Morning Headlines 5/26/14

At Cerner’s annual meeting, executives express confidence

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

Thaw resigns as Athens Regional CEO

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

Report reveals America’s top companies for pay and benefits

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

Why I Blew the Whistle on the V.A.

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

Monday Morning Update 5/26/14

Top News

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

Reader Comments

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

HIStalk Announcements and Requests

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

Announcements and Implementations

KLAS announces that it is developing a myKLAS mobile app.

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

Government and Politics

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

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

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

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

Innovation and Research

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

Other

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

HIMSS congratulates some new EMRAM Stage 6 organizations.

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

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

— Pallav Sharda (@Pallavsharda) May 23, 2014

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

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

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

Photo: Pete Marovich/EPA

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

Book Report
Where Does It Hurt?

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

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

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

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

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

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

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

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

Contacts

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

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

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

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

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

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

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

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

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

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

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

Operational considerations:

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

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

Operational considerations:

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

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

Operational considerations:

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

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

Operational considerations:

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

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

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

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

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

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

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

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

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

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

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

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

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

What are the biggest challenges for the medical group?

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

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

How are you positioned in terms of electronic medical records?

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

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

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

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

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

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

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

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

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

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

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

Exactly.

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

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

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

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

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

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

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

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

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

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

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

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

What are physicians looking for when you recruit them?

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

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

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

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

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

Morning Headlines 5/23/14

Health Site Under Fire, Nevada Alters Path

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

Finding the Missing Link for Big Biomedical Data

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

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

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

AHRQ: 2014 Hospital Survey on Patient Safety Culture

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

News 5/23/14

Top News

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

Reader Comments

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

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

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

HIStalk Announcements and Requests

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

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

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

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

Acquisitions, Funding, Business, and Stock

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

ZirMed acquires population health management platform vendor Intelligent Healthcare.

Sales

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

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

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

People

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

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

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

Announcements and Implementations

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

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

Government and Politics

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

Innovation and Research

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

Other

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

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

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

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

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

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

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

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

Sponsor Updates

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

EPtalk by Dr. Jayne

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

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

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

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

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

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

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

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

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

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

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

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

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

 Contacts

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

More news: HIStalk Practice, HIStalk Connect. 

Get HIStalk updates.
Contact us online.

Morning Headlines 5/22/14

Surescripts: E-prescribing up, but still faces challenges

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

Ex-WellCare CEO Gets Three Years for Medicaid Scheme

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

Federal investigators issue subpoena to Cover Oregon, Oregon Health Authority

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

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

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

CIO Unplugged 5/21/14

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

Marching to the Syncopated Beat

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

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

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

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

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

Insignificance is not my calling. Nor is it yours.

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

HIStalk Interviews Pat Cline, CEO, Lightbeam Health Solutions

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

Tell me about yourself and the company.

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

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

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

How big is the company?

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

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

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

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

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

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

How does the integration with EHRs work technically?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Do you have any concluding thoughts?

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

Morning Headlines 5/21/14

CMS rule to help providers make use of Certified EHR Technology

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

Commonwealth Fund EHR Survey

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

Review recommends new name, direction for PCEHR

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

News 5/21/14

Top News

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

Reader Comments

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

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

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

HIStalk Announcements and Requests

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

Acquisitions, Funding, Business, and Stock

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

— Patrick Dempsey (@PatrickDempsey) May 20, 2014

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

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

Sales

Vanderbilt University Medical Center chooses Allscripts EPSi for financial planning.

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

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

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

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

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

People

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

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

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

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

Announcements and Implementations

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

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

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

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

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

Government and Politics

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

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

Other

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

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

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

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

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

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

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

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

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

Sponsor Updates

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

Contacts

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

More news: HIStalk Practice, HIStalk Connect. 

Get HIStalk updates.
Contact us online.

Morning Headlines 5/20/14

VA Faces Systemwide Problems With Patient Scheduling

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

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

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

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

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

Surgeon Cuts Vendors Out Of EHR Quest

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

Curbside Consult with Dr. Jayne 5/19/14

Outside of healthcare, very few people understand what a CMIO does. Usually when I meet new people I explain that I’m a doctor, but I work in the information technology world. If I get a totally blank stare, I might go on to say I work on the electronic records systems that hospitals and physician offices use.

Some will ask why I’d want to give up the money and excitement of being a physician. I suspect they don’t have any idea of what being a primary care physician actually looks like. Occasionally someone will ask me if I can help them with some home networking problem, which I find pretty funny that people assume that everyone “in IT” knows how to do desktop and network support.

Inside the hospital, I’m not sure that many physicians actually understand what we do either. They know we’re the people to call when they have complaints and that we’re usually the figurehead telling them they have to do something for Meaningful Use or CMS audit purposes. Physicians may not understand the role we play as their advocate or the depth of the battles that we fight on their behalf.

I’m not sure our role is always fully understood by the IT teams either. Some analysts think we’re just super-nerdy physicians or that we had to leave full time practice for some reason. Others are afraid that having a physician on the team means that we’re going to try to call the shots or be the boss all the time. Frankly there are some days that I’m not even sure what I do. Teams work more effectively when they understand where the various members are coming from. In that spirit, here’s a week in the life of a CMIO.

I started Monday with a half-day of teach-back training for a couple of our new implementation team members. Our organization is a stickler for making sure that training is consistent and reproducible so that no one can complain that he or she didn’t have every opportunity to learn the material. As part of that process, I deliver train-the-trainer sessions for the team.

Some of our team members come from non-clinical backgrounds. It’s important that they understand the training scenarios and clinical pearls we incorporate for our end users. Having that knowledge helps them build credibility and trust with the end users. They’ll also shadow other members of the training team so they can see various presentation styles before it’s time for them to start deliver their own sessions independently.

Over lunch, I returned a couple of phone calls from cranky colleagues who don’t understand why we won’t customize the system for their individual needs. Although our EHR is template-rich, it lacks content for some of our subspecialty physicians. They all have access to voice recognition so they can dictate narrative as part of their notes, but some are insistent on wanting click-the-box type templates.

From experience, we can build them whatever they ask for and they still won’t like it, so our bent has been to steer them to using dictation, but creating macros and templates to make it even faster. One of them agreed to try our standard approach but the other was more skeptical, so I convinced him to shadow one of his colleagues and see how well it can work. I’m cautiously optimistic.

The afternoon was filled with a mountain of email that had built up from taking Friday off. I make it a habit to not work on the weekends unless it’s an upgrade situation or a critical outage. I hope setting that example for our team means something, but I still see entirely too much correspondence originating during the off hours. Maybe it’s time for another work-life balance discussion with a couple of them.

Tuesday began early with the hospital credentialing committee, which is always somewhat of a snoozer. I appreciate the need to have medical staff committees, but they can be pretty dry. In a world where I preach the gospel of working to the top of the license, it’s hard to justify having 10 physicians sit in a room and make decisions that would be quite amenable to the committee equivalent of a refill algorithm or a standing order.

After that, I had a meeting with one of our physicians who is interested in our open associate medical director of informatics positions. He’s qualified, but reluctant to give up any of his current duties to make it a reality. Somehow he thinks he can just fit it in, and that’s not going to be the case. I keep trying to explain that we’re not going to put someone in a position where they’re destined to fail, but he isn’t getting the message. I’d really like to add him to the team, but you can’t just squeeze 16 hours a week of informatics work in between patient appointments.

I met in the afternoon with our project team to run through the presentation we’d be doing for our bi-monthly steering committee meeting on Wednesday. The budget numbers looked a little funny, so we had to dig into the reports and the time-tracking system, which is never fun. It turned out to be some operating expenditures that should have been capitalized, but it took forever to find the discrepancy.

In between meetings, there is a steady stream of email, requests to visit practices, and occasionally help desk tickets that providers want escalated directly to “a real doctor who will understand.” Most of the time those end up being user error or training issues, but they take a lot of time to explain, reassure, and arrange for retraining when needed.

Wednesday can only be described as Meet-a-Palooza. We started with the steering committee. One of our hospital VPs must be reading some kind of leadership book because he was all over asking hard questions just for the sake of asking hard questions. Although no one of them stumped us, it drives me crazy when people use meetings to try to make a name for themselves. Following that was our regular project leadership team meeting, followed by an implementation team meeting, which I usually sit in on so I can stay on top of any practices that are having difficulty with EHR.

I hid in my office with the door closed during lunch because one of our junior analysts has decided he wants to go to medical school and is driving me crazy. I think he’s watched too many episodes of “Grey’s Anatomy” and his expectations are completely unrealistic, but he’s persistent. Unfortunately he didn’t like biology or chemistry in school, and although he has a masters in health information management, his undergraduate major was political science. He’s not willing to concede that he’ll have to go back and take all the science 101 classes, so until he does, I’m avoiding him.

The afternoon’s scintillating meetings included: monthly clinical quality measures review; MU status review; new provider on-boarding; and a red-hot discussion of whether or not we should pay our providers to attend training (we don’t, but they always ask us to).

Thursday is my work from home day, which is the only day I can get anything done. I had a couple of presentations to prep – one on change leadership that I’m submitting to present at a conference, the other for a local residency program on the business of healthcare. I was able to get them mostly done, but I like to let them rest for a week or so then revise, so I’ll be back at them again. In the afternoon I worked on performance reviews. Although I don’t have any direct reports, our organization believes in a 360-degree evaluation, so I end up doing reviews of most of the implementation team and support analysts. I can only do a couple at a time before my brain shuts off, so I punctuated them with some gardening, which was pretty therapeutic.

Friday I met with our testing coordinator to review the test plan for a new specialty we’re bringing up. She’s going on maternity leave soon and I suspect she won’t be coming back, so we’ve been spending time making sure we document the process we use to evaluate new content, build scripts, and ultimately test new content. Although that will make on-boarding her replacement easier, I hate to see her go. We’ve had too much turnover in that position and I’d like to find someone who will stay for the duration.

Next it was on to our monthly ICD-10 update for senior leadership. The delay has taken the wind out of our sails. I wish someone would just cancel the meeting for a couple of months and then we can pick it up full steam, but instead it languishes on the calendar and doesn’t have a real purpose. It’s not my meeting, though, so all I can do is suggest a different path, and when we run out of agenda items, be the one to recommend we adjourn early.

Friday afternoon I came full circle with the implementation team, this time being the student instead of the teacher. I have to say I was impressed with how quickly they were able to pick up the material and how well they did. We cleared them both to go out into the field and work with seasoned trainers. They’ll initially just shadow and assist with the hands-on portions, but over the next month they’ll start teaching parts of the new employee sessions until they’re eventually teaching the entire course with another trainer as backup. By mid-June they’ll be out of the nest and on their own.

I always end Friday by looking over my calendar for the next two weeks. It gives me an idea what I need to focus on for the coming week and lets me see any conflicts or major issues in the one that follows. Sometimes our administrative assistants get a little cavalier with our schedules, so if we want to be able to breathe or eat during the day, it pays to be proactive. I realize they’re trying to squeeze every minute out of the day and respect what they do, but ultimately I’m the one who looks bad when I’m absent or late due to an overcommitted schedule.

Some weeks are different, but many are the same but with just different meetings and different cranky colleagues. When we’re close to a major upgrade, it looks completely different, with much more focus on the new version but with all the same standing meetings continuing. It can be quite the juggling act at times. Nevertheless, I enjoy doing what I do. But sometimes it’s just easier to be “the doctor who works in IT.”

Email Dr. Jayne.

HIStalk Interviews John Gobron, CEO, Aventura

John Gobron is president and CEO of Aventura of Denver, CO.

Tell me about yourself and the company.

We were founded at Denver Health. We were built to fix and improve a problem called clinical work flow. In the Denver Health case, especially with respect to roaming desktops. In the process, we came up with some pretty neat ways to solve security problems and came up with some mobile innovations as well.

I’ve been in healthcare IT for 20 years. I helped build a company called Sentillion. I spent time with Microsoft’s Health Solutions Group in the UK and ran the healthcare vertical for Symantec.

What are the big issues in trying to balance clinician convenience, access to systems, IT security, and device standardization and setup?

The big challenges often come down to workflow. Ultimately, we’re trying to facilitate a system that improves patient care and does it largely in a digitized way.

If you go back 20 or more years, everything was paper. The physician-patient relationship was based on intimate eye-to-eye contact. The doctor wrote stuff down and still maintained eye contact, but that wasn’t perfect. 

We’ve tried to introduce computers, with a lot of success in some areas and less so in others. Innovations like CPOE tried to help with the mistakes that were being made largely through human error, like handwriting and things like that. But the problem is that computers tend to interrupt workflow, especially when it comes to a physician or a nurse treating a patient. 

We get in the middle and make the interactions faster and more intuitive. For all the great work computers do, they are fundamentally dumb instruments. They don’t know what to do until you tell them what to do. We provide what we call awareness to the computing experience. We try to know what the user wants to do and tell the computer that before the user actually interacts with the computer itself.

Who are your competitors?

We’re doing new stuff. We don’t have any directly line-of-sight competitors, but we have a lot of what I will call peripheral competitors.

The most notable is probably Imprivata on the single sign-on front. We’re often compared to the traditional space of access and identity management and you have Caradigm in there and Imprivata as well. Two big ones. On the virtualization side, we’re largely complementary to our partners like Citrix and VMware.

In the sense of awareness, we really don’t have anyone. We can provide user awareness and that’s largely thought of as a single sign-on. but we’re also providing location awareness, device awareness, patient awareness and a combination of those. There’s really not anyone in our direct line of sight.

What can you do with that information?

We create effectively an immediate and customized user experience for the doctor and nurse. Capture their badge or otherwise identify themselves to a machine. Because of who they are, where they are, and what they want to do, we custom-mold that desktop to say, the user might need this set of applications. They might need to be in this area of this application. We deliver it in generally four to six seconds.

You can do this with any major system, such as Epic, Cerner, and Meditech?

Yes. We’re 100 percent application agnostic. We’re really managing the desktop itself and then the applications on the desktop. We haven’t had an application we couldn’t interface with or a workflow we couldn’t solve. We’re pretty agnostic when it comes to what applications a doctor and a nurse might be using.

The earlier challenge was to get clinicians to use systems since that use was not mandatory. Now it’s mandatory in most cases, so instead they complain about the overhead required. Is that better or worse for the company?

That’s a very interesting way of saying it. It’s very accurate. In my life with Sentillion, we were largely dealing with a voluntary user population. The nurses today and yesterday were largely employed by the hospital and had to do what the hospital told them to do. Doctors weren’t employed.

Today, there’s still a mismatch and there’s acquisitions going on. But from a hospital perspective and even an outpatient perspective, they’re needing to use the EHR or risk not getting money or getting fined. It doesn’t fundamentally change the need to make it better because it’s not optimal.

But the way we go about it is different in that the days of, “We can save you some time, that’s great, let’s buy this system” are mostly in the past. The world in front of us, the world we live in now, is “show me the hard ROI.” If I’m going to buy something like your solution or anything like it, show me how you reduce my actual spending or increase my actual revenue into the hospital.

It must be tough with EMR optimization and mandatory regulatory work to convince people to look at your system in addition to everything else.

It is. Probably every vendor reading HIStalk probably has a similar perspective on this. We look at what’s important to the hospital we’re talking to, overlaid with whatever will bring the most amount of value. Then we have a good match, and if we don’t, we come back and talk to them at a later date.

Hospitals are interested in anything that can help them with Meaningful Use, integration acquisitions, or connecting with physician practices. Does Aventura’s product look more attractive with those issues?

Absolutely. That’s where we stand out. 

I mentioned awareness. A lot of the core measures go way beyond just getting into the application. That’s good, but that’s commoditized technology. The next generation is not just getting me to an app, but getting in the right place of that app, eliminating a lot of the clicks and menu choices and navigation that get me where I need to be in order to hit my Meaningful Use number, in order to hit my 60 percent CPOE or my core measures or things like that.

That’s where we’re looking to innovate and have been innovating, with respect to putting information up. We can help navigate to a patient record. We can put some information there that may assist with helping the hospital achieve their Meaningful Use numbers in particular.

When you think about acquisitions, you largely think about the drive in healthcare across America right now to move care outside of the four walls of the traditional hospital and out to an outpatient setting, or even ideally out to the home. That’s the ultimate mobility. Historically we saw mobility as a doctor and nurse going from room to room to room rounding or providing care or surgery. That happens in the inpatient workflow. But the outpatient workflow is where we as a health system or as an ecosystem are going to see some of the bigger financial savings and impact and obviously outcomes as well. People heal better faster and less expensively in their homes, in places of greater comfort. 

As healthcare looks to do that, people will still need to use the computer systems. They’re just going to be more mobile. That’s a really good place for us to innovate with the ability to go back and forth between desktops and mobile devices, whatever they may be. Still bringing access to the information, but doing it anywhere they want to be.

You’ve worked outside of the US and for big companies outside of healthcare. What is the most striking thing about healthcare right now?

I had a wonderful experience in the UK. I had moved there in 2008 to lead Sentillion’s European expansion. It was a privilege to learn about how healthcare is delivered in different parts of the world.

The striking similarity is that workflow, is workflow, is workflow no matter where you are. Clinicians in Birmingham, England see patients and use computers largely the same way as doctors and nurses in Birmingham, Alabama do. In socialized medicine countries, these systems are obviously less concerned with transactional billing, but the core focus of improving patient care is still the same, as are the core struggles of improving this workflow

Where do you see the company going in the next three to five years?

The excitement that I have, and that is shared by Aventura and our customers, is that we’re really onto something with respect to a platform called awareness. We can be aware of a user, their location, their device, and the patient they’re in front of.

But my favorite question when I wrap up meetings is, what else should we be aware of? What else could we be aware of to help you? Those discussions are fun to have and they help drive our innovation in the company.

At a high level, where we will be going is an expansion of our awareness platform, to be able to do more things to drive efficiency, security, all those good benefits into the clinical workflow.

Do you have any final thoughts?

I just wanted to say thanks for HIStalk. I’m a huge fan and I really appreciate the work that you do. It’s not only informative for people like myself, it’s fun to read. I helps foster a nice sense of  camaraderie in our industry and I’d just like to say thanks for that.

Morning Headlines 5/19/14

Veterans Affairs Chief Accepts Resignation Of Robert Petzel, Under Secretary For Health

Robert Petzel, the top VA official for health care, resigns after it was discovered that the Phoenix VA Medical Center had been falsifying appointment wait lists to appear compliant with the VA’s standards. Petzel was already scheduled to retire in just a few months, so the resignation is more political than a meaningful effort to remove a problematic leader.

Health Care Leaders Gather to Address Challenges, Opportunities of Open Health Data at Health Datapalooza 2014

Health Datapalooza unveils a packed speaker lineup for its June 1-3 conference: US CTO Todd Park, HHS Secretary Kathleen Sebelius, AHIP CEO Karen Ignagni, author and surgeon Atul Gawande, athenahealth CEO Jonathan Bush, UK Secretary of State for Health Jeremy Hunt, and Time author Steven Brill, among others.

LIJ Medical Center Introduces One-of-a-Kind Video Monitoring Project to Enhance Patient Safety in ORs

Long Island Jewish Medical Center (NY) has installed a new real-time auditing system in its operating rooms that use video cameras to monitor the procedure and provide real-time guidance. The system ensures that timeouts, surgical checklists, and pre and postoperative equipment inventories are all being properly conducted according to protocol. Hospital executives say that within a few weeks of implementing the system, they saw meaningful quality improvements.

IBM Reveals New Companies Developing Watson-Powered Apps

IBM unveils the first consumer apps that integrate services from its Watson supercomputer. Modernize Medicine, a dermatology EHR system, is included on the list with its new point-of-care reference app called schEMA.

Monday Morning Update 5/19/14

Top News

Robert Petzel, the VA’s undersecretary of health, resigns over allegations of falsified electronic wait time records at  the Phoenix VA hospital. The only benefit is political since Petzel had previously announced plans to retire this year. Arguably the VA and Kaiser have led the healthcare industry in innovation, quality management, and use of technology even though the VA is, like all federal agencies, a politically motivated money pit. The VA’s problem is the tsunami of returning veterans who were sent off in huge numbers to fight pointless political wars that left many of them physically and psychologically damaged, leaving the VA to pick up the healthcare pieces with minimal increases in funding. It would be interesting to see the VA’s volume and quality metrics over the past 10 years. The VA is the ultimate ACO provider that might be able to provide warnings about the hazards ahead to the ready-fire-aim pioneers charging down the path of managing populations even though their outcomes and cost effectiveness in managing individual encounters have been unimpressive.

Reader Comments

From Beth: “Re: IT productivity. I’m looking for better ways to measure and compare with other facilities. Do people use closed help desk tickets, number of network nodes, number of user accounts, adjusted patient days, or some other formula?” Leave a comment if you can help Beth. It’s always tough to benchmark IT as an entire department since hospitals configure it differently – outsource parts of it, include biomedical engineering or not, have field support in individual hospitals in the system that aren’t assigned to corporate IT, use external consultants for application support or training, etc. I’m always skeptical of benchmarking since it’s hard to find a two hospital IT shops that are mostly alike, not to mention that once metrics have been identified, everybody’s goal shifts to gaming them rather than actually improving service (see: VA patient scheduling.) It’s like school testing: the metrics are supposed to be a by-product of excellence, not the sole focus of the program where teachers teach run entire classes on how to pass standardized tests rather than comprehend reading and math. Maybe that’s a case for metric opacity vs. transparency – let an independent organization define and report the metrics as broad themes without telling anyone, including management, how they are measured. That keeps your help desk people from begging users on Friday to let them closed unresolved tickets so that Monday’s numbers don’t get them in trouble.

From The PACS Designer: “Re: Apple and biosensing. They have a patent for a pedometer that could be a biosensing device as well for an iWatch. Apple has hired biomedical engineers from Vital Connect, Masimo Corp., Sano Intelligence, and O2 MedTech.” The timing is good since the fitness tracking device craze is in full retreat, making it ripe to become just another part of your smartphone rather than a dedicated piece of hardware, much like portable music players. Few people want to pay $100 for a not terribly intelligent pedometer that needs to be recharged separately.

HIStalk Announcements and Requests

The recent buzz about athenahealth’s prospects and share price was negative to one-third of respondents. New poll to your right: should ONC require certified EHRs to offer open APIs? You can elaborate further after voting by adding comments to the poll.

Welcome to new HIStalk Platinum Sponsor Glytec. The Greenville, SC-based company is admirably focused on one big hospital problem: improving insulin management and glycemic control. Around 40 percent of inpatients experience hyperglycemia or hypoglycemia during their stay, which requires lot of clinician time and contributes to infection, length of stay, and mortality. Glytec’s Glucommander Suite is the only FDA-cleared glycemic management and surveillance system. It delivers physician-directed computer algorithms to both adult and pediatric patients and those on either IV or SC insulin. It offers one-click access to the patient’s chart in the EMR. GlucoSurveillance flags patients in real time who may require glycemic therapy, while GlucoMetrics Analytics monitors the success inpatient glycemic control initiatives. According to the VP of medical affairs of Sentara Healthcare, “If you aren’t using Glytec, you aren’t using the standard of care,” while University of Virginia’s consult team reported a length of stay reduction of over one full day in the first six months of using Glucommander. Thanks to Glytec for supporting HIStalk.

I found this just-published YouTube video by Sentara Healthcare describing  in a remarkably frank manner the problems it was having with glycemic control and how it uses Glytec’s eGlycemic Management system. It isn’t the usually glossy overview – the physicians in the video get into specific details, such as how they made EMR changes to drive some improvements but then “hit a wall.”

Listening: new Tori Amos.

Announcements and Implementations

Health Datapalooza announces the speaker lineup for its June 1-3 conference in Washington, DC: US CTO Todd Park, HHS Secretary Kathleen Sebelius, AHIP CEO Karen Ignagni, author and surgeon Atul Gawande, athenahealth CEO Jonathan Bush, UK Secretary of State for Health Jeremy Hunt, and Time author Steven Brill, among others. I’ll be there, so you’ll read more about it on HIStalk. I don’t attend many conferences and in fact I don’t even hear about most of them (the appetite for HIT-related conferences is apparently ferocious given the number of people who seem to make a career of tweeting from them), so if there’s one you recommend that’s worth the time and money to attend, let me know.

Massachusetts Health Data Consortium elects four new board members: Frank Barresi (VP/CIO, Fallon Health); Julie Berry (CIO, Steward Health Care System); Joseph Frassica, MD (VP and chief informatics / chief technology officer, Philips Healthcare); and James Noga (VP/CIO, Partners HealthCare.)

IBM announces that Modernizing Medicine is one of three partner companies that will release “Made with Watson” apps this year. The company offers specialty EMRs and is developing an iPad app that will guide physicians through a patient encounter to provide evidence-based medicine suggestions.

Other

Constantine Davides of AlphaOne Capital Partners LLC has updated his HIT Family Tree that shows pretty much every company’s acquisition history over the years. It is fascinating, useful, and sometimes a bit scary when you see the number of acquired pieces and parts that make up a vendor’s “integrated” systems.

Apple and Google drop their smartphone lawsuits against each other and agree to work together on patent reform.

The Chicago business paper describes interesting hospital-doctor conflicts at 313-bed Swedish Covenant Hospital (IL) following the hospital’s firing of its chief of medicine after he and other of his independent practitioner colleagues joined a rival hospital’s accountable care organization. The issues: (a) new payment models make it difficult for doctors who practice at multiple hospitals to choose their loyalties; (b) independent doctors say they are forced to take ED call, but most of the patients they see there are sent to the hospital’s employed physicians; (c) the hospital is demanding that independent practices adopt EHRs that integrate with their systems, leading to concerns that the hospital will use the information in them to tell them how to practice medicine (which of course they will since that’s the whole point of analytics-powered population health management, which like most powerful forces can be used for both good and evil.)

The former president of the Philippines, now a representative, proposes creating an Electronic Medical Record Center (an HIE-like central records strorage center) under the Department of Health, with initial funding of $230,000 USD.

Long Island Jewish Medical Center (NY) installs video cameras in all of its 24 operating rooms as a remote video auditing (RVA) system. Staff will check the cameras every two minutes to make sure the surgical teams take the mandatory pre-procedure timeouts and patient safety measures. The cameras will also be used to alert housekeeping of completed procedures so they can clean the room and as a video record that room disinfection was performed properly. The video can be monitored live throughout the OR and on smartphones. The system was provided by the hospital’s anesthesia contractor and Arrowsight, Inc., whose video system the hospital installed in 2011 to improve hand hygiene rates to nearly 90 percent (I’m picturing in-room loudspeakers from which emanate the stern voices of invisible handwashing video overlords who tell doctors to step away from the door and toward the sink.)

Centura Health (CO) will replace Meditech with Epic, a good source tells me.

Police say they may make more arrests in the identify theft case at Albany Medical Center (NY), in which a nurse and her boyfriend have been arrested for using the Social Security numbers of over 100 patients to apply for credit cards, write bad checks, and file fraudulent tax returns.

New tax returns filed by UPMC disclose that CEO Jeffrey Romoff was paid $6.6 million in 2012, with 30 other health system executives and physicians exceeding $1 million each in compensation. SVP/CIO Dan Drawbaugh makes the list with $1.6 million in 2012 income, a big drop from the $2.3 million he took home the previous year. UPMC is famously embroiled in a lawsuit with the City of Pittsburgh in claiming that it is a humble non-profit that should not contribute to the city’s budget by paying taxes.

Here is Regina Holliday’s keynote speech from the We Can Do Better conference from a couple of weeks ago.

Contacts

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

More news: HIStalk Practice, HIStalk Connect. 

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