces plans to shut down its site, saying it will instead rely on Healthcare.gov for at least a year and then decide whether to spend many more millions to build a new exchange. The state has paid Xerox $12 million of the $72 million contract value and says the site’s many problems can’t be fixed by the next enrollment period that starts in November despite a personal promise from the CEO of Xerox. According to a board member, “We’ve seen so many broken promises from Xerox on how they’re going to fix it that at some point it just becomes not credible.”

Reader Comments

From Skeptic: “Re: Patrick Dempsey investing in CrowdMed. He made a big splash in Seattle about a year ago, coming in to ‘save’ Tully’s, a local coffee company. After incredible news coverage, he pulled out as an investor.” Dempsey ended up suing his investment partner, claiming that the owner borrowed money against the coffee company’s assets at an exorbitant rate without telling him. I think I would be cautious about bringing in a celebrity investor with deep pockets and high visibility, but also an ego accustomed to constant care and feeding.

From Jackie: “Re: HIStalk emails. Just wanted to say I love the new format with a snapshot of the article and the time it will take to read it. Great idea!” Thanks. I’m not doing it for news posts since those are broken out by category and therefore reading time isn’t as relevant since not everybody reads them all.

From MoreCowBells: “Re: new CMS rule. The press release includes the matrix you published, but not the asterisk and footnote. For Stage 2 sites, it makes a hug difference in what they will and won’t be able to do to attest.” Above is the footnoted version from the NPRM (highlighting mine), which seems to suggest that 2011 Edition CEHRT can be used in 2014 only if the provider’s EHR vendor hasn’t released a 2014 certified product. Lots of people are complaining about the proposed change for one reason or another, but the bottom line is that as long as providers plan to keep cashing HITECH checks, Uncle Sam gets to attach the strings. It also provides a lesson learned: if more than 20 percent of providers are moaning that they won’t be ready by a given federal deadline, don’t bother getting ready yourself because the date will be moved back.

HIStalk Announcements and Requests

Welcome to new HIStalk Platinum Sponsor Logicworks. The New York City-based company, founded in 1993, helps providers meet MU Stage 2 requirements to automate security risk analysis, address encryption and security of data at rest, and implement security updates. It offers an application-specific solution for NIST 800-certified cloud-based offsite disaster recovery for EHRs, with unplanned system failover with less than two hours of downtime. Its medical image archive and vendor-neutral archive for PACS breaks the never-ending cycle of adding storage capacity as imaging data grows. The company can help with application decommissioning as well, retaining legacy data in a cost-effective, HIPAA-compliant cloud. Logicworks also offers cloud solutions (public, private, and hybrid) and managed Amazon Web Services cloud hosting. As the company says, customers don’t come to it looking for a cloud, they’re looking for solutions for particular problems, and that’s what they offer. Thanks to Logicworks for supporting HIStalk.

I cruised YouTube to see what’s available for Logicworks and found this overview.

This week on HIStalk Practice: HHS representatives weigh the pros and cons of using Medicare data to alert public health officials to the potential needs of vulnerable patients during a disaster. Accountable Care Options and its physician network earn a $4.2 million bonus from CMS as part of its participation in the Medicare Shared Savings program. Oncologists list the pros and cons of moving from independent practice to hospital employment. A solo physician line items his reasons for closing up shop, citing meaningful use of an EHR as the final straw. Health systems and public health departments enter the new world of urgent care and retail clinics. The VA’s troubles show no signs of being swept under the rug. CMS and ONC publish a proposed rule that would slow down the MU program by extending Stage 2 through 2016. The government considers a national “biosurveillance” system that will give it near real-time access to the private medical information of citizens in the name of national security. Not all physicians stick their heads in the sand when it comes to online reviews. Thanks for reading.

This week on HIStalk Connect: As Apple’s WWDC nears, Dr. Travis speculates on how its anticipated new mHealth app Healthbook will work. Rock Health introduces its sixth class of startups that focus on ICU analytics tools, primary care telehealth, population health, and a private health insurance exchange. High school Junior Jack Andraka wins the Siemens We Can Change The World Challenge with a water purification text that is nearly 200,000 times cheaper than currently available tests, also having in 2012  won the Intel International Science and Engineering Fair with a new pancreas cancer screening test that is 168 times faster and 400 times more accurate than currently available tests. Mango Health raises a massive $5.25 million Series A round for its medication adherence app.

Acquisitions, Funding, Business, and Stock

Healthcare consumer marketing vendor Clariture gets $1 million in seed funding from Nashville VC The Martin Companies.

ZirMed acquires population health management platform vendor Intelligent Healthcare.

Sales

Marshfield Clinic chooses Strata Decision Technology’s StrataJazz as its integrated financial platform.

Community Care of North Carolina will implement CitiusTech’s BI-Clinical platform.

St. Joseph Health (CA) selects InterSystems HealthShare for its data sharing initiative.

People

AMC Health names Walter D. Hosp (HMS Holdings) to the newly created position of CFO.

Intelligent InSites names Shane Waslaski (Varistar) as president and CEO.

MEA|NEA appoints Mary Dooley (Xerox) as director of sales, partners, and channels.

Announcements and Implementations

Henry Schein Medical will offer athenahealth’s services to its customers as part of its ConnectHealth offering that includes Dell, Midmark, Siemens, and Welch Allyn.

Ping Identity announces Ping One, a mobile app for single sign-on for iPhone, iPad, and Android devices.

Government and Politics

The Senate shelves the Innovation Act, a patent reform bill overwhelmingly approved by the House that would have made it harder for patent trolls to sue companies (most of them in the technology sector) using dubious patent claims. Senator Patrick Leahy (D-VT) removed the bill from the Senate Judiciary Committee, stating in his announcement that patent trolls are a real problem, but that the proposed bill would have imposed unintended consequences on legitimate patent holders.  

Innovation and Research

A JAMA opinion article on big biomedical data says that deep EHR information can be connected to broad data sources such as claims data, social media, and credit card purchase history to create a big-picture view of individual patients and their health risks. The problems are lack of a national patient identifier and privacy and security concerns. The authors are Harvard docs Griffin Weber, MD, PhD; Kenneth Mandl, MD, MPH; and Isaac Kohane, MD, PhD. I would think that a patient survey would find considerable discomfort with this possibility.

Other

The Houston paper profiles Memorial Hermann Hospital’s Virtual Care Check program, in which discharged patients at high risk for readmission receive home visits and are monitored remotely via a scale, blood pressure cuff, pulse oximeter, daily questionnaires, and a tablet running software from the hospital’s partner Vivify Health.  The hospital says the program’s patients are readmitted as low as 5 percent of the time vs. the national average of 12-15 percent. Memorial Hermann also announces the rollout of a free 24-hour RN-staffed Nurse Triage Call Center that anyone in greater Houston can call to ask questions or determine where to seek care, created after a study found that about half of Harris County ED patients could have been managed in a primary care setting.

Valley View Medical Center (AZ) loses its external phone connectivity and computer network for 11 hours after a Frontier Communications outage caused by a damaged cable.

Surescripts says that more than half of all eligible prescriptions in 2013 were transmitted electronically, with nearly three-fourths of office-based physicians using e-prescribing.

A law firm that had just won a $25 million verdict against a Korea-based medical imaging company withdraws from the case when its client, Texas-based cardiac MRI vendor LDBS, admits that a Cerner contract it introduced into evidence was falsified by using a fictitious email address. The CEO of LDBS had claimed he attended RSNA 2010 and saw the Korean company’s engineers demonstrating LDBS’s technology in a competitor’s booth.

A Reuters investigative report says that a grand Black Sea estate allegedly built for Russian President Vladimir Putin was paid for by skimming money from $200 million in inflated medical equipment contracts. The report names two people it claims bought medical equipment from Siemens and then sold it at inflated prices to the Russian government as part of a $1 billion healthcare modernization project, with $56 million of the money finding its way to Swiss bank accounts and then to the builder of the estate.

An AHRQ hospital survey on patient safety culture finds that while organizations are encouraging teamwork and organizational learning, more than half of respondents fear mistakes they make will be held against them, nearly half say patient care information isn’t communicated well when patients are transferred or during shift changes, and nearly half think employees are too overworked to provide the highest quality care.

An PwC report says Hispanics will drive the US healthcare economy because: (a) more than 10 million of them will gain insurance through the Affordable Care Act; (b) they are cost-conscious; (c) they are heavy mobile users; (d) they don’t like sharing medical information; (e) less than half have a regular doctor and they don’t necessarily believe that the doctor knows best; (e) they will use retail clinics, community health clinics, and pharmacists to manage non-urgent problems; (f) they distrust the government and insurance companies and would rather see information in English since the translations are often poorly done.

NPR profiles Qstream, a Harvard-created company that sends sequential emailed quiz questions to doctors and nurses to keep their education current. Eight Boston hospitals are testing a series of blood pressure questions that use bizarre stock photos and memorably silly cases to entertain and inform the recipients, who often compete against other using assumed names. Hospitals are posting leaderboards of the aliased participants, and as always happens with anonymized physician performance metrics, the always-competitive doctors have figured out who is who and where they stand among their peers. 

Sponsor Updates

• HealthMEDX is rated as the #1 EMR vendor in the new KLAS report, “Long-Term Care 2014: Which Vendors Deliver on the Fundamentals?” with 100 percent of customers saying they would buy its product again.
• Forward Health Group CEO Michael Barbouche will speak at Connecting Michigan for Health June 4-6  in Lansing. He presented last week at the CEhp’s Alliance Industry Summit in New Brunswick, NJ.
• Nordic releases a case study on Baylor Scott & White’s use of its remote solutions offering for go-live support.
• DataMotion discusses current and future email regulations.
• Premier Inc’s safety expert Gina Pugliese joins The Physician-Patient Alliance for Health & Safety board of advisors.
• Kareo is selected as a 2014 Red Herring Top 100 North American award winner.
• GetWellNetwork clients experience a 76 percent improvement in pain well controlled as well as improvements in environment of care, medication teaching, heart failure readmissions, and falls.
• MedAssets announces that its 2014 Technology and Innovation Expo, to be held October 28 in Dallas, TX, is accepting applications for exhibitors.
• NTT Data commits  three years of support for the North Texas Food Bank’s Food 4 Kids – Plano Program.
• OTTR Chronic Care Solutions will integrate XynManagement’s XynSiteTM suite of data analysis tool with its longitudinal patient tracking solutions and services.
• Nuance will add voice capabilities to Oracle mobile apps.

EPtalk by Dr. Jayne

As you would expect, the hot news in the administrative halls of our medical group this week was the play by CMS to again change the game for Meaningful Use. On the first pass, it looks like a benefit for providers, but I’m always skeptical until I look at the complexity of the details. Honestly, I tried to read the entire document (which at only 28 pages is nothing compared to the other Proposed Rules that emanate from CMS) but just couldn’t make it through.

I’m a TV junkie, so I was reminded of an episode of “Grey’s Anatomy.” One of the characters has a photographic memory. Some of the senior residents need information from paper charts to prep for their oral board exams, but they can’t take the charts to study them. They convince Lexie to try to memorize the charts and she starts, but partway through, she just snaps and her brain quits working. Another character makes a comment along the lines of, “You broke her.”

After today, I know how that feels. My boss expects me to be an expert on everything CMS within moments of its release. There is just no way to do so. CMS often conflicts itself (look at the FAQ evolution if you think I’m kidding) and delegates authority to a maze of regional contractors who each make their own de facto rules.

As a provider, I’ve had it up to here with CMS and Congress meddling in health care. If I was an independent physician, this would be the final straw that would convince me to opt out of Medicare and take my chances.

I’m a good reader, logical thinker, and smart enough to make it through medical school, yet I cannot begin to understand all of the regulations, especially when they start conflicting with each other. Our health system now employs a team of people to try to keep up with them and we can barely keep our heads above water. By extension, I can see no way (other than paying a fleet of consultants or going crazy) an independent provider can hope to play the game.

And that’s what it is — a game. Meaningful Use is just another fiery hoop for everyone to jump through. Since it’s all or none, you can work yourself to the bone, have everything right, but be thwarted by arcane rounding rules (don’t get me started) that will defeat you in the end. You can be defeated by patients who refuse to comply with your advice and have no interest in accessing their records. (I was visiting a practice today where nearly 80 percent of the patients refused their clinical summary documents or left them in the exam room.)

You can be defeated by the inability to get all the reports to run at the end of your attestation quarter if you’re trying to hit July / August / September. There’s no grace period – attestation has to be done by October 1 – so prepare for an all-nighter. If you have a power outage, you’re doomed. Hope there aren’t any hurricanes that weekend for our east coast readers trying to squeeze it in.

Anyway, we’ve all been through the angst of this for months and months, and now they’re going to probably change the dates again. We don’t know whether we can trust CMS. We don’t know how hard to work in the mean time – there is a 60-day window for commentary on the rule and no guarantees that it will be put into place unchanged – so essentially many of us are still on the hamster wheel whether we want to be or not. It’s discouraging, disheartening, and disrespectful to the many people who have worked so hard over the last year, only to have the end game change again.

I understand how we came to be here. I understand population health and the need to have big data. I understand the need to see vast numbers of patients to make sure everyone is served. I understand the need to coordinate care. But on the other hand, I understand the need to be able to spend my time just being a doctor – listening to patients, understanding their needs, and helping them get better. It seems that has been completely lost in all the noise and churn of regulations, guidelines, and rulemaking.

I’m not old enough to have practiced in the “olden days” of medicine when you could get away with writing a note that said “Sick – Penicillin” and charge $5 and be done with it. I certainly see the appeal however. I wonder if I could deliver primary care much cheaper if I went to the old-school approach? Without insurance or all the referral-chasing, I could probably slash my overhead by 80 percent. Without all the overhead, I could lower my prices. With lower prices and fewer distractions, I could help more patients. This is the heart of the direct primary care model, which is gaining traction in many communities. It’s an appealing proposition for more and more physicians.

A lot of providers who are learning to use electronic health records complain of being turned into data entry clerks or having to take on the duties that used to belong to the unit secretary. I initially went into IT and administration to help patients (and my peers) at a higher level. Unfortunately, I’m spending more time chasing federal rules, reading legislation, and trying to understand arcane documents than I ever thought possible.

Maybe I should have gone to law school after all. Maybe it’s just CMIO burnout. Maybe my brain is broken. Maybe I just need to get over it.  But on the other hand, maybe we just need all these other entities to get out of our patient -physician relationships.

What do you think about the proposed changes to MU? Email me.

 Contacts

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

More news: HIStalk Practice, HIStalk Connect. 

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Morning Headlines 5/22/14

Surescripts: E-prescribing up, but still faces challenges

Surescripts reports that over one billion prescriptions were filed electronically in 2013, accounting for 58 percent of all eligible prescriptions and up 32 percent since 2012.

Ex-WellCare CEO Gets Three Years for Medicaid Scheme

Todd Farha, the ex-CEO of WellCare Health Plans, is sentenced to three-years in prison following a 2013 conviction for overseeing a scheme to defraud Florida’s Medicaid program for $40 million.

Federal investigators issue subpoena to Cover Oregon, Oregon Health Authority

The FBI has issued a subpoena seeking documents, memos, and emails between Cover Oregon and the Oregon Health Authority, the two organizations responsible for the rollout of Oregon’s botched $250 million health insurance exchange.

Introducing Insight, the nation’s largest real-time healthcare database

Practice Fusion launches a free, publicly available version of Insights, its analytics solution. The new platform was enhanced to provide de-identified health data to public health researchers, students, and the general public.

CIO Unplugged 5/21/14

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

Marching to the Syncopated Beat

Syncopate – to place the accents on beats that are normally unaccented.

At our last quarter IT leadership team offsite, we invited our Business Technology Leadership Academy cohort to join us. As part of the icebreaker, I asked everyone to describe a leadership paradox — philosophies that don’t seem particularly logical on the surface, yet are quit profound and effective. Since the paradoxes are not mainstream, we may overlook some of these leadership gems in search of the quick fix.

Here is what the team came up with. As you read these, ask yourself: do you operate in each of these areas? If not, what if you did? I know I can read lists and say to myself, “Well of course I do all these things.” But when I am intellectually honest with myself, I begin to see my gaps more clearly, which in turn motivate me to action. I don’t want to toil in vain; I want my work to count for something. I know you do as well. Embrace the gaps and work to close them.

• Serve, not be served. The day we left the assembly line making widgets is the day we stopped adding direct production value to our organization. Therefore, focus on those who do the actual work and seek to serve them instead of seeking to be served.
• Patients come second. Heresy? Nope. This book, co-written by one of our hospital presidents, speaks about employee engagement as the key factor to higher quality of care and services. When you focus on people first, everything falls into place.
• Letting go enables influence. Too often we grip everything with an iron fist trying to protect what we believe belongs to us. While we might succeed at protecting our turf, our influence is stifled. Rather, give everything away and it will come back to you threefold, pressed down and shaken together. Our CMIO and CNIO used to report to me. I purposely had them report elsewhere in our organization, effectively multiplying the influence of IT threefold. You do not have influence until you give it away.
• Love when you want to hate. Admit it. Sometimes people can just beat you down and for no good reason. You are maligned or disrespected or taken advantage of and your natural inclination is to strike back. Instead, double down on your efforts to love on that person. Clearly, they need it. Hate only fuels hate. Love puts out the fire.
• Turnover is awesome. We used to have these KPI that were, in a sense, perverse. Someone decided 10 percent was the high watermark for turnover. That generated a lackadaisical attitude and atmosphere. Transforming an organization sometimes requires clearing out non-performers. Embrace appropriate turnover, KPI or not.
• Turn your leaders. Longevity has value to a point, but it also cultivates complacency and inflexibility. I will delight in celebrating the day one of my team resigns after years of serving—but not necessarily serving me or my organization. I’ve enjoyed a greater pleasure watching one of my directs fly the coup and continue on their journey to reach their career goals. I have six CIOs out there who used to report to me. I am a proud papa!
• Hide your rank. I will rarely introduce myself or say, “I am the CIO.” I actively participate in meetings and rely more on my logic and persuasiveness than on rank. If I relied on rank, the world would not be a better place. People are less inclined to contribute and engage if some arrogant ass is leading them.
• Build villages, not castles. We all have a set amount of mortar and brick at our disposal. The real action happens in villages, in the town square, among the people. Get out of your castle and live among your people. You will not only better understand how to serve them, but you will experience real joy.
• Ask for help. Everyone already knows you’re partially incompetent. You can’t possibly know everything. The gig is up. Just admit it, ask for help, and move on. You will earn respect and more will get accomplished.
• Give credit to the team. Obvious, yes, but hardly practiced. Hello? You want glory? Then take the glory that comes with taking bullets for your team when a project goes sideways. You want the most loyal team on earth that will jump on grenades for you? Protect them. Take the shit when it hits the fan.
• Embrace challengers. At first, I’ll hate them; but then I’ll love them deeply. They are one of the reasons I’ve experienced success. I grit my teeth and embrace those who challenge me; I glean all I can. They have the inherent ability to transform me more than any who kiss my ass. Ass-kissers feel good. Challengers make you good.
• Never coast. I have participated in about 125 triathlons now. Coasters never win. They look good for a while, but they never achieve significance. I know people who achieved a level of success and decided to retire while working. When all is said and done, they will be depressed knowing they had more to give but kept it to themselves.

As I review the above list and contemplate the personal application, I see where I have fallen short and need to take another run at them. I know that if I do not continuously look for and fill gaps that I will become the kind of leader I fear most. A complacent leader. An impotent leader. A leader in name only.

Insignificance is not my calling. Nor is it yours.

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

HIStalk Interviews Pat Cline, CEO, Lightbeam Health Solutions

Pat Cline is CEO of Lightbeam Health Solutions of Irving, TX.

Tell me about yourself and the company.

I’m a 53-year-old cross between father, husband, entrepreneur, healthcare IT investor, and company operator. I started in healthcare IT about 34 years ago.

Most of my career has been with NextGen Healthcare. I retired from that company in 2011. I found that I was terrible at retirement. I came out of retirement a few months later and started to put together the concept of Lightbeam.

Lightbeam Health essentially is a population health management platform that aggregates data from many different sources and normalizes that data, represents it properly, mines that data for gaps in care, and does risk stratification. Then puts those gaps in care back to providers at the point of care, where we can affect change.

How big is the company?

Relatively small. It’s a software is a service model, so building revenue is slow in the early stages. From a revenue standpoint, we should be about five million run rate by the end of this year. From an employee perspective, I think we’re about 22 or 23 employees.

It seems like everybody’s next big thing after EHRs was electronic data warehouse and analytics. A lot of those companies are going to fail. What do you think will distinguish the winners from the losers?

Great question, and I think you’re right. One of the things, I believe, is experience. The team at Lightbeam has very broad and very deep experience in end-to-end data management based on our background in ambulatory health records.

When I talk about aggregating data, normalizing it, representing it properly, and de-duping it, there’s a lot of heavy lifting involved. That’s an area where we see some of our competitors faltering.

Many of our competitors are doing similar things, but with claims-based data, and as you know that data tends to be eight or 10 weeks old. This company can not only use claim data feeds and drug claims and those kinds of things, but also can get at the real-time or near-time electronic health record data.

Another uniqueness is, as I mentioned, our software as a service or our subscription model. It makes the cost of entry very, very low. Based on all of the costs that have imposed on medical providers and health systems recently with the move to ICD-10 and the costs involved with achieving Meaningful Use, most of them seem to find a subscription model without an upfront fee more palatable.

How does the integration with EHRs work technically?

I’m not a technologist any more. They threw me out of that profession in the 1980s. But the experience that too much of our team went through or gained during our years in electronic health records for provider organizations includes integrating and interfacing with many, many different systems, all of the prevalent systems both in hospitals and on the ambulatory side, and participating as we did at NextGen with many of the different early pilots and actually developing an HIE and those kinds of things. 

We’ve got a team that’s experienced in doing that. Beyond that, if I start talking the actual technology, I’ll get in over my head pretty quickly.

Are your provider customers expecting a lot of hand-holding or do they know what data that they want and what they’re going to do with it?

There’s always a certain amount of hand-holding, but generally as providers move more toward shared savings programs — whether that’s participating in or forming an ACO or commercial-shared saving or move more toward risk-based or value-based reimbursement — they tend to want some of the standardized guidelines and managers. They want data mined for gaps against some of these standard measures, like HEDIS measures and ACO measures and those kinds of things.

At least for the interim, providers are going to have mixed panels where they’ll have some patients that will be under some new payment model and then others that are traditional fee-for-service. Will they ask for data to treat those patients differently?

So far, we’re not seeing that. So far, practices seem to want to include all of their patients in population health management.

If you believe that proactively managing patients is a good thing, then you want to spread that across your entire population. The difference is, as you pointed out, many of them are fee-for-service and therefore the providers aren’t paid for the proactive management as much as they are more reactive point of care or fee-for-quantity or fee-for-service business. But by and large, we’re seeing that providers want to manage care for all of their patients the same way.

What’s your assessment of the ambulatory EHR market, looking back on your time with Quality Systems and NextGen?

The market is maturing. While it’s not saturated, it’s reaching that point.

Over the next few years, there will be a tremendous replacement market, where providers that perhaps moved too quickly or made mistakes purchasing systems that didn’t quite meet their needs circle back and replace systems. That will also lead to a robust services market over the next few years.

It seems to me that it’s also increasingly difficult for the smaller companies in electronic health records to keep up with all of the government-mandated changes as well as market pressures. In the near term, we’ll continue to have a robust market even if it’s largely replacement oriented, and then in the long term, a lot of those companies will be adding features like the ones that Lightbeam Health provides.

HITECH created a big market. Was it a good thing?

Yes. The stimulus was needed.  We would otherwise be at far less than 50 percent saturation. Once EHRs are installed and we move from that era of physician adoption — getting physicians to use the systems and enter data — to an era of doing something intelligent and actionable, it can move the needle relative to clinical outcomes and therefore costs.

As a business coach, mentor, and investor, what advice would you have for healthcare IT newcomers and startups?

You’re probably looking for a different answer than this, but as a coach and mentor at this stage of my career, I would tell you that I see a lot of healthcare IT people that work awfully hard. It doesn’t seem like there’s ever an end to the work to be done. I would tell those people to slow down a little bit and spend a little more time with their families and smell the roses along the way.

Along those lines, I’m fascinated that you’re a sommelier. If you were spending $30 in a red wine, what would you choose?

I would probably spend it on one of the mass-produced California or Oregon cabernets.

Getting back on track, what trends or factors will be important in the next handful of years?

The next few years will continue to be very exciting. The folks that predict that market saturation will cause a drop-off and things will level out I believe are wrong. As providers move from fee-for-service or fee-for-quantity to value-based reimbursement, it will be a very interesting time, both for the existing vendors and for new vendors like Lightbeam.

Specifically, I think we’re moving to a new era of interoperability. While interoperability and system connectivity have been talked about for a long, long time, there are strides being made and strides in standardization as well. That will bode well for the whole system and will improve quality and outcomes and will lower cost. I’m looking forward to the day when data mining might even lead to cures, which will also be extremely exciting.

Do you have any concluding thoughts?

First, I want to thank you for the opportunity and for the exposure. Young companies like Lightbeam can use it and we really appreciate it. Secondly, I’d say that Lightbeam Health has a number of unique advantages relative to population health and helping physicians move to value-based reimbursements to invite those in the market to speak with us.

Morning Headlines 5/21/14

CMS rule to help providers make use of Certified EHR Technology

CMS and ONC publish a proposed rule that would extend MU stage 2 through 2016, explaining "By extending Stage 2, we are being receptive to stakeholder feedback to ensure providers can continue to meet meaningful use and keep momentum moving forward.”

Commonwealth Fund EHR Survey

A Commonwealth Fund survey finds that federally qualified health centers have increased adoption of EHRs by 133 percent since 2009, with nearly all centers now using EHRs and 76 percent qualifying for MU Stage 1 incentive payments.

Review recommends new name, direction for PCEHR

In Australia, a review of the floundering nationalized personal health record program concludes with a handful of recommendations aimed at bringing the project on track, including: changing the name from personally controlled electronic health record to My Health Record, pivoting from an opt-in enrollment process to an opt-out process, a redesign of the PHR layout that would make it more usable for clinicians, and the dismantling of the organization responsible for rolling out the PCEHR program and replacing it with a new organization comprised of clinicians, vendors, and bureaucrats.

News 5/21/14

Top News

CMS and ONC publish a proposed rule that would slow down the Meaningful Use program by extending Stage 2 through 2016 (starting Stage 3 in 2017) and allowing providers to attest for FY2014 using a 2011-certified EHR. National Coordinator Karen DeSalvo, MD seemed to express concern that EHR vendors would not have their products certified under the 2014 criteria in time, referring to users would would miss the dates “through no fault of their own,” while the bill referred to “availability and timing of product installation, deployment of new processes and workflows, and employee training.” Public comment on the proposed bill will be open for 60 days. The proposed change follows CMS’s acknowledgment that almost no providers have attested for Stage 2 so far. CMS had also previously defined a easily claimed, one-year hardship exception for providers unable to meet Meaningful Use dates.

Reader Comments

From Hogan: “Re: Centura. Their selection of Epic hurts Meditech since they are a large percentage of Meditech’s Stage 7 hospitals. In England, InterSystems was named vendor of choice against Epic and Meditech in a three-trust procurement called SmartCare. Epic won the clinical vote, but lost on price. It’s interesting that outside the US, Epic and InterSystems compete.”

From Topaz: “Re: health equipment innovators. I live in the Netherlands and a colleague is looking for help for his 16-year-old daughter Doreen, who is paralyzed. It is hard to get equipment in Dutch healthcare. Are companies in America looking for people to test their developments?” I created an online contact form for anyone who wants to get in touch.

From Arborio MD: “Re: Health Datapalooza. I am so happy that Mr. H decided to go this year so we can all enjoy vicariously the platitudes from Vinod Khosla, who believes that 80 percent of doctors can be replaced by technology, and 20-cups-a-day coffee drinkers who in their garages and basements hope to disrupt healthcare and become millionaires overnight in the process. The sad part is that even respectable HIT leaders like Ed Park recognize the big schism between the promise of Big Data in healthcare and the reality. Last year athenahealth sent 40 people, while AMA – whose president, Dr. Ardis Dee Hoven, has not even heard of this conference — sent only one. I wonder how many docs toiling down in the trenches are even aware that a bunch of geeks are about to eat their lunch?”

HIStalk Announcements and Requests

Welcome to new HIStalk Platinum Sponsor Healthcare Data Solutions. The healthcare-only Irvine, CA-based company offers databases of providers (physicians, dentists, PAs, NPs, pharmacies, hospitals, and EHR users); email lists and services;  and real-time physician verification for open payments, state license verification, and DEA/NPI validation. Customer testimonials on the company’s site vouch for its “great pricing,” “most dependable data,” and “data models [that] are a perfect fit.” EHR vendors use the company’s physician database for marketing and to determine if the provider has implemented an EHR. The company offers white papers, webinars, and database layouts on its site. Clients include MD Anderson, UC Irvine Health, Cedars-Sinai, NextGen,, and Philips. Thanks to Healthcare Data Solutions for supporting HIStalk.

Acquisitions, Funding, Business, and Stock

Excited to announce my investment in @CrowdMed! Check out the @WSJ story by @lorakolodny: http://t.co/KhJbIW8szc. @jaredheyman @patrickchung

— Patrick Dempsey (@PatrickDempsey) May 20, 2014

”Grey’s Anatomy” actor Patrick Dempsey invests an unspecified amount in startup CrowdMed, which crowdsources diagnoses using volunteer clinicians called “Medical Detectives.” PR from someone who used to play a doctor on TV may not be all that appealing to the real experts whose free labor fuels the business model.

Cleveland Clinic forms a joint venture with telemedicine kiosk vendor HealthSpot and will integrate its product with the clinic’s Epic system.  

Sales

Vanderbilt University Medical Center chooses Allscripts EPSi for financial planning.

American Samoa Medical Center will implement Medsphere’s OpenVista EHR.

Atlantic Health System (NJ) selects TeraMedica’s Evercore Clinical Enterprise Suite for vendor-neutral archive storage of both DICOM and non-DICOM data.

Delaware Health Information Network will implement Halfpenny Technologies’ intelligent integration technology hub.

Advocate Health Care chooses identity and access management systems from Courion.

Avita Health System (OH) will implement NextGen Healthcare’s EHR, practice management, patient portal, population health EHR Connect, and ED solutions at its two hospitals.

People

Karen Chapman (Northrop Grumman) joins Medicomp Systems as senior product manager.

Phoenix Health Systems names Jim Griffith (Siemens Medical Solutions Health Services Division) as EVP/COO.

Vocera announces that CFO William Zerella will resign on June 6 to become CFO of an unnamed pre-IPO consumer wearables company. Vocera also announced that Bob Zollars has transitioned from executive chairman to chairman of the board.  

Terry Cameron (Emdeon) joins Recondo Technology as president and COO.

Announcements and Implementations

Beacon Partners will implement and offer advisory services to providers deploying Caradigm’s Risk Management and Care Management population health management products.

Philips releases eCareManager 4.0 that includes acute care, part of its Hospital to Home telehealth program.

MyMedicalRecords adds three more patents to sue EHR vendors over: EHRs in clinical trials, online sharing of medical records, and legal records including power of attorney and wills. As you might expect, the announcement promises litigation rather than innovation: “MMR’s goal is to leverage its products and services and patents and other intellectual property to create working relationships with more companies in the biotechnology field so that patients and shareholders ultimately benefit.”

Pharmacy systems vendor PioneerRX will replace its existing drug database with Elsevier’s Gold Standard Drug Database.

Greater Regional Medical Center (IA) goes live on PeriGen’s PeriCALM.

Government and Politics

The VA opens an investigation of the Gainesville, FL VA hospital after discovering that employees were keeping follow-up appointment schedules on paper instead of on the electronic system that made results visible to VA management.

House Oversight Chairman Rep. Darrell Issa (R-CA) chews out the CMS official in charge of fraud prevention for falling several months behind on delivering a report that will document the effectiveness of CMS’s fraud prevention software.

Other

The CEO of Massena Memorial Hospital (NY) blames Meditech’s LSS software, which he says “created some kind of strange numbers off the report,” for incorrect financial reports. He adds, “We’ve been experiencing over the last couple of months some significant issues with our LSS software system that was recently installed in a number of our physician offices.” 

The AMA’s American Medical News shuts down after 55 years due to a 67 percent drop in annual revenue caused by declining circulation and ad revenue. The publication transitioned poorly to an online format and was hit hard by declining drug company advertising.

In Australia, a review panel suggests that the personally controlled health record (PCEHR) be renamed to My Health Record, that participation be changed from opt-in to opt-out to increase enrollment from the current single-digit percentages, that physician usability be improved, and that doctors be paid incentives tied to meaningful use metrics and their contribution of patient data to the common record. The panel also recommends that the National eHealth Transition Authority be dissolved and its oversight role transferred to a group called Australian Commission for Electronic Health that would include clinicians and software vendors.

The City of New York temporarily halts its 911 communications project, which was supposed to take five years and cost $1.3 billion, now at the 10-year mark with estimated costs at over $2 billion.

A Commonwealth Fund survey finds that EHR adoption by federally qualified centers more than doubled from 2009 to 2013, with 93 percent of them running an EHR and 75 percent meeting MU requirements. Most of them do CPOE, clinical documentation, and lab results, but only about half say their providers have access to clinical decision support beyond canned drug warnings. The FQHCs say their biggest EHR-related problems are undertrained staff and loss of productivity.

A former nurse at Houston Methodist Hospital (TX) files suit against the hospital and hopes to turn it into a class action, claiming that the hospital’s time tracking system deducts 30 minutes for lunch even when the employee’s duties preclude stepping away.

In England, the CEO of a hospital is criticized for describing hospital patient care errors in her tweets. She has only 200 followers and uses her account mostly to praise employees and promote hospital events, but had some such as, “Signed patient letter enclosing incident investigation report following medication error openness+learning essential feedback= improvement.”

A care coordination “virtual health village” and single, real-time electronic health record for students of two Pennsylvania school districts has enrolled only 4,000 of 32,000 students, a quarter of the expected number. Health officials planned to make enrollment opt-out until attorneys from the school districts told them that HIPAA requires opt-in, meaning students have to request access. The schools used $850,000 in grant money to hire an outside vendor to create the exchange and connect it to the EHRs of local hospitals.

Weird News Andy calls this story “Wide-Eyed Wonder.” Texas doctors are working on an app that detects “white eye,” the opposite of the red-eye reflection effect that is normal when someone takes a flash picture. A white reflection is abnormal and indicate the possible presence of several eye problems, including a rare eye tumor.

Sponsor Updates

• InstaMed releases its “2013 Trends in Healthcare Payments Annual Report” as a video.
• CompuGroup Medical’s three EHRs earn ONC 2014 certification as Complete Ambulatory EHRs.
• McKesson Total Payment achieves a CMMI Level 3 appraisal rating.
• Arcadia Healthcare Solutions offers a white paper on pay-for-performance strategies.
• Extension Healthcare is participating in an elite platinum sponsor two-year initiative of the National Coalition for Alarm Management Safety.
• MissionPoint Health Partners (TN) and Hospital Corporation of America’s South Atlantic Division (SC/GA/FL) are awarded the 2014 Crimson Physician Partnership Award during The Advisory Board Company’s national Crimson summit in Orlando.
• EBSCO Health’s Patient Education Reference receives certification as an EHR Module for inpatient and ambulatory settings.
• Ingenious Med is named a Pacesetter by The Atlanta Business Chronicle.
• Sagacious Consultants launches Sagacious Go-Live Success for hospitals and clinics at the go-live juncture with Epic.
• Covisint launches its Certified Service Partner Program.
• NantHealth SVP and iSirona founder Dave Dyell is named a finalist for Ernst & Young Entrepreneur of the Year award.
• RazorInsights will incorporate TruCode’s Encoder Essentials into its ONE Enterprise HIS solution offering an integrated encoding solution with its HIS.
• Walnut Hill Medical Center (TX) opens its doors with 75 Voalte smartphones following its iHospital initiative.
• Valence Health launches Valence Partner Network to offer complementary solutions to its client base.

Contacts

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

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Morning Headlines 5/20/14

VA Faces Systemwide Problems With Patient Scheduling

In a Senate Veterans Affairs Committee hearing today, VA Secretary Eric Shinseki said that he is "mad as hell" that new instances of waitlist gaming tactics had been reported from around the country, and that he was ordering a system wide investigation in response. Since the news that the Phoenix VA Medical Center had been maintaining an off-the-record waitlist, similar stories have been reported from whistleblowers in Colorado, Florida, Texas and Wyoming. President Obama has assigned White House deputy chief of staff Rob Nabors to work alongside Shinseki to investigate the allegations.

Pilot at Boston’s Beth Israel Deaconess gives patients electronic access to therapists’ notes

Beth Israel Deaconess Medical Center is expanding its Open Notes program by providing patients online access to their therapists notes, a decision that has spawned extensive internal debate at BIDMC.

MyMedicalRecords Receives Three Major Health IT Patents Expanding PHR Portfolio to Add Clinical Trials & Legal Records

MMRGlobal is on its way to securing three new health IT related US patents, including: one that describes functionality that allows patients to use a PHR to self report clinical trial data, one that describes patients sharing PHR data with secondary care providers, and one that describes expanding what is stored in a PHR to include wills, powers of attorney, and other portions of the legal record.

Surgeon Cuts Vendors Out Of EHR Quest

Dr. Lloyd Hey of Hey Clinic for Scoliosis and Spine Surgery (NC) hires a full-time programmer to build a custom EHR after concluding that the systems available today were designed for primary care physicians rather than surgeons, and that none deliver the benefits he believes EHRs should generating.