HIStalk Interviews Joseph Mayer, MD, CEO, Cureatr

Joseph Mayer, MD is founder and CEO of Cureatr.

Tell me about yourself and the company.

I started Cureatr when I was a resident at Mount Sinai here in New York City. Prior to that and during my residency, I’ve always been a clinical research guy. I did med school at Columbia and focused on clinical operational workflow research. How you optimize consults, communication between the floors and pharmacy, and even looked at inter-organizational workflows like PCP into the hospital, etc. This is an area I’ve been passionate about since I started my training. 

I started Cureatr with a guy that I had gone Stanford undergrad with, Alex Khomenko, about two weeks before I started my residency. I had formed this idea during the last couple of years of medical school and worked closely with Bob Sideli at Columbia. I got together with Alex who, at that time was director of engineering at 23andMe on the West Coast, flew out and met with him, and said, “I’ve got this idea. I’m starting my residency in a couple of weeks, but let’s work on this together. I’ll be in a great environment to get feedback to understand what our users need, also what the administrators need.”

One thing led to another. We built out Cureatr  during the first year of my clinical training. Our first real launch was in the medicine department at Mount Sinai in January 2012. 

It’s been really a whirlwind since then. We were part of this New York Digital Health Accelerator program, with 20 leading payor-provider orgs in the state which works closely with companies like ours to make sure there’s a product fit for what their needs are. We just closed our Series A financing with Cardinal Partners and Milestone Venture Partners. It was a $5.7 million around in October of this year.

Many companies are suddenly offering secure messaging for clinicians. Who are your biggest competitors and how is your product different?

We’re running into the guys you would expect, the TigerTexts of the world on the lightweight messaging side of things and on the nurse-first device side of things, Voalte and the legacy guys like Vocera and Avaya.

When I started Cureatr, I was interested in messaging as a part of some of these workflow problems. If you look at what a workflow consists of, you’ve got the communication piece. That’s a huge part of it, probably about a third of your time. You’ve got the documentation piece and CPOE documentation — that’s probably another third of your time.The last third is management, getting access to actual data. Obviously, unfortunately, you probably spend less time on implementation than you do in a lot of other areas of the care process. When I started Cureatr, I was interested in how do we build a tool for the whole part of this. 

Let’s start with messaging. There probably are a lot of messaging companies, but the penetration of these types of modern communication and workflow tools is incredibly low in this market. There’s no clear leader. It’s still a very green market.

We’re trying to differentiate ourselves by coming at this from the angle of, let’s find a couple of specific use cases or workflows that are highly repeated in your organization or for your patient population. Let’s deploy this combination of communication plus some task management plus some basic integration with other systems. Routing and care team mapping is a big part of that. That’s our differentiator. That’s the way we’re looking at helping our customers. 

The other big thing is more and more of our customers are interested in inter-organizational use cases. They need to think about what goes on beyond the four walls of the hospital, because from their perspective, the care episode no longer ends with discharge. We’ve gotten some early customers, like the DaVitas of the world, who are thinking a little bit ahead of the curve on cross-continuum care management and want to apply our tools to those areas. We are focusing on customers who are interested in that today because we think that’s going to be a growing need in the future where we can build some expertise.

Is the model that an enterprise would pay for the system, but there’s an individual app that people can download for free?

We are very hands on around implementation, very hands on around working closely with the enterprise and finding these specific use cases. But we get contacted all the time by folks like my father, a small private practice who want to use it. We obviously see value in letting them, but above value to them, the value to the bigger hospital customers we work with making the onboarding experience for the smaller organizations very easy, very lightweight. But our customers are mostly large enterprise guys like Sinai.

It’s same product that could be downloaded for free, just with more enterprise-type services bundled?

It’s modular. We have our core messaging piece. Then we have something we call structured messaging, which is a feature that the enterprise needs to create a step-by-step workflow for a specific use case. There’s a core, very lightweight messaging piece that’s very easy to download and get up and running within a couple of seconds, but if you want to get those other modules, if you want to get single sign-on, if you want to get documentation or tie in to your ADT or EMR or lab system, that’s what our enterprise customers will get.

What kind of numbers do you have using just the standalone free version versus those that are using it via enterprise?

It’s almost all enterprise customers. We wanted to get the product right. We wanted to build the infrastructure of a company before we started doing a lot of marketing. We haven’t done a lot of this “are your docs texting?” replacement-type marketing. We’ve mostly focused on talking to thought leaders and rolling it out to larger enterprises. I would say 90 percent of our customers are through an enterprise customer, any organization that’s purchased 500-plus licenses.

How many organizations do you have as customers?

We have about 10 large enterprise customers and then some large primary care groups, some larger multi-site practice groups. But in terms of large paying enterprise customers, we have about 10.

You offer read receipts and the ability to attached a photo securely. Is that unusual?

That stuff’s great and useful, but it’s what our customers expect. I would think anybody who is a serious company in the states does have that type of functionality.

The things that are really different between us and the product are, first of all, we built this from the ground up in a hospital and a health system. Our products have been optimized for clinical users. We have status and presence, which is a big thing in a clinical space.

The way I look at the world, and I think the way most providers do, is that there are only probably four or five pieces of information at any given time that are actionable and valuable to the care team. We are trying to create a shared view of the patient around this in real time as much as possible for the care team. It’s tying into those other systems and understanding how to smartly separate the signal from the noise around very actionable information is what we’re trying to optimize the product. But also maintaining a very good, solid, secure messaging user experience. 

That’s why things like read receipts, directory integration, scheduling integration, photo sharing, document sharing …  we have the wound care company that’s piloting our product, and it’s revolutionary for them because all of a sudden they can, instead of having to fax the face sheet from the patient when they’re discharged where they’re going to follow up with wound care or with vascular, they can send the PDF or even send a photo of the face sheet and have a very real-time, two-way back and forth to make sure that that patient is getting the right follow-up care. We’re starting from almost ground zero in healthcare, so things like that can have a very large, positive impact on workflow, on efficiency, on provider and patient experience, and satisfaction and experience.

You have data from Mount Sinai that was self-reported from a survey. Do you have any more specific analyses of either outcomes or anything more than just what the users report?

We’ve got a study that just came out that I can share with anybody who’s interested in following up privately, but we don’t have permission yet from this large academic health center to share that data because it’s literally fresh off their presenting at a conference. But we have some very exciting data around time saved, efficiency linked to earlier time of discharge, i.e. length of stay reduction and HCAP impact. We do not have randomized, evidence-based clinical trial data at this point. Very few companies in healthcare IT do.

We have two customers we’re partnering with to run some 12-month longitudinal studies looking at outcomes on specific clinical hospital performance metrics, both on the inpatient and outpatient side.

How did working with an accelerator help the company?

I am very grateful to the NYeC because we got unique exposure to the best hospitals in New York. Even more than that, everybody who was doing this program was very invested in trying to create a new ecosystem around where … Hospitals are just not used to working with startups. As a startup, time is your most valuable resource. Hospitals don’t move quickly. The thing that we got from the accelerator — more than the money and more than the PR — was literally a very accelerated access and  feedback to the C-suite and users.

The big challenge for anybody in healthcare IT today is, how do you think through the ROI story and how to measure the ROI for your product? There are a lot of companies right now in this healthcare IT space sprouting up. The death of many them will be not thinking about that piece, not having access to the right folks in the big health systems and the healthcare world in general to think through that piece.

That’s what we got out of this accelerator much more quickly than we would have from one customer or from going and talking to your friend’s dad who’s some executive at a hospital. We had invested folks giving us that kind of feedback through this program. I would recommend that program for anybody and I would do it again.

Where do you see the company going in the next few years?

There’s real value in secure texting or replacement pager stuff, but we’ve come up with what I think is the most effective, repeatable process for deploying secure messaging leveraging mining of the data for optimizing secure messaging in these larger enterprise customers. The next 12 months is really about what’s coming after messaging. Optimizing the care team mapping side of things, i.e. routing of messages to the right person at the right time, or routing information at the right time beyond messaging, task management.

These are the workflow tools. That’s what customers are telling us that they want. When you look at the most successful implementations of technology in healthcare IT and most successful companies, they’re very much focused on a couple of specific use cases or clinical use cases or workflows where they’re doing that better than anybody else. Our goal is, let’s find those use cases, let’s deploy messaging and these other tools around it, then let’s actually measure an ROI and let’s actually make it very clear for our customers how to achieve that ROI in future implementations. 

Building the product and the implementation and services side of the business to support that is the most critical thing right now, because from a sales side, there’s great demand for this right now. It’s almost a function of keeping up with that demand and making sure that our product is truly adding value to our customers.

Curbside Consult with Dr. Jayne 1/6/14

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I wrote in Monday’s Curbside Consult about a reader’s comments to my recent EPtalk piece. His comments were similar to those shared by many physicians I meet, so I’m responding to some of them. As background, my organization is seven years into its ambulatory EHR journey (many more on the hospital side) so we’re definitely not new to this game.

There is no infrastructure for EHR outside of big groups. CMS subsidized us to buy Ferraris and then we have to drive them in a corn field. A bike would be much faster in a corn field. Meaningful Use should have required EHR vendors to provide infrastructure to connect all the computers involved in a patient’s care. Our EHR doesn’t talk to our hospital and the vendor wants $100,000 to write an interface for a single clinic. Who can afford this?

It’s great that MU requires interoperability, but the infrastructure is still a challenge for many, especially independent groups. We’ve been struggling with this for years as we’ve watched RHIOs go bankrupt, competing HIEs squabble within the same state, and more. My own state was one of the last to have an immunization registry.

Other competing factions make interoperability more difficult even if the infrastructure is in place. Our health system gave away access to our HIE and we still struggled with physicians reluctant to participate due to privacy concerns. Patients are eager to participate, but don’t get me started on the complexity of the whole patient identity problem and data integrity. I’m pretty sure it has taken years off my life.

Some of our rural clinics are still regularly taken down by well-meaning guys with backhoes. A cut T1 line doesn’t help patient care at all, and that’s assuming you can even get a line there in the first place. One site took nearly six months to get an appropriate line installed.

Trying to get all the vendors to work together is an adventure. More money earmarked specifically for physician connectivity would be helpful. I think there were a lot of physicians out there that thought $44,000 in MU money would actually pay for their EHRs. The true cost of doing an EHR (and doing it right) is far more than that, and considering maintenance, the expanding burden of Meaningful Use requirements, and other costs, I don’t see a long-term ROI over paper. Depending on how much you leverage the system you purchased and how much potential it has, you might be neutral at best.

I like your “bike in a corn field” analogy, especially being a farm girl. I may have a good story involving a broken leg and trying to take a motorbike across a corn field, but it will cost you a martini to hear it. Providers were lured into purchasing EHRs with more bells and whistles than they can understand, let alone use.

The late adopters are at a huge disadvantage because vendors now have thousands of customers to get ready for MU Stage 2. There’s not enough time to do phased implementations like we used to do. Everyone is rushing towards October 1.

As for that charge for an interface (knowing the vendors in question, although keeping their names out of it since I can’t confirm it) that’s exorbitant. Look outside the box for other strategies, like exchanging CCDs or doing a daily extract. You could hire contractors to double-key the information in both systems for several years and still be revenue neutral.

Our EHR is ranked near the top, so I wonder what kind of disasters the rest of the EHRs are? When I read about people who use them and say how good they are, I wonder what is behind their enthusiasm? Is it bribes or just pure ignorance and/or ego of the ones who refuse to see the truth?

There are plenty of disasters out there from all vendors, and plenty of good installations as well. I’m a user of five vendors at the moment (on staff at three different hospitals plus one system I use in the office and one ER I work at makes me use two different systems.) Two of the hospitals use the same system and one works well, yet the other drives me batty. Those kind of situations make it hard for me to understand tarring and feathering any vendor based on anecdotal reports.

As far as enthusiasm, I can understand where a lot of groups are coming from. When you have a good system and it’s running well, it can make a tremendous on patient care, especially where population health is concerned. On the other hand, I’ve been a user of one of those “disasters,” and when it happens to you, it’s not pretty. My previous EHR vaporized parts of nearly six months’ of chart notes because it wasn’t set up properly and there were some database issues that kept the problem from being detected.

Before someone asks how many people might have been harmed from faulty charts, I’ll say it’s far less than the number who might have been harmed had I lost all my paper charts in a fire, flood, or tornado. I’m grateful for EHR because unless it’s a cataclysm that takes out our two data centers 35 miles apart plus the offsite backup vault in South Dakota, we’re OK.

I lived through a year of hell after that while we went through the entire purchase process again. I’m convinced that clinical conversion and reconstructing parts of all those charts took years off my life. I use those experiences to motivate me as I help other users and provide feedback to vendors in the hopes that no client will ever have to go through something like that again. I’m pretty much my vendor’s QA nightmare. If it’s broken I’ll find it. They actually include some of my real-life patient scenarios in their testing process now. It’s much easier than having me yell at them if I find defects later.

As for the results, however, we’re not delusional. We’ve had great clinical outcomes (data proven) but we’ve worked really hard to get there and it hasn’t been easy. For us the key has been emphasizing people and process much more than the technology, which needs to be seen as the tool that it is. Too many groups view the technology as the be-all, end-all and that can be detrimental to their success. Vendors don’t help this perception and need to be spending more time helping customers work through policy / procedure and workflow issues before they implement rather than dealing with train wrecks after.

As to your last comment. there certainly are some egos out there. Our ambulatory vendor once brought a client with a failed implementation to visit our organization. We went through our standard site visit presentation, basically gave away thousands of dollars in free consulting on how to be a success, gave them our implementation plan, etc. and showed them how we did it.

Their CMIO was one of the most arrogant people I’ve ever met. His response was, “I’m sure that worked for you, but we have our own plan.” I wanted to jump across the table and ask him why he was even there. Why did his team of ten fly hundreds of miles and take up three days of my team’s time? If he was so successful with his own plan, why was he starting his implementation over? I had over 150 live docs at full productivity at the time. He had 10 docs who tried to go live and who were only seeing 60 percent of their desired volume and his vendor was paying other customers to try to help his team save their implementation.

I’ve got one more set of questions I’ll answer next time. Tune in to hear my thoughts on Meaningful Use vs. meaningful patient care. Wouldn’t you like to see that in a steel cage match? We’ll also talk about conspiracy theories and whether real live physicians have anything to do with EHR design.

Email Dr. Jayne.

Morning Headlines 1/6/14

Biotech Firm: We Will 3D Print A Human Liver In 2014

Organovo, a San Diego-based biotech company, says it will produce functional 3D printed human livers by the end of 2014. The organs will be used for pharmaceutical testing, not implanting.

Online Doctor’s Notes a Hit with Patients, Study Shows

A study published in the New England Journal of Medicine follows three hospitals as they go live with patient portals that include unedited physician notes. The year-long study found that 80 percent of participating patients had read their physician’s notes, and that "large majorities reported having better recall and understanding of their care plans and feeling more in control of their health care. Moreover, two thirds of patients who were taking medications reported improved adherence."

Computer failure adds to ambulance patients’ pain

In Australia, an ambulance service is seeking a government bailout after its electronic billing system malfunctioned and left it with $7.5 million in unbilled services.

Monday Morning Update 1/6/14

From The PACS Designer: “Re: Google Apps starter. With the continued growth of mobile devices, Google has exploited this trend with a mobile app landing platform for the iPad, iPhone, Android Tablet, and Android Phone. Now and in the future it will be easier to get apps to play on no matter which mobile device you may have in your possession as Google expands this landing platform with even more mobile solutions.” Google is everywhere these days, but I’m finding their apps less capable and more annoying. They tie everything into your Gmail account even when you don’t want them to, and the initially intriguing minimalist design of all Gmail-related apps is now just as annoying and clunky as a 1980s Invision screen (example: Gmail doesn’t support using the Delete key to delete an email, instead going the proprietary/obscure route by using the E key instead.)

Poll respondents find Medicare’s fraud-sniffing efforts to be unimpressive. New poll to your right: what will be the biggest challenge for hospital CIOs in 2014? The length of the list suggests the challenges inherent in that job.

Upcoming Webinars (Times are Eastern) 

January 7 (Tuesday), 1:00 p.m. Clinical Analytics for Population Health Management. Sponsored by HIStalk. Presenter: Cora Sharma, principal analyst, Chilmark Research. As providers move from fee-for-service to value-based payment models, they must not only comply with ever-proliferating quality metrics, but also transition from a cost-plus business model to one of cost containment. 

January 9 (Thursday), 2:00 p.m. Beyond the Summits. Sponsored by HIStalk. Presenters: Ed Marx, SVP/CIO, Texas Health Resources, and Elizabeth Ransom, MD, FACS, EVP/clinical leader North Zone, Texas Health Resources. Everyday healthcare executives share leadership and teamwork principles they learned from climbing some of the world’s highest peaks over the last four years. 

January 16 (Thursday), 1:00 p.m. Advanced Efforts to Identify and Eliminate Waste from Healthcare. Sponsored by Health Catalyst. Presenter: David Burton, MD, executive chairman, Health Catalyst. Based on a breakthrough analyses using several large healthcare data sets as representative samples, Dr. Burton and team will present insights designed to help executives struggling to identify, quantify, and extract waste from their systems.

HIStalk-sponsored webinars are non-commercial presentations of broad interest. I appreciate our pro bono presenters, who get a sizeable audience and recognition without the frustrations involved with presenting at a conference. Contact me if you’d like to present.

Welcome to new HIStalk Gold Sponsor The Loop Company. The Williston-VT-based research advisory firm helps companies launch new offerings, enter new markets, win more business, and create customer loyalty. They design programs to help companies understand how the market perceives them and can help improve sales, marketing, product development, and operations. It’s a new venture from old HIStalk friend and industry long-timer Gino Johnson, who created the excellent CapSite healthcare IT research and advisory firm that HIMSS acquired and rolled into HIMSS Analytics in October 2012. Thanks to The Loop Company for supporting HIStalk.

HISsies nominations continue, so please submit yours now. It will only take a couple of minutes and you can skip categories you aren’t interested in.  I’m enjoying reading the early nominations for worst vendor, Lifetime Achievement Award, and the always-popular “industry figure with whom you’d most like to have a few beers.” Long-time readers may remember years ago when Jonathan Bush won that category (as he often does) and agreed to let me auction off an evening with him as a charity fundraiser.

Listening: Blue Coupe, made up of hard-rocking 1970s legends Dennis Dunaway (the shamefully underappreciated bass player and principle songwriter for Alice Cooper when it was a real band) and the Bouchard brothers Joe and Albert (key members of Blue Oyster Cult), thus the band’s name as a nod to the respective histories of its members. The band started out playing Alice Cooper covers, but earned Grammy attention for new material in 2011/2012.

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

In Australia, the ambulance service of New South Wales requires a government bailout after its aborted EMR and billing system project left it with $7.5 million in invoices it couldn’t send out.

North Carolina, which just passed a law requiring hospitals treating Medicaid patients to participate in the state HIE, sends out nearly 50,000 new Medicaid cards to the wrong people.

Intelligent InSites names investor and executive board chair Doug Burgum as interim president and CEO, replacing Margaret Laub, who has left the company. Burgum founded accounting software vendor Great Plains and sold to Microsoft in 2000 for $1.1 billion.

Weird News Andy likes the story that he titles “Print a Liver – 2014,” to which he adds a “Silence of the Lambs” pop reference in wondering if they can also print a nice Chianti (although I seem to remember that the book instead said “big Amarone” before Hollywood dumbed down it down for less oenophilic  moviegoers.) A California biotech firm says it will successfully use 3D printing to create a human liver (or more precisely, a working model of a human liver suitable for drug company research) by the end of this year.

“Taking from Peter to Pay Paul” is WNA’s assessment of a survey of doctors in England, in which a third of them want to charge each ED patient $16 to to discourage usage for minor complaints. The patient counterpoint would be that appointments are hard to get and practices are closed nights and weekends. We have similar challenges here, obviously: the ED is always open and free if you can’t or won’t pay, while urgent care isn’t always open and they expect money upfront.

Strange: a medical student examining a standardized patient (an actor playing the role of a patient) pretending to have an abdominal aortic aneurysm detects the actual condition, alerting the instructing physician to urge the man to see a cardiologist. He does and is found to require stent replacement surgery. According to the patient’s wife, “Jim’s life was saved by a UVA medical student, no doubt about it.”

Vince covers the $14.5 billion acquisition of HBOC by McKesson in this week’s HIS-tory. I think he’s planning to wrap up his HIS-tory series after the next couple of installments. I will miss them since I have enjoyed every one.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: Notice of Proposed Rulemaking: Everybody Must Watch Jay Leno at 11:35 Eastern

I wrote weekly editorials for a boutique industry newsletter for several years, anxious for both audience and income. I learned a lot about coming up with ideas for the weekly grind, trying to be simultaneously opinionated and entertaining in a few hundred words, and not sleeping much because I was working all the time. They’re fun to read as a look back at what was important then (and often still important now).

I wrote this piece in January 2010.

Notice of Proposed Rulemaking: Everybody Must Watch Jay Leno at 11:35 Eastern
By Mr. HIStalk

I’m excited about the government’s encouragement (or mandate, depending on your perspective) that doctors use electronic medical records. Mandatory progress must go on despite the gripes of a few malcontents (i.e., the majority of doctors, patients, and taxpayers).

It is a travesty that more healthcare providers don’t use computers. Software can make healthcare as transparent, efficient, and consumer-driven as other organizations that have spent billions of taxpayer dollars on technology (such as the IRS, the military, and Medicare). The federal government must intervene when minimally educated and technologically illiterate doctors refuse to adopt EMRs voluntarily in their private businesses.

(It worked for TVs. The government decided that Americans should enjoy the benefit of watching cultural programming such as “Judge Judy” and “America’s Next Top Model, in visually stunning high-definition glory. The FCC ordered broadcasters to switch exclusively to HDTV, thus stimulating the economy by selling tons of imported flat panel TVs, enriching lenders as financially strapped citizens let the balance ride on their high-interest credit cards, and increasing landfill employment to bulldoze now-useless tube models.)

In fact, I believe that this “cure all ills” administration needs to take a step further. It’s time to support the most visible employee of the biggest EMR vendor company – Jay Leno.

Jay’s audience, like that of EMRs, has been pathetic in number and more indifferent than loyal. Hype and gimmicks weren’t enough to entice viewers (even the large number of unemployed ones with nothing better to do) to sit through an hour of his cheaply produced and repetitive nightly show.

Jay is a national treasure, too important to be left to the whims of fickle TV viewers. It is therefore essential to mandate, for the economic good and the image of America worldwide, that every one of those new LCD TVs must be tuned to NBC’s “Tonight Show” every night once Jay comes back.

(NBC’s owner GE bought back Jay’s 11:35 slot with $40 million of its own cash. Admirably, it did not ask for a federal Conan bailout.)

To encourage the development of cultural refinement in appreciating Jay’s hilarity and keen interviewing skills, it will be necessary to equip cable and satellite receivers with sensors that will detect households that are not compliant at least four of five consecutive weeknights. Those tuning in will receive a rebate on their bills that non-watchers will forego. After a few years, those non-adapters will have a “Jay support surcharge” included on their bills.

Each viewer must also be a Meaningful Viewer, jotting down Jay’s bon mots for repeating later, paying attention to the commercials, and laughing with significant amplitude at Jay’s latest carefully constructed John Edwards quip (rim shot!) This, too will be monitored electronically.

Jay is an experienced late-nighter, so it would not be prudent to spent taxpayer money on untested hosts such as Conan O’Brien. Therefore, Jay alone has been certified for the 11:35 slot. All other programs, such as the Magic Jack infomercial or “Cake Boss” marathons, are not permitted even when Jay has on dull guests such as Paris Hilton or Larry the Cable Guy.

Lastly, it is imperative that Jay receive feedback about which of his jokes and sketches are working. Technology will be added to the set-top box to solicit constant feedback about the quality of Jay’s humor, which will be de-identified and aggregated quarterly for analysis by the same crack NBC executives who couldn’t make his show work before. With this information, Jay can develop monologue templates that the government will mandate for use by up-and-coming comics, thereby protecting viewers from edgy humor from fresh newcomers.

All of this government spending will actually prove profitable to taxpayers, according to bailout expert Timothy Geithner. While Jay’s show will probably never make money, it will provide an effective advertising platform for the upcoming Chevrolet Volt. What’s good for GM is good for the country, given that the country now owns 61 percent of GM.

Does Jay think this bold, essential plan will work? You bet! His new sidekick Triumph the Insult Comic Dog (merged from a previously retired product line) says you can “bank” on it (rim shot!)

Morning Headlines 1/3/14

President Obama Announces More Key Administration Posts

Leon Rodriguez, director of the Office for Civil Rights of HHS, will be nominated to take over as the Department of Homeland Security’s director of the United States Citizenship and Immigration Services.

Other new NC laws taking effect with the new year

In North Carolina, a law that took effect on January 1 requires that all hospitals connect with the North Carolina HIE and submit data on any services paid for by Medicaid.

Pentagon Kicks Off Procurement To Maintain Current Health Record Until 2018

The DoD initiates a procurement process that will allow it to stick with its existing EHR until 2018.

Cerner ‘seals the deal’ on $4.3 billion office plan at Bannister site

Cerner completes its purchase of a 237-acre property outside Kansas City where it will build a $4.3 billion campus over the next 10 years, eventually providing office space for 15,000 employees.

Digital Health Funding: A Year In Review

Health IT startups raised $1.9 billion in VC funding during 2013, a record breaking year and 39 percent increase over last year. Most money went to EHR vendors, big data startups, population health tools, wearable biosensors, and patient engagement platforms.

News 1/3/14

Top News

President Obama announces that he will nominate Leon Rodriguez, director of the Office for Civil Rights of HHS that enforces HIPAA, for Director of Citizenship and Immigration Services in the Department of Homeland Security.

Reader Comments

Photo: Brian Snyder/Reuters

From DZA MD: “Re: Baystate Medical Center. Cerner PowerChart crippled with record inpatient census and Nor’easter in full effect. Unable to process timely discharges before brunt of storm arrives.” Unverified. As I write this Thursday evening, Massachusetts is about to get nailed by a winter storm that will bring up to 30 inches of snow in places with wind chill as low as 20 degrees below zero and even colder Friday night.

From Dirk Benedict: “Re NextGen lawsuit. Mountainview Medical Center in Montana sues NextGen, saying it didn’t install its $441,000 EHR system as promised.” The six-bed hospital contends that NextGen was to install a system “which would permit MVMC to demonstrate ‘meaningful use’ of such electronic health records through all stages of applicable federal regulations” and was to complete implementation by October 1, 2013. According to NextGen’s website, NextGen Inpatient Clinicals EHR 2.6 is 2014 Edition certified as a modular EHR, so it’s difficult to determine what the exact issue(s) might be. NextGen provided us with this statement:

We cannot comment on the pending litigation, other than to say that we firmly believe the allegations made by Mountainview Medical Center are without merit and we will defend against them vigorously. We confidently stand behind the quality and performance of our products and offerings.

From Intractable Vermonting: “Re: Vermont health insurance exchange. The cost overruns have been tremendous and the politicians responsible pass it off as ‘changing project scope costs money.’ 99 percent of all IT leaders in the US would be fired if they managed a project in this fashion. Also, security is the last thing that is built into the technology before it goes live and I am sure there were shortcuts taken with all these exchanges. The hackers know that most sites require Social Security number to register.” The Vermont Health Connect insurance exchange website is the most expensive IT project ever undertaken in the state, running up a tab of $172 million, of which the federal government contributed $48.7 million. One big contractor was the ever-present CGI, which managed to turn its $42 million contract into $84 million worth of billables while missing key deadlines that kept the site from being ready on October 1. CGI was smart: the state says the delays cost $26 million, but CGI’s contract says it can be penalized a maximum of $5 million.

HIStalk Announcements and Requests

It’s time for the HISsies nominations. What’s your choice for “Stupidest Vendor Action Taken,” “Most Overused Buzzword,” “Industry Figure With Whom You’d Most Like to Have a Few Beers,” and “HIStalk Healthcare IT Industry Figure of the Year?” Enter your nominations, from which the most-nominated choices will go on the final ballot in a week or so. That means no complaining if your choice isn’t on the ballot and you didn’t nominate them.

HIStalkapalooza registration will open up the week of January 13. Read HIStalk religiously for the link to the signup notice in the next couple of weeks. We fill up really fast every year. Above is a photographic hint of the venue for those wondering. The primary sponsor has a couple of co-sponsors whose support will allow the event to be even bigger and better. If your company is interested in getting exposure as a HIStalkapalooza co-sponsor, let me know and I’ll connect you since they are willing to take on two more.

Welcome to new HIStalk Platinum Sponsor healthfinch (they tell me it’s supposed to be all lower case). The company offers RefillWizard, which improves doctor efficiency as a “Team-Based Decision Support System” that improves patient safety while reducing refill turnaround time by up to 95 percent. They begin by preparing a customized savings document like the one above and making recommendations to optimize the refill process. They have found that 62 percent of refills can be selectively and safely delegated to clinical staff, reducing the staff time to 34 seconds (some PCPs spend 1-2 hours per day just managing refills.) RefillWizard, which just won the Allscripts Open App Challenge, works either with paper protocols or integrated with the EMR. HIStalk readers probably know DrLyle (Lyle Berkowitz, MD), the company’s chairman and chief medical officer. Thanks to healthfinch for supporting HIStalk.

I found this healthfinch RefillWizard overview on Vimeo.

Upcoming Webinars (Times are Eastern) 

January 7 (Tuesday), 1:00 p.m. Clinical Analytics for Population Health Management. Sponsored by HIStalk. Presenter: Core Sharma, principal analyst, Chilmark Research. As providers move from fee-for-service to value-based payment models, they must not only comply with ever-proliferating quality metrics, but also transition from a cost-plus business model to one of cost containment. 

January 9 (Thursday), 2:00 p.m. Beyond the Summits. Sponsored by HIStalk. Presenters: Ed Marx, SVP/CIO, Texas Health Resources, and Elizabeth Ransom, MD, FACS, EVP/clinical leader North Zone, Texas Health Resources. Everyday healthcare executives share leadership and teamwork principles they learned from climbing some of the world’s highest peaks over the last four years. 

January 16 (Thursday), 1:00 p.m. Advanced Efforts to Identify and Eliminate Waste from Healthcare. Sponsored by Health Catalyst. Presenter: David Burton, MD, executive chairman, Health Catalyst. Based on a breakthrough analyses using several large healthcare data sets as representative samples, Dr. Burton and team will present insights designed to help executives struggling to identify, quantify and extract waste from their systems

Acquisitions, Funding, Business, and Stock

Healthcare Data Solutions acquires StratCenter, a provider of healthcare provider data.

Stryker Corporation will acquire surgical sponge counting technology vendor Patient Safety Technologies, Inc. for $2.20 per share. The company’s market cap is $85 million.

Sales

In the UK, King’s Mill Hospital signs a five-year, $5.9 million EHR contract with Specialist Computer Centres and McKesson.

Medical billing company Medorizon Partners selects InstaMed’s patient payment plan technology.

The Defense Logistics Agency awards TeraRecon a maximum $30 million fixed-price contract for the procurement of radiology systems and services.

Central Georgia Health System will implement Infor’s healthcare business automation applications.

People

CareTech Solutions hires Daniel Lincoln (Palace Sports & Entertainment) as corporate controller.

CMS announces the retirement of COO Michelle Snyder, who supervised development of HealthCare.gov. The agency says Snyder had originally planned to retire in 2012 but stayed on at the request of CMS chief Marilyn Tavenner.

CareView Communications, which offers patient flow and safety solutions, promotes Steven G. Johnson from president to CEO, taking over for Samuel A. Greco, who is retiring for health reasons. Careview also names Sandra K. McRee (McRree Consulting) COO and appoints Jason T. Thompson to the board, replacing his father, Tommy G. Thompson.    

Direct Consulting Associates promotes Frank Myeroff to president.

Announcements and Implementations

Baptist Memorial Health Care (TN) goes live on Epic this week at four minor medical centers and at its Baptist Medical Group clinics. Four Memphis-area hospitals are scheduled for a March 11 go-live.

Government and Politics

A new North Carolina law requires hospitals with EHRs to connect to the state’s HIE and submit data on services paid for with Medicaid funds.

The Department of Defense issues an RFP to keep AHLTA and CHCS running through the end of 2018 after plans for a joint DoD-VA EMR were scrapped last year when costs were estimated at $28 billion. The value of the new contract is estimated at $250 million to $1 billion. DoD is looking at a commercial replacement for contractor-developed AHLTA, whose estimated cost to taxpayers was up to $5 billion.

Innovation and Research

A study of 295 smartphone apps that claim to prevent, detect, or manage cancer finds no published studies that prove their usefulness, effectiveness, or safety.

Technology

The FDA extends the Kinsa Smart Thermometer the first-ever 510(k) clearance for a smartphone-connected thermometer.

The US Patent and Trademark Office issues CommVault Systems a patent for efficient data management improvements, such as docking limited-feature data management modules to a full-featured data management system.

Other

Riverside Health System (VA) announces that a now-terminated LPN inappropriately accessed the records of 919 patients over a four-year period.

Cerner completes the purchase of the 237-acre tract for its planned $4.3 billion office development in south Kansas City.

Sponsor Updates

• Sunquest releases new versions of Sunquest Laboratory and Sunquest Molecular.
• The Boston Globe profiles Sumit Nagpa, CEO of Alere Accountable Care Solutions.
• Jason Fortin, senior advisor for Impact Advisors, discusses the impact of Meaningful Use in 2013.
• EDCO Health Information Solutions posts a Point of Care Scanning Process video.

EPtalk by Dr. Jayne

I received a lot of feedback about this week’s Curbside Consult. I’ll be posting more responses to the original reader email in the next Curbside Consult, but wanted to share some quick responses in the interim.

One reader asked for more detail about how we’ve tied the physician bonuses to EHR use. I can’t claim credit for the approach since we copied it from another organization, but it has worked well. It only applies to employed physicians using the group’s EHR platform. We have a couple of practices that we have acquired that are on other systems and are not yet converted, so they are exempt for now.

Physician bonus amounts are determined by three factors: patient satisfaction, clinical quality scorecard results, and productivity. A sliding scale is used for each element. For example you might receive 100 percent of your patient satisfaction and productivity bonuses but only 80 percent of your quality bonus.

The EHR plays into that in two ways. Since we’ve been fully adopted on EHR for many years, all of our quality reporting is now derived from EHR data (no more manual chart reviews). If providers are not documenting in the EHR, their scores will be low. We initially did a hybrid approach with both manual chart review and EHR reporting while physicians were adopting, but that has been phased out. Our staffing for compliance reviews has dropped significantly. They used to take three full work days per physician and now they take two to three hours per physician.

The major way that EHR applies to the bonus, however, is simple. All visits must be documented in the EHR and must meet our minimum data standards. These aren’t a lot different than the paper chart. The visit has to be complete within 24 hours of the patient visit and has to include certain critical data elements that essentially align with CMS coding requirements. For example, documentation has to have a chief complaint, history of present illness, review of systems, review of pertinent patient history, physical exam, and an assessment and plan.

We expected this to be present in the paper world and now it’s actually easier since the data is shared across the multispecialty group rather than living in separate paper charts by location. Providers can review histories with one click rather than having to dig for histories that may have been mentioned in various progress notes. Our physicians were not particularly good at keeping the paper problem list and past / family / social history face sheets up to date on paper.

For some practices that were challenging implementations, we actually had to physically visit the practice and make sure they didn’t have shadow charts. One site didn’t have charts, but had “jackets” for each patient. We didn’t just fail them outright but gave them three months to remediate, then audited them again. Over the last few years that the EHR requirements have been attached to the bonus structure, we’ve been fair about doing pre-audits so people know where they stand, then allowing enough time for them to remediate before their final audit.

The reader also asked about the “standards” that I mentioned our physicians have to meet to stay employed. Some are pretty simple – no OSHA or CLIA violations, favorable scores on coding and compliance audits, and getting along with their partners and staff. Some are more rigorous. We have high standards for clinical quality, and physicians are graded on blood pressure control, appropriate use of drugs for coronary artery disease, cholesterol control, influenza vaccination, cancer screening (colorectal, breast, prostate), diabetes management, and a couple of others. Physicians who can’t keep their scores in the desired range are remediated (as are their office staff – many of the metrics can be improved by leveraging staff and using standing orders including vaccination and screenings).

Finally, physicians are expected to be productive – specifically, to be above the 75th percentile based on MGMA data. That’s a lot to ask, but the group makes it clear when physicians join and it’s actually spelled out in the contract. Our compensation parallels this – our physicians consistently earn salaries in the top 20 percent based on MGMA data. If they choose to work less than full time, the productivity expectations are scaled accordingly. Our retention rate has been very good. Most of the providers who leave within five years of joining have a family reason. For example, they may only work with us for a year or two while they wait for their spouse to receive a residency or fellowship appointment that requires relocation.

In addition to their bonuses, our providers also received a hefty chunk of their Meaningful Use payments as a cash bonus. This differs from most organizations I’ve talked to that tend to keep the MU payments at the corporate level. I think the way we shared them is especially surprising given the fact that our providers don’t pay anything for EHR software, training, or maintenance. The only EHR-related charge that the practices incur is for hardware, which averages $8,000 – $10,000 per provider every three to four years.

Another reader asked how we handle the EHR records with a physician who chooses to leave the organization (or is let go) yet wants to keep his or her patients and office location. It’s actually pretty easy. We have a subsidized EHR offering (under the Stark exception) so we already have local private physicians on our EHR database with independent practice data. We simply copy the charts of active patients (those seen by the provider within the last three years) into a new practice in the EHR. Only clinical data is copied, no financial data and no accounts receivable.

If the provider is on staff at one of our hospitals, he or she may be eligible for a subsidy. Otherwise they pay fair market rate and we host it similar to a SaaS model offering. Although the providers can still share data with the employed practice, they have to do it through our private HIE rather than sharing a direct chart within the multispecialty practice. Providers are charged $0.50 per chart for the copy. That’s a holdover from our old contract when we had paper charts and they paid that much for the paper charts. I have no idea where that number came from — it’s been in place for at least 15 years.

If they choose not to stay on our platform, we have a third-party consultant perform an extract based on the new vendor’s specifications. It’s the same very skilled consultant we use when we acquire practices and bring the data into our system. Once the drive goes into the Pelican case and enters the physical transport protocol, though, it’s out of our hands.

I’ve seen two physicians treated poorly by their new vendors. One took several months to move the extracted data onto the new EHR. Another simply turned the data into PDFs and parked it in the new EHR’s scanning system, which is pretty sad considering the level of discrete data we can provide. Providers can also buy a system directly from our vendor and we’ll do the extract in that situation as well.

I’ve shared a lot of fairly specific information this week, so I hope it doesn’t come back at me. Stay tuned for the next Curbside Consult. I’ll be sharing my thoughts on infrastructure and interoperability as well as what happens when you try to drive a Ferrari in a corn field.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 1/2/14

White Sulphur Springs hospital says company never installed health records system

Mountainview Medical Center (MT) is suing NextGen Healthcare Information Systems for failing to install a certified EHR by a contractually agreed upon install date of June 1, 2013. When the date passed, the NextGen and Mountainview agreed to a new delivery date of October 1 but, according to the lawsuit, the extra time did not resolve the underlying issues and no system was ever installed.

3 hospitals start new year at Stage 7

Hilo Medical Center (HI), Round Rock Hospital (TX), and White Health System (TX) are all named to the HIMSS stage 7 list. Round Rock and White Health’s ambulatory clinics received stage 7 ambulatory designation as well. Both run Epic across their networks, while Hilo is a Meditech 6 site.

Stocks of KC firms large, small did well in 2013

Cerner is profiled by the Kansas City Star newspaper in a year-end review of the city’s top performing businesses. Cerner shares grew 43 percent in 2013.

Advisory Panel: Alarm Fatigue

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: Is your organization using or considering IT solutions to the challenge of alarm fatigue?

Note that while I was thinking specifically of physiologic alarms at the bedside, I didn’t state that explicitly, so some answers reflect clinical alerts in traditional IT systems. Seven responses indicated a “no” answer with no IT solutions being considered.

We struggle to balance harm prevention and user design.  We are biased toward harm prevention.

We haven’t found a good solution yet. We’re looked at things like alarms that start out low and increase in volume if not addressed, but many/most vendors haven’t embraced that idea yet. We’re looking at routing alarms to phones, but that also has challenges. If you find a good solution, let me know.

We are currently considering a few IT solutions to address this, but no decision has been made to move forward.

We are currently investigating tools to consolidate alarm management but we have not yet developed an RFP or even a vision for the future.

We are currently investigating and likely to pilot a solution to integrate nurse call bells into nursing phones to improve the alarm fatigue of the ears. In the EHR environment, we are continually analyzing the alerts that fire for their utility, appropriateness, and actionability and working to reduce those that are more "noise" than "signal".

Alarm fatigue happens when the technology was not supportive of the end user – it should not exist if each vendor really knew the topic and client being served.

We have explored alarm management systems, but I was left with the realization that the devices can alarm on anything and it’s up to each organization to determine what’s important. I am not aware of any national standards.

We learned early on to be very judicious with alarms and try and keep them to a minimum. As we’ve merged in some additional physician groups, the governance of managing alerts will get increasingly interesting however. I’d be curious what type of IT helps with alarm fatigue (i.e. do they make alarms more sensitive/specific somehow?)

I wish !!! Turning off the drug duplicate alerts would be like manna from heaven as they are invariably uninformative and annoying. For example, renewing a drug always gives a duplicate alert even though the system obviously knows that if you click "Renew" it will automatically stop the current order and start the new one. But the current order is still active when the system compares the new order to the med list. Ergo, duplicate alerts gone wild. One of my other favorite alerts tells me that the patient is taking two non-phenothiazine antipsychotics.  If I was really concerned about duplication, I would want to know if they were taking two antipsychotics period. Whether it’s a non-phenothiazine makes no difference whatsoever.

Primarily focused on refining medication alert rules to reduce unnecessary noise.

I assume you are talking about actual alarms, vents and IVs and tube feeding pumps and such, not EMR alerts. Since noise levels can exceed OSHA standards 80 percent of the time in an ICU, we are keenly interested in the twin problems of noise from alerts and the false positive / false negative rates of the alerts. We do not have a good answer, but I would be happy to buy one that worked.

We’re still trying to reliably deliver secondary alerting. Alarm fatigue getting some notice, but no definite intervention as of yet.

Yes, considering FDB AlertSpace to achieve what should be included in their product in the first place (we’re on Epic/FDB).

Readers Write: Ten Steps for Surviving ARRA and ACA Requirements in 2014

Ten Steps for Surviving ARRA and ACA Requirements in 2014
By Dick Taylor, MD

The 2009 American Recovery and Reinvestment Act (ARRA) changed the healthcare IT landscape for providers by offering money in exchange for the adoption and implementation of electronic medical records. One year later, the Affordable Care Act (ACA) upped the ante with new regulations for privacy, accountable care, and insurance coverage. The combination of the two acts has left most providers and provider organizations struggling to see the forest through the trees as we enter 2014, and the deadlines for both acts draw ever closer.

Controversial from the start, the Affordable Care Act (ACA) was landmark legislation three years ago. It remains front and center after being tested by the Supreme Court, a presidential re-election, and most recently, a government shutdown. Like the ARRA, much of it is yet to be written, requiring tens of thousands of pages of regulations to explain the details. Like the ARRA, it is deeply flawed in places and will require many years of refinement.

The ACA tries to supercharge the required transition from a reactive, episodic care based payment system to one that might reward preventive care, wellness, and patient outcomes. Providers generally see the promise, but they almost universally question the ability of the law to achieve its outcomes, particularly in light of modern medicine’s rapidly changing cost factors.

Healthcare is getting more expensive, and the healthcare IT transition mandated by the ARRA has not yet reached the break-even point for expense control for many (if not most) provider organizations. Demand is down in many segments, particularly for inpatient and elective procedures, and margins are under heavy pressure.

To make matters worse, regulatory oversight is rising and is highly unpredictable. As an example, on September 1, 2012, CMS finalized a rule that gave eligible providers until July 1, 2014 to begin attestation for Meaningful Use. Up to that point, providers generally believed that they had 15 months longer. In contrast, the ICD-10 implementation date was arbitrarily delayed a full year in August 2012 from October 1, 2013 to October 1, 2014. Regulatory changes of this nature are difficult to predict and require both flexibility and preparation from providers.

As we enter 2014, the final sprint toward ARRA and ACA’s deadlines, surviving this environment will require providers to focus on achieving the following goals over the course of the coming year.

1. Reduce expenses, both per-patient and fixed overhead. Admittedly, this is easier said than done.
2. Where practical, grow larger through acquisition or affiliation. This spreads fixed overhead over a larger patient volume and allows much more efficient team-based and whole-patient care. Growth must however, be calculated and managed to capture these savings. Rapidly growing organizations must be especially watchful to avoid operational and cultural traps.
3. Achieve Meaningful Use and avoid ARRA Medicare penalties. Providers who have missed Meaningful Use to date are now looking at reduced awards and penalties (amounting to small but significant percentages of CMS billing) beginning in just over a year.
4. Achieve ICD-10 compliance on time (by 10/1/14) without destroying the organization. While ICD-10 is critical (not billing with ICD-10 is simply not survivable for most providers), this has become the Y2K for healthcare. Caution, particularly around involving physicians and mid-level providers in the minutiae of coding, is strongly advised.
5. Pursue transparency for quality outcomes and cost. Payors, employers, and patients are all watching these very carefully, and organizations who are not forthcoming will become less favored over time.
6. Pursue transformation in long-term healthcare, including population health, chronic disease management, and wellness. Fee-for-service is likely to become far less sustainable as a primary business model over time.
7. Reduce clinical variation, both by pursuing good evidence (where available) and by achieving agreement on leading practices among providers. Much of the variability in clinical care is not associated with improved outcomes and some of it is actively harmful, both in cost and patient outcomes.
8. Recognize and honor the risk you own. Health systems have always owned the risk for charity and self-pay patients. The ones who recognize and accept this are much more likely to provide good care and keep costs under control.
9. Look for whole-patient (“accountable”) care opportunities within your own orbit. While the ACA set out the framework for Accountable Care Organizations, the reality is that these are still embryonic. Organizations that begin at home will be ready for risk-sharing moving forward.
10. Treat your IT expenditures as long-term investments, not expenses. Organizations should expect to spend an increasing percentage of capital dollars building technology assets. Acquire standards-based IT assets that will stand the test of time. Expect, plan, and capture the hard- and soft-dollar returns from them. Organizations that view IT simply as an expense will forego future profits in the pursuit of short-term efficiency.

Dick Taylor is managing director and chief medical officer of MedSys Group of Plano, TX.

Readers Write: 2014 Resolutions

2014 Resolutions
By Vince Ciotti

I’m getting ready to wrap up the HIS-tory series with the final episodes on McKesson, so it’s apropos to take a break and look at the future a bit with these 2014 New Year’s resolutions for today’s leading HIS vendors (in order of their 2012 annual revenue).

McKesson

They’re doing so well with Paragon that they made a resolution to rename their other legacy systems:

• Horizon = Parazon
• Series = Seriegon
• Star = Staragon
• Practice Partner = Practice Partagon
• RelayHealth = ParlayHealth
• Homecare = Homecaragon
• InterQual Online = InterQual Paragonline
• Capacity Planner = Capacity Paranagon
• Performance Analytics = Performagonalytics
• Patient Folder = Patient-Paper-Folder-Gone
• (you get the idea…)

On another front, McKesson announced plans to open Paragon’s first international office in either Aragon or Patagonia, depending on negotiations with their governments about minor changes to the spelling of their names.

Cerner

Will make an epic move of their HQ from Kansas City to Salt Lake City and re-name Millennium HNA as Millennium IHCNA.

Siemens

After cutting 15,000 jobs worldwide over the past two years, Siemens will announce several openings in its HR recruiting department for 2014.

Allscripts

Will join Cerner, McKesson, athenahealth, Greenway, and RelayHealth in the CommonWell Health Alliance to promote EHR interoperability in 2014 in 49 states (excluding Wisconsin).

Epic

Will be recognized as the KLAS act in 2014 by becoming the only HIMSS Stage 8 vendor in Gartner’s Magic Quadrant.

GE

Will announce a program in 2014 whereby any hospital buying Centricity will receive a free refrigerator for every nurse station.

Meditech

Will announce the 2014 version of Release 6.0, which will be called Focus, er, MAT, I mean, 6.0.1, that is 6.1, or maybe 6.0.A…

NextGen

Will announce the 2014 re-packaging of Opus, Sphere, and IntraNexus as “ThisGen.”

CPSI

Will sets the goal of having 500 of their clients attest for MU by the end of 2014, a total of over 1,000 beds.

Harris

A subsidiary of Constellation Software Inc. (from Canada) announces a project for 2014 of using the other Harris (from Melbourne, FL) CareFX interoperability workflow solutions to differentiate their company names.

NTT Data

ヴィンスがこれらの不快な言語の策略を用いるのを止めてください。

HMS

After being re-named Medhost, company executives will announce a joint effort with the AHA to launch a campaign in 2014 that re-defines all US hospitals as ancillary departments of their emergency rooms. 

Healthland

Will resolve to combine its two corporate offices in Minnesota (Glenwood and Minneapolis) once the roads are plowed in August 2014.

Vince Ciotti is a principal with H.I.S. Professionals LLC.

Morning Headlines 12/31/13

10 things to know about Karen DeSalvo

Karen DeSalvo, the new national coordinator for health IT, is profiled in a GovHealthIT article that reviews her past accomplishments and experiences.

Hospital patients can track care with bedside tablet computer

Ohio State University’s Wexner Medical Center is profiled by local media after piloting Epic’s myChart Bedside, a patient portal designed for patients currently admitted to the hospital. The app allows patients to see pictures and profiles of their care team, review their daily plan as well as lab results, and read or watch patient education material.

The December deluge: 1.1 million have enrolled on HealthCare.gov

Healthcare.gov turns in its best month to date, with 975,000 newly enrolled in December, for a total of 1.1 million since launch.

Dermatology practice settles potential HIPAA violations

A dermatology practice in MA pays $150k in fines to HHS over HIPAA violations after an unencrypted thumb drive with the ePHI of 2,200 patients get stolen from an employees car. Officials from HHS say this case marks the first time that a covered entity has been fined for not having implemented the breach notification provisions of the HITECH act.

Curbside Consult with Dr. Jayne 12/30/13

One of my favorite readers shared last week’s EP Talk with one of her struggling physicians. He made a lot of good points and they’re similar to those expressed by many physicians out there, so I thought I’d take a stab at responding to some of them. If you work directly with physicians and end users, they should resonate.

Dr. Jayne makes using the EHR seem like a piece of cake. I would like to see how it is working in her organization.

Actually, lots of people have seen how it works for us. We’re a reference site for several vendors (ambulatory, hospital, hardware) so we have sales prospects come on site to see how our physicians work with the system. We’ve also served as a reference site for existing clients who want a “do over” after failed implementations.

Our model has worked well for us and has been cloned by other clients and even by some who didn’t end up buying from our vendor. Keep in mind, though, that we’re seven years into our EHR journey, but I’d say most of the major kinks were worked out in the first 18 months while we were implementing. Key things that have made us successful compared to our peers:

• Heavy use of piloting for everything we do, whether it was the initial rollout, adding a module, adopting PCMH workflow, etc. You name it, we pilot it first. Would-be pilots have to apply – it’s not a political giveaway and they have to understand what piloting means. It’s not a cakewalk. We use them to break the product and re-engineer the workflows to make it better before mass rollout. Sometimes it’s not pretty. Sometimes they never ask to pilot again, and that’s OK. It’s supposed to be shared learning.
• We heavily incent our physicians to do the desired workflows and gather specific discrete data. We initially hoped for compliance through altruism or desire for quality, but what made the difference was cash. It’s remarkable what tying an annual bonus to EHR use can do to a physician’s attitude. We phased the requirements in over three years for legacy physicians, but new hires are expected to be immediately compliant.
• Strong governance. We’re not afraid to terminate disruptive physicians or to encourage those who can’t meet our standards to leave the organization. Our non-compete is written so that providers can purchase their practices and keep their panels and stay in the same location as long as they don’t go to work for a corporate competitor. This lets those who are not a good fit depart without losing their livelihood. This is rare, but it’s one element of our success.

The quality of EHR progress notes is much worse than it was on paper. You get consults back with 5-6 pages of fluff but lacking the important information. This is only because the truly useful medical data is limited by the data entry speed.

I agree. Some of the notes that I receive are unmitigated garbage. Documentation quality is part of our peer review process as well as our coding review process. We’ve heavily modified the “stock” vendor notes for formatting, font, layout, and overall readability. Chart notes are in the APSO format with Assessment and Plan first rather than traditional SOAP format where the important information is at the bottom. We permit providers to dictate assessment and plan so that it’s readable and data entry speed is not a concern.

We assume wrongly that the doctors can be taught fast typing. The young doctors who learned at a young age will be proficient. And voice recognition sucks at this time, even for physicians without accent.

From experience, I disagree. Many of our more seasoned physicians are proficient with touch typing and with the EHR in general. One of them often reminds me how well he does with his favorite statement: “Young lady, I have been waiting for an electronic medical record since before you were born. I’d go up against any of you young pups with it.” He’s not kidding, either. For those who can’t type, they’re allowed to dictate through voice recognition.

Incidentally our voice recognition also does navigation and complex macros within the EHR templates. It’s truly amazing. I wasn’t specific about this in the EPtalk piece last week. A couple of readers reached out to me about similar systems in their organization and I agree they’re extremely valuable and very helpful for physicians who are challenged by EHR.

The training phase for voice recognition can’t be short cut. Our vendor has worked one-on-one with physicians who are having difficulty. We didn’t struggle so much with accents as we did with what I’ll call “surgical mumblers” who are used to hospital-based transcriptionists who slow down the dictation to listen at molasses speed so they can make out the words. When they complained about the system, I went and shadowed them. Frankly, I couldn’t tell what they were saying, so I wasn’t surprised that the system had problems with it.

Patients aren’t happy that we don’t give them undivided attention during the visit. Some physicians can multitask but others can’t, but the impression on patients is the same.

Again from experience (and also from data), I disagree. We actually surveyed the patients (during pilot phase of rollout) about EHR use by the staff and used it to reshape workflow during the rollout. Before they’re ready to go live, physicians have one-to-one coaching sessions and mock patient visits where they are critiqued on how they use the EHR. I’ve personally taken a Sawzall to office cabinetry when maintenance was taking too long and the exam room layout was a barrier.

If physicians still struggle, we’ll bring them to our residency program practice (which has cameras in the exam rooms) and work with them both in person and with mock patients. It’s not cheap and I don’t know any other organization that does this to the degree that we do, but it has saved a couple of physicians from leaving when they truly wanted to be successful.

Those physicians who did multitask before (such as performing physical exam while talking to the patient) do well on EHR. Those who didn’t multitask before don’t do so well with it. No surprises there.

What we do, though, is help those who don’t multitask by identifying what tasks must absolutely be done in the room (meds, allergies, orders, and patient plan is our policy) and the rest they can do immediately after the patient visit. We don’t force everyone into a cookie cutter workflow. We also include questions about EHR and the visit on our patient satisfaction surveys. Those results factor into physician bonus payments as well.

Looking at patient satisfaction scores before and after EHR, we noted no substantial differences on a per-provider basis. Those who struggled with patient satisfaction continued to do so after EHR, and some worsened. Those who were doing OK continued to do well. A fair number even improved, although most patients indicated patient portal and decreased wait times due to better scheduling as causative reasons rather than bedside manner.

Our product doesn’t work properly in Windows 7, only Windows XP, which is an issue. A good EHR should be multi-platform, should work on Apple computers, Linux, and other operating systems as well.

I absolutely agree with you here. Many vendors have struggled with this issue. I ran across one the other day whose product only runs on Google Chrome. I actually like Chrome, but it’s not exactly the most widely used, and is especially problematic considering that the limitation also applies to their patient portal. Chrome isn’t as popular among the Social Security set who seem wedded to Internet Explorer. I think they’re going to regret that narrow niche and I do wonder what exactly is going on with the programming that it won’t even run correctly on Firefox.

For client-server apps, the popularity of Citrix has helped systems feel more agnostic to end users, although Citrix itself can be a complicating factor in support and maintenance.

There were quite a few more comments, but I’m going to save them for the next EPtalk. What do you think about these issues? Leave a comment or email me.

Email Dr. Jayne.

Advisory Panel: Telehealth Projects

The HIStalk Advisory Panel is a group of hospital CIOs, hospital CMIOs, practicing physicians, and a few vendor executives who have volunteered to provide their thoughts on topical industry issues. I’ll seek their input every month or so on an important news developments and also ask the non-vendor members about their recent experience with vendors. E-mail me to suggest an issue for their consideration.

If you work for a hospital or practice, you are welcome to join the panel. I am grateful to the HIStalk Advisory Panel members for their help in making HIStalk better.

This question this time: Is your organization running or planning telehealth projects?

Assuming the term telehealth includes scope of technologies included in the HRSA definition, we run remote ICU monitoring across our WAN. In addition, we continue to expand the use of mobile clinics that roam around our geography. These clinics include videoconferencing between clinic providers, patients, and remote specialists. We are planning additional work with a national telehealth provider.

No, my organization is still struggling to implement CPOE, keep the beds full, reduce readmissions, etc., etc., and we have not got that far yet.

This shows up in our annual strategic plan every year and it’s there this year too. But I haven’t been able to generate much interest among my medical staff, even the members who travel hundreds of miles for outreach clinics. We run a telemedicine epilepsy clinic and we have the usual teleconferences, but that’s about it. So I’ve retained some consultants to explore options like e-visits, home monitoring, and video visits using webcams with the med staff.

We have a few telehealth services we consume for a couple of specialties. For example, we have a small pediatric hospital and will perform remote echoes with specialists at a leading children’s facility for special patient cases. We do not have any plans to provide any additional telehealth services within our organization or service areas at this time.  

Multiple coordinated efforts related to telehealth as we are approaching from a number of perspectives. More traditional eICU, using remote monitoring of multiple ICUs from a centralized location where critical care physicians and other clinicians are monitoring beds across multiple hospitals. Tele-psych consults in our emergency departments. Developing newer capabilities for virtual ambulatory visits, more acute or urgent care conditions where audio/video is effective in connecting a patient and a provider. Our EMR is really helping with efficiency in this service area and also with tele-psych and ICU areas. The key being that tele-X software, hardware can help best facilitate the patient encounter but it’s important to realize our EMR is needed for order entry, documentation, communication with the local hospital pharmacy, etc.

We currently have a monitoring station set up in our ICU for pediatrics so that our patients can be “seen” by a specialist at a large teaching hospital in the state.  We are currently proposing to provide healthcare services to our local detention centers. If accepted, we’ll go the telehealth route.

ANGELS – Antenatal & Neonatal Guidelines, Education, and Learning System – consists of 23 hospitals and clinics who receive clinical services from us, as well as 18 hospitals who participate in a tele-nursery with us as the hub. Neonatal mortality rates for Medicaid declined from 4.5 per thousand to 3.3 per thousand. ANGEL EYE – one-way video from NICU to authorized family members. AR SAVES – Stroke Assistance Through Virtual Emergency Support – consists of emergency support for 42 hospitals across the state. Increase delivery of TPA from <1 percent to 29 percent in participating hospitals. Other telemedicine services – psychiatry, pediatrics, geriatrics, rehab medicine, cardiology, internal medicine, burn, trauma, genetic counseling.

We’re doing projects with telehealth, telepsych, home health monitoring, remote hospitalist consulting, and have others we’re thinking about. While telemedicine has been around for decades now, it seems to be really heating up lately.

[from a vendor member] We are working with several organizations who are planning telehealth projects. However, it is like NLP at this point – all talk, no action.

We are on the receiving end in that we use a telehealth service (neurology consults) in our ED. It works well, although the service and support has proved problematic. The cart contains all the video components, but when there was a problem, they had no local service techs. This left it to our staff to troubleshoot – if we were a smaller very rural hospital we may not have had the expertise to troubleshoot their equipment on our end. Overall the service has been a benefit to the hospital in that we have a shortage of these specialists to take call.

We actually do a lot of telemedicine, both inside our health system and with external partners and that program is continually expanding. Our main service lines at this point are Neuro, Pediatrics, and Psychiatry. The primary locations served tend to be emergency departments in order to deliver otherwise unavailable specialty care to patients.

Yes, for various disease states and ethnically diverse populations.

A year and a half ago, we agreed to work with a vendor on a case study to determine if telehealth would positively impact outcomes. Telehealth was new to them and they struggled to develop a website for data collection and patient interaction. For the research study we needed IRB approval and a contract with us. Once the attorneys got involved, everything came to screeching halt. A year later, we have a contract and pending IRB approval. Perhaps in the near future we can begin the study with our diabetes and CHF patients.

We have long offered telehealth via phone and web visits for mild, acute problems (e.g. URI, UTI), and we charge a separate fee for those. We are also now looking at using telehealth technology to do remote care at corporate clients.

Vague talk only about telepsychiatry to local ERs and jails.

Telehealth in use for burn, stroke, and psych consults. All working very well with different technology solutions including iPad and a mobile robot looking device.

To meet requirements for Level 1 nursery, we have neonatology sub-specialists on tap, credentialed and available. This is a great solution to consultations that would otherwise require transfers. It is another question entirely whether early transfers are in the baby’s best interest; it may be that telehealth consultations get an actual consultation in the odd hours, where if the baby were in the actual institution providing the consultants, there would be more of the "I’ll see them in the morning" mentality. Of course, in that setting, the consultant is probably more comfortable with the nursing and ancillary staff, so it may be about the same outcome. Still, it feels good to have an actual clinician to clinician discussion about a specific case.

We’re doing a lot of tele-stroke work. A real smart stroke neurologist with an interest in the technology. He’s serving other organizations and when not on site, he starts care using his tablet and the stroke robot in the ED supported by a stroke nurse-practitioner or neurosurgery PA.

Virtual visits are part of our future plans, none running yet.

We are rolling out telemedicine to support our network of six rural health clinics. This will be essentially to push the access to our specialists. Rollout is over next three months.

Radiology uses NightHawk services from the other side of the globe for night preliminary reads, but that’s it.

Morning Headlines 12/30/13

PCORI Awards $93.5 Million to Develop National Network to Support More Efficient Patient-Centered Research

The Patient-Centered Outcomes Research Institute will invest $93 million in a new project aimed at developing a collaborative network of health systems, payers, and patient groups working together to conduct more efficient health research.

Use of a Text Message Program to Raise Type 2 Diabetes Risk Awareness and Promote Health Behavior Change (Part I): Assessment of Participant Reach and Adoption

A study published in the Journal of Medical Internet Research designed to measure the participation and adoption rates of a text-based type 2 diabetes program finds that only 39 percent of enrolled participants completed the 14 week program, leading researchers to conclude that text-based programs may not be appropriate for everyone.

HIMSS Career Services to Focus on Veterans

HIMSS will launch a program aimed at introducing military veterans to " future careers in the health IT industry." The program, which was government funded, will be located on the exhibit floor at HIMSS14. Any military veterans that might be interested in the health IT industry need only get themselves down to the HIMSS conference, pay $575 for a single day conference pass, and then proceed to the “A Hero’s Welcome to Health IT” booth. Once there, they’ll meet other veterans that are working in health IT that will be able to answer questions for them, and they’ll learn about HIMSS entry-level certification exams.  

Monday Morning Update 12/30/13

From Informatics Doc: “Re: PCORI. Announces who they will fund to build clinical data research networks and patient-powered research networks, which has a fairly ambitious national goal. MU-compliant EHRs will be a key component to several networks.” The Patient-Centered Outcomes Research Institute, a non-profit created as part of PPACA/Obamacare,  approves $93.5 million to fund 29 clinical research data networks that will form PCORnet, a national network that will study clinical outcomes. Of the 29 participating organizations, 11 are hospitals, plans, and health networks that will provide real-time patient encounter information, while the other 18 are patient-operated, condition-focused groups. Quite a bit of technology is involved, including interoperability and data collection from EHRs such as Cerner and Epic, data standardization, patient-facing applications, and population health management tools. Harvard Pilgrim Health Care Institute won a $9 million contract in September to run the program, naming as directors Richard Platt, MD, MS from Harvard Medical School along with Robert Califf, MD from Duke University Medical Center. I think it’s a great idea, although the politics and special interests involved in translational research make it hard to predict whether it will be successful in turning new medical data into health-improving and cost-saving principles. 

From The PACS Designer: “Re: iPhone 5S. With the gifting completed for the holiday, TPD thought it would be useful to post instructions for the HIStalkers who may have received the iPhone 5S. Since it can be daunting getting started with the 5S,  providing detailed instructions will get you going sooner.”

Barely more than half of poll respondents think Karen DeSalvo was a good choice to be Farzad’s replacement as National Coordinator, although none of those who voted added a comment to explain their position. The suck-up organizations (which is pretty much all of them) can’t say enough good things about her even though most of their flattery is either superficial or irrelevant, so to you naysayers, what don’t you like about her? Leave a comment on this post if you like. New poll to your right: how would you grade Medicare’s fraud prevention efforts?

The Associated Press Oregon names Cover Oregon’s botched insurance exchange website as the state’s top news story for 2013, summarizing:

Once considered a national health care leader, Oregon produced the worst rollout in the nation of the new national health insurance program. While the crippled federal website eventually got up and walked, Oregon’s remained comatose, unable to enroll a single person online. The state had to resort to hiring 400 people to process paper applications. Officials lay much of the blame on the primary information technology contractor, Oracle Corp., and withheld some $20 million in payments. But state officials’ own actions played a role, too. In the face of disaster, they insisted on doing things The Oregon Way, clinging to a grandiose vision of creating a grand health IT system that would not only enroll new people in the national health insurance program, but also provide other vital services. In the midst of the finger-pointing, executive director Rocky King went on indefinite medical leave, and chief information officer Carolyn Lawson resigned.

Massachusetts, whose healthcare programs inspired Obamacare, has paid $11 million of a $69 million contract for creating its health insurance exchange website, which has enrolled only 2,800 people due to technical problems. The state says the system, built by Healthcare.gov lead contractor CGI, is slow, displays random error messages, and times out. It requires applicants to submit their information online, then wait for a mailed letter before signing up for insurance. Both Massachusetts and Vermont have halted payments to CGI for their insurance exchange sites, saying the company isn’t meeting its obligations.

Canada-based CGI, whose Healthcare.gov contract is worth around $300 million of that site’s $700 million cost so far, has a market cap of $10.6 billion. It’s one-year share price chart is above, with GIB in blue and the Dow in red. Vanity Fair’s profile of CGI is unflattering, citing previous unhappy customers and creative acquisition-related accounting practices (the company is made up of 70 acquired entities.) Industry long-timers will remember its 2004 acquisition of American Management Systems (AMS), from which quite a few hospitals bought medical records scanning and workflow applications. Including my hospital at the time, which earned AMS/CGI strong consideration for my “worst vendor” list. The article summarizes:

The story of how the Obama administration and the Centers for Medicare and Medicaid Services (CMS), the agencies tasked with implementing the Affordable Care Act got it so wrong is still unfolding. Much of the blame has to fall on an insular White House that didn’t want to hear about problems, and another chunk has to land on CMS, which instead of hiring a systems integrator, whose job it would have been to ensure that all the processes feeding into healthcare.gov worked together, kept that role for itself. As anyone who has worked with the federal government on such projects knows, it is utterly inept when it comes to technology.

Palomar Health’s Glassomics incubator for Google Glass releases a demo video of potential medical applications, including real-time integration with patient monitors and the EHR.

Hawaii Governor Neil Abercrombie releases $21.7 million in state capital funds for healthcare projects, of which Hawaii Health will receive $14.3 million for EHR-related projects.

Venture Beat predicts the hot tech buzzwords for 2014: “growth hacker” (data-driven marketing people); “nth screen” (sharing across devices); “design thinking” (human-focused innovation); “ephemeral sharing” (Snapchat-like shared data that disappears); and “hyperdata” (cooler than the now-unhip term “big data,” but meaning about the same thing).

In England, NHS and Department of Health create The Walk, an exercise app that combines a pedometer with a mystery story that unfolds as more steps are accumulated toward 500 miles of walking. It was developed by the creators of Zombies, Run!, which similarly combines a mystery story with running.

Hope Phones collects unwanted cell phones, allowing individuals and companies to outfit global health workers with the erased and furbished devices. Donation couldn’t be simpler: just print a postage-paid label from their site and put your phone in the mail. It’s part of Medic Mobile, a San Franciso-based public charity that uses mobile technology to improve health.

A Hero’s Welcome to Health IT, a government-funded program, will introduce military veterans to careers in health IT at the HIMSS conference. It offers mentoring and entry-level certification.

ONC’s annual meeting will be held January 23-24 at the Washington Hilton in DC, with 1,200 attendees expected.  It will probably be the first public appearance of new National Coordinator Karen DeSalvo, MD, who will start at ONC on January 13. 

The txt4health mobile personalized messaging program for diabetes management launched by three ONC-designated Beacon Communities reached a good many participants in Michigan, Ohio, and Louisiana, but more than half of them dropped out of the 14-week program, many of them apparently just ignored the messages, and only 3 percent of active participants tracked their weight. The article generously concludes that “this type of approach may not be appropriate for all.”

The board chair of a children’s hospital in Greece is arrested for demanding a $34,000 bribe from an advertising company that had been awarded a $262,000 contract to develop an anti-obesity campaign for children. He was also fired from his full-time position with the National Bank of Greece. The bribe was paid by an informant wearing a wire, which recorded the man’s stated rationale: “What kind of an idiot would I be to have made a 190,000-euro deal and not kept a cent for myself?”

Strange: parents of a newborn sue a Pittsburgh rabbi, claiming he severed their son’s penis while circumsizing him. Surgeons reattached it during an eight-hour microsurgery that involved six blood transfusions, two months in the hospital, and leech therapy. According to the rabbi’s website, “A doctor’s medical circumcision, usually performed in the hospital on the second or third day after birth, does not fulfill the requirements of a Bris Milah and is not considered valid according to Jewish law.”

Sponsor Updates

The annual holiday fundraiser held by Surgical Information Systems raised $15,000 from employees to support Cookies for Kids Cancer, Donor’s Choose, Toys for Tots, USO Wishbook, and The Weekes House.

Employees of ESD donated toys for Lucas County Family Services, which supports abused and neglected children.

The Lab Executive War College and CHUG (Centricity Healthcare User Group) donate hundreds of extra conference backpacks annually to Coffee Creek Backpacks project, run by Frog Pond Church in Wilsonville OR, which provides women newly released from the local correctional institute with essentials to help them return to society.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 12/27/13

Centers for Medicare & Medicaid Services (CMS) and Office of Inspector General (OIG) Extend Sunset Dates for Electronic Health Records (EHR) Subsidy Rules

CMS extends the sunset date on the Stark exception to December 31, 2021. The decision will allow hospitals to continue to finance EHR implementations for referring physician practices without breaking anti-kickback laws.

More partnerships between doctors and hospitals strengthen coordinated care for Medicare beneficiaries

123 new ACOs are announced, bringing the national total to 360.

MaineHealth increasing spending on software system that was involved with billing glitches

MaineHealth will increase the budget on its Epic install from $145 to $200 million. Bill Caron, president of MaineHealth, says that the health system underestimated the total cost of training all its staff on Epic, and acknowledges that it was a mistake to start the install at 600-bed Maine Medical Center, the systems largest hospital.  The additional funding will be used to provide end users additional Epic training.

EMR alert cuts sepsis deaths

Active surveillance alerts generated by the EHR at Mount Sinai Hospital (NY) have led to earlier detection of sepsis in its inpatient census, resulting in a 40 percent reduction in its sepsis mortality rate.