Morning Headlines 9/6/13

Health IT Czar on Making Meaningful Use ‘Meaningful’

Outgoing ONC Chief Farzad Mostashari, MD, offers advice to clinicians during an interview with Medscape Editor-in-Chief Eric Topol, MD.

Health IT Policy Committee Summary

The HIT Policy Committee hears final recommendations from the FDA Safety and Innovation Act Workgroup, concluding that for the most part HIT should not be subject to FDA premarket requirements unless the product qualifies as a medical device. The group agrees that post-market surveillance should include reporting and implementation testing.

NextGen Healthcare, Clinical Decision Support Consortium and WVP Health Authority Join to Launch Clinical Decision Support Pilot

NextGen announces that it has created an interface to Partners Healthcare Systems’ clinical decision support tool so that physicians using NextGen will be able to send a CCD to the tool and then immediately receive an evidence-based set of recommendations appropriate for that patient.

3D Printing Is a Matter of Life and Death

A surgeon at the University of Michigan prints a lung splint with a 3D printer, saving an infant with a collapsed trachea.

News 9/6/13

Top News

The HIT Policy Committee approves multiple recommendations presented by the FDA Safety and Innovation Act (FDASIA) Workgroup, including:

• HIT should not be subject to FDA premarket requirements except when it constitutes medical device accessories or involves certain forms of high-risk CDS, such as computer-aided diagnostics. EHRs, decision support algorithms, and HIE software may be subject to regulation.
• Vendors should be required to list products that are considered to represent potential risk.
• Post-market surveillance of HIT should include reporting from users and vendors and also include post-implementation testing.

The committee also called for adoption of existing standards and creating new standards to address specific areas, including HIE. The recommendations now go to the FDA, ONC, and FCC, which are expected to release a proposal for public comment early next year.

Reader Comments

From Dr. Loredana: “Re: male vs. female physician compensation. A study found that women docs spend more time with patients. Therefore, they see fewer patients and thus make less money. Physicians’ time should be valued and addressed just like any other resource in healthcare. It is finite and scarce and we only have 24 hours in the day like anybody else.” A quick Google search uncovered a number of studies indicating that female physicians spend an average of 10 to 50 percent more time with patients than their male counterparts. Now I am curious if there are any studies tying outcomes with time spent per patient encounter.

From Tallman Letters: “Re: consulting firms and vendors. I’m turning to you, our most trusted source! Which healthcare consulting firms or vendors are most qualified to (a) provide technical consulting to providers about what technical architecture they should use; (b) build a healthcare data model; and (c) implement the tech architecture for full EDW/BI? Keep up the great and amusing work you do for us all!” I’m turn to my most trusted source – readers. Please leave a comment with your thoughts for TL.

HIStalk Announcements and Requests

Some of this week’s highlights from HIStalk Practice include: athenahealth reveals development plans for its recently purchased Arsenal complex, including walking and biking paths, an incubator for HIT startups, and a beer garden. Minnesota State Fair visitors are given coupons for free healthcare e-visits. More than half of all medical students use tablets as part of their medical training. The IT administrator at an orthopedic practice accesses a physician’s electronic signature to forge prescriptions. Dr. Gregg discusses the darker side of vendor-provider relationships, including Practice Fusion’s opt-out policy for sending patients emails that appear to come from providers (I also share my view.) Thanks for reading.

On the Jobs Board: Healthcare Customer Advocate, Clinical Applications Consultant, Project Manager.

Acquisitions, Funding, Business, and Stock

Agilum Healthcare raises $1.43 million in a debt offering.

Teladoc acquires fellow telemedicine services provider Consult A Doctor for an undisclosed amount.

SAIC announces Q2 results: revenue down 12 percent, EPS $0.13 vs. $0.32, missing expectations and cutting its 2014 outlook. Its health an engineering segment did better, but only because of the recently acquired maxIT Healthcare. SAIC plans to split itself into two companies, with its national security, health, and engineering operations to be moved to a new company called Leidos, with headquarters in Reston, VA. Healthcare is the smallest of the three operations with 6,000 employees.

Sales

Tenet’s Saint Louis University Hospital selects iSirona’s device connectivity solution.

Pekin Hospital (IL) selects Interbit Data’s NetSafe business continuance and downtime protection software.

The VA awards AMC Health a five-year, $28.8 million contract to provide telehealth solutions and services.

Mt. Washington Pediatric Hospital (MD) contracts with HealthCare Anytime for its Enterprise Patient Portal Suite.

Community Medical Centers (CA) selects Infor Cloverleaf.

People

Cerner promotes Zane Burke from EVP of the company’s client organization to president. Neal Patterson, who covered the president role since former President Trace Devanny left in 2010, will retain the titles of chairman and CEO. Cerner says that Burke’s promotion does not represent a formal succession plan announcement.

HIT consulting firm Meditology Services names Michael Flynt (Workday) VP of sales.

Patient engagement portal provide Omedix appoints Shay Pausa (ChiKiiTV/Magnet) CEO.

Caradigm appoints Joel Ratnasothy, MD (Fujitsu) as medical director for Europe, the Middle East, and Africa.

Anil Chakravarthy (Symantec) joins Informatica as EVP/chief product officer.

Diane Cecchettini, RN, president and CEO of MultiCare Health System (WA), announces her retirement next year. She served as a flight nurse in Vietnam, was a troop commander in Desert Storm, was president of the Washington State Hospital Association from 2005 to 2007, and won several IT awards.

Marc Donovan (World Wide Technologies) joins Nexus as sales director for the company’s connected healthcare practice.

Announcements and Implementations

Virginia Hospital Center will invest five to $10 million to consolidate its 100-plus employed physicians into one multi-specialty group and migrate the currently separate practices to eClinicalWorks.

Cerner will integrate Elsevier’s CPM CarePoints and InOrder evidence-based content solutions into its PowerChart EHR.

Artemis Health Group will add Health Language’s clinical language management tools from Wolters Kluwer Health into the Artemis OB/GYN EHR, PM, and patient engagement solutions.

Carolinas HealthCare System will use aggregated claims and clinical data from Verisk Health to analyze and manage population health.

Castle Medical Center and Hawaii Pacific Healthcare will join Health eNet, Hawaii’s statewide HIE.

A new KLAS report on enterprise patient access finds that best-of-breed solutions are common, with the most important functions to users being calculation of estimated patient responsibility, eligibility verification, and preauthorization.

HealthTech’s YourCareCommunity.Com v1 earns ONC-ACB certification as a modular EHR.

Intelligent InSites adds integration with HyGreen’s hand hygiene monitoring system to warn workers who haven’t washed their hands.

The UHC alliance announces plans for an automated program that will extract clinical and administrative information from the IT systems of its members and transfer it to UHC for benchmarking. NYU Langone Medical Center and Cleveland Clinic will be the first adopters, with the system expected to be available to all UHC members by the end of 2013.

NextGen Healthcare client Willamette Valley Providers Health Authority (OR) deploys a clinical decision support tool developed by the Clinical Decision Support Consortium that takes a request for CDS from NextGen Ambulatory EHR, delivers it to an enterprise clinical rules service at Partners HealthCare for analysis, and immediately returns recommendations within the NextGen application. The “cool” factor here: community-based physicians can access CDS data from a large academic medical center across the county and retrieve recommendations at the point of care. The Consortium aims to establish nationwide consistencies for CDS recommendations and is comprised of members from provider organizations and EHR vendors, including Partners and NextGen.

Government and Politics

Brian Norris of Social Health Insights LLC  created a cool visualization page for Meaningful Use attestation data using tools from Tableau Software.

Innovation and Research

GE, Under Armour, and the National Football League launch the GE NFL Health Health Challenge, which will award prizes of up to $10 million for concussion-related solutions that can include technologies to detect and measure brain injury.

Palomar Health expands its Google Glass incubator Glassomics to include smart watch technology in healthcare. For some background on the smart watch market, see Lt. Dan’s post on HIStalk Connect, “A Primer on the Up-and-Coming Smartwatch Market and What It Means for Healthcare.”

A Mayo Clinic study finds that data from the Fitbit activity tracker can help predict the mobility of post-op patients and help clinicians customize their care plans.

Research by the Pennsylvania Patient Safety Authority finds that EHR default values cause quite a few errors in drug doses and times, although nearly none of the errors caused patient harm.

Other

John Halamka’s five biggest CIO challenges for the next few months:

1. IT requirements driven by mergers and acquisitions
2. Regulatory uncertainty related to ICD-10, HIPAA Omnibus, and Meaningful Use Stage 2
3. Meaningful Use Stage 2 requirements, particularly at shops like BIDMC that build their own applications
4. The ability of provider organizations to keep the doors open while trying to meet all the regulatory requirements as revenue declines and risk-based reimbursement increases
5. Leading in real time

I am ashamed to admit that I found this story just a teeny bit amusing, though so pathetically wrong. A patient files a civil lawsuit against Torrance Memorial Medical Center (CA) after discovering that an anesthesiologist had decorated her face with stickers while she was unconscious during surgery. A nurse’s aide snapped a photo of the patient, who was freshly adorned with a black mustache and teardrops. The anesthesiologist and other involved employees were disciplined but not fired.

Three UK doctors face a loss of their medical licenses after allegations that they copied material from a book to create an iPhone app that helps evaluate clinical evidence. One of them faces an additional charge of posting a positive review of the app on the App Store without disclosing that he has a financial interest in it.

A Forbes article wonders if Cleveland Clinic can save its home city with its $6.2 billion in revenue, $300 million in operating income, $10.5 billion in assets, 42,000 employees, its own 141-trooper division of the state police, and now its plans to spin off for-profit companies and jump start the local economy with the Global Center for Health Innovation, scheduled to open next month with HIMSS as its largest tenant. Cleveland’s population has dropped 10 percent in the last decade and median income fell 60 percent, with its only economic bright spot being healthcare.

Anybody see a HIPAA problem with this pre-med student’s Google Docs-based patient tracking solution?

Cardiologist Eric Topol, MD, who is also editor-in-chief of Medscape as of February 2013, interviews Farzad Mostashari, MD. It’s good. Some snippets and factoids:

• Mostashari came to the US from Iran at 14, then went to Harvard and Yale.
• “Ninety percent, probably, of what happens in healthcare today has no basis in evidence. At the very least, I think what we owe ourselves and our patients, what we really want to do is: If we have variation, if we make a decision that is not based on the general guideline, it should be studied so that we learn something from that variation.”
• “The dream is that with every encounter, you know everything about the patient. You know everything about any medical knowledge that has ever been generated and you know everything about what is happening right now in the community where we are. Because the treatment for a sore throat is going to be different in January with the flu epidemic than it is going to be in September when asthma is peaking. So you have to bring in the 10 to the 6th power, the 10 to the 3rd power, and the 10 to the zero in that encounter. Whatever you do generates and goes back to teaching everybody else what is going on in the community, what is going on in medicine, and contributes to this patient’s knowledge. Right now my visit doesn’t even contribute to my next visit.”
• On $37 billion in HITECH incentives: “I think doctors would say that they earn it. No one gives out anything.”
• Mostashari and US CTO Todd Park roomed together when they moved to Washington, DC four years ago in July, sharing a small apartment with no air conditioning.
• On the jokes that ONC stands for “Office of No Christmas” because of the push to get the work done. “That is what it felt like — that there is this incredible urgency. You have a day, a week, a month, and pretty soon the opportunity to make a difference is gone.”
• “Meaningful Use, it is a tool. Take that certification, take that decision support, take that quality measurement. Don’t have quality measurement done to you or say, ‘I am going to be paid and judged based on quality. I can’t control that.’ What you can do is make it meaningful; take the tools and make them meaningful. Help your staff make the tools meaningful.”
• “We are going to solve this path that we have been on towards unsustainable cost growth. One out of every $5 spent in this country is being spent on healthcare. It is just amazing, and it is not sustainable. It is not sustainable for people, for families, for businesses, for state governments, for federal governments. It is not sustainable for anybody. We are going to solve that. I think we are going to solve it not by cutting people back, not by saying ‘You can’t get that,’ but by delivering better care. I really believe that.”

Weird News Andy thinks it’s cool that a University of Michigan 3D-printed lung splint saved a child’s life. The surgeon says he hand-carves such devices when necessary, but he can’t match the accuracy or speed of the computer.

Sponsor Updates

• Forrester Research names Ping Identity a leader in its identity and access management report.
• EDCO creates  a video explaining its point-of-care medical records scanning process.
• Truven Health Analytics releases ActionOI Practice Insights, which allows hospitals and practices to compare productivity, costs, and utilization.
• ZirMed partners with EHR Integration Services to provide Allscripts PM and GE Centricity Group Management customers integration with ZirMed’s RCM, clinical communications, and analytics solutions.
• Kareo tops Black Book’s list of Top 20 Seamless Software Vendors for EHR, Practice Management, and RCM.
• NYC REACH, the REC for New York City, assigns Aprima the Medical Meaningful Use Champion status in its vendor recognition program.
• Medseek reports that 10 healthcare organizations are using its Empower enterprise patient portal and another 11 will go live in the next six months.
• Paul Taylor, MD, CMIO of Wellcentive, outlines the performance and improvement part of the Health Care Network Maturity Model.
• Vitera hosts a September 25 webinar on preparing for the PCMH transformation.
• An SiS blog post lists the “Top 6 Things Anesthesia Providers Should Know When Evaluating AIMS.”
• GetWellNetwork shares data from its healthcare system customers that demonstrate the relationship between patient engagement and improvements in patient satisfaction, quality and safety, and finance and operations.

EPtalk by Dr. Jayne

I wrote last week about a Wall Street Journal Health Blog piece. It referenced a survey about what motivates doctors as they make care decisions. More than half felt physicians want to do what’s best for the patient, where the choices of “fear of lawsuit” and “business / financial considerations” each received 21 percent of the response.

Since I covered fear of lawsuits already, let’s talk a little bit more about financial considerations. It’s easy to see a response of “business / financial considerations” and assume that means “what’s in the provider’s best financial interest.” I don’t think the vast majority of clinicians think that way. If we were constructing this survey, we’d have more granular choices. One of the main things I think about (after discussing the clinical appropriateness of a proposed procedure, treatment, or test) is whether there is a way to pay for the test. It was bad enough when all I had to worry about was whether the patient had insurance that would cover it, but today it’s so much more complicated. It doesn’t do any good to recommend a treatment if there is no way the patient can receive it due to financial constraints.

First, we have to think about whether the patient even has insurance coverage or not. If they do, is this symptom or condition related to anything pre-existing that may or may not be covered? If not, do I need to contact the payer for an authorization? How difficult is it to obtain the authorization? Are there tests, documents, or examples of trials of therapies that have to be provided for a medical review board to determine coverage? Does the payer have arcane rules that have been grandfathered into the plan regardless of recent legislation to ensure services are covered?

Should the authorization be obtained, are there limits on where I can send the patient? Does the patient have geographic or transportation issues that would make it more feasible (economically or otherwise) to do it at one facility over another? Does the patient have religious preferences that are in conflict with the mission of the preferred facility? Do I have to write a letter to explain the distress it would cause if allowances can’t be made for a non-preferred facility?

The next consideration is that even though the patient may have insurance and the procedure may be authorized, the out of pocket cost for the patient may be more than he or she can bear. Those under high-deductible plans are electing to defer care to the end of the year in hopes that they will meet their deductibles by then. If it’s a preventive service, we may have the opposite time shift: some plans have yearly aggregate limits on preventive services, so if they’ve already met the limit for the year, they may elect to push it to the next calendar year. Regardless of the kind of coverage, we have to know whether the patient can afford the patient portion of the cost, whether it’s a deductible, co-pay, co-insurance, or something else.

Let’s say the patient does not have insurance coverage. We have to think through whether the patient qualifies for any public assistance programs and if so, how long it would take to become enrolled vs. how acute the need for the test / treatment / procedure might be. If they don’t qualify for public assistance, are there any grant programs? Are there public health resources? Is there a hospital or imaging center doing a free outreach program? If not, do I have any colleagues in my hip pocket who would be willing to perform the procedure with a payment plan or under other medical hardship arrangements? Does the facility make allowances for self-pay patients and do they allow them to negotiate price? If so, what is a reasonable price? Where can the patient get more information?

Once we get through figuring out if we can proceed and how we’re going to pay for it, can the patient afford to take off work to have surgery, complete treatment, etc.? Is he or she covered by the Family and Medical Leave Act? Does he or she have to wait until they are eligible for coverage? Is there a short-term disability policy in place, and if not, does the patient have enough vacation time or other resources to be able to be off work? Or does he or she have to take the time off unpaid? Are there other family dynamics or barriers to care, such as who will take care of small children while the patient is in treatment? (Remember assessing barriers to care is part of being a patient-centered medical home and participating in pay-for-performance and accountable care initiatives. Believe it or not, worrying about the patient’s childcare arrangements has become our problem.)

If you’re not a provider, are you exhausted just reading this? I know I am. The absolute last thing to cross my mind in these situations is whether my practice will make any money ordering the intervention. Looking at the costs in the office for clerks, paper pushing and administrative shenanigans, multiple phone calls, faxes, the patient’s time, and my time to work through all of this, we’ve already lost money before the order even leaves the EHR. When you think about it this way, I’m surprised that business and financial considerations didn’t rank higher in the survey because it seems they’ve become part of nearly every clinical decision we make.

Maybe elements like this roll up under the attempt to do the right thing for the patient. Or maybe the average person taking the survey didn’t think about all these different factors. This wasn’t really a scientific survey, but I bet if you wanted to create one, the qualitative researchers would have a field day. I’d enjoy seeing the comparison between a survey of the general population vs. a survey of healthcare providers.

What do you think motivates doctors as they make care decisions? Email me.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 9/5/13

Cerner names new president

Cerner promotes Zane Burke to president, replacing Chairman and CEO Neal Patterson, who temporarily added the President title when Trace Devanny left the company in July 2010. Burke has been with Cerner since 1996 and most recently served as executive vice president of the client services organization.

Mostashari leaves policy designers final thoughts

National Coordinator for Health IT Farzad Mostashari, MD attends his final HIT Policy Committee Meeting, discussing the goals of MU3 and the challenges the industry will likely face on the road ahead. He also took the opportunity to thank the committee members for their work.

Your Heartbeat Is Your New Password

Developers at Bionym have created a bracelet that authenticates users based on the unique peaks and valleys of their heart’s rhythm. Users place their fingertip on a sensor embedded in the bracelet for a few seconds while an ECG is captured and compared to a stored version to confirm the wearer’s identity and authenticate that user to a host of devices.

Readers Write: Be the One

Be the One
By Daniel Coate

Amidst all the paperless aspects of our world, last year I subscribed to the New York Times Sunday edition on paper. I really enjoy the old-school nature of waking up Sunday morning, walking down my driveway to pick up the paper, and spending a couple of hours with a cup of tea or coffee reading the in-depth analysis of the week’s news.

I was taken by an article in the December 8, 2012 edition of the paper entitled, “Billion-Dollar Flop: Air Force Stumbles on Software Plan.” I’ve had it on the corner of my desk since and am just now thinking I should write about it.

The bottom line is that the Air Force is canceling a six-year modernization effort of its logistics systems and processes. On the technology front, they were attempting to convert from custom legacy logistics systems developed in the 1970s to an Oracle ERP system. The six-year track of the project cost “them” $1 billion (oh, and when I say “them”, I really mean “us”). By the time the Air Force canceled the project, it had realized it would cost an additional $1 billion just to achieve one-quarter of the capabilities originally planned. As a reminder, one billion is a big number – if you were to start counting right now at a rate of one number per second, you’d get to 1 billion in 2045 (32 years).

In analyzing the reasons for this colossal failure, many contributing factors were identified, such as starting with a big bang approach that tried to put every possible requirement into the program, making it very large and very complex.

However, the main reason identified was, “…a failure to meet a basic requirement for successful implementation: having ‘a single accountable leader’ who ‘has the authority and willingness to exercise the authority to enforce all necessary changes to the business required for successful fielding of the software.’”

As we all know, there are a number of exciting developments and converging forces changing the healthcare industry right now. With these converging forces, healthcare organizations are under tremendous pressure to address a number of priorities simultaneously:

• Reduce operating costs while driving value
• Implement and realize the full benefit of electronic health records
• Transition from volume to value and plan for the accountable future
• Harness the power of data and analytics to drive a data driven culture
• Enable the connected community across the care continuum
• Achieve Meaningful Use and complete ICD-10

While it seems like a tidal wave, these initiatives are aimed at paramount goals: better care, better health, and lower per capita costs. It’s essential that we as an industry heed lessons learned like this example from the Air Force to avoid similar stumbles or flops. While it’s never a comfortable position to be that single accountable leader, I think it’s important that as we all do our day-to-day work, we look for ways where we can either assume that leadership or recommend that a specific person assume that position. It is a key way to drive value from investments in information technology, operations and process improvement, and change leadership.

Daniel Coate is principal and co-founder of Aspen Advisors of Pittsburgh, PA.

Readers Write: Paper Bills Can Be Hazardous to Your Practice’s Health

Paper Bills Can Be Hazardous to Your Practice’s Health
By Tom Furr

Every time I go through a healthcare facility I am struck by all the paradigm shifts, inflection points, and market disruptions glistening under the bright lights alit in examination rooms, labs, and other clinical areas.

It truly astounds me that there is such a yawning chasm separating the business office from the clinical side of the practice. It hits me all the more when I pause to consider most of what’s going on in medical practice management revolves around how a doctor will get paid for services provided.

This is part of the fundamental changes needed in the business office that requires a massive disruption to the way patients get billed, payments are secured, and – yes – the embrace of productivity- and profit-improving technology.

In fact, the MGMA states that today practices need to send out an average of 3.3 paper statements to secure payment. It’s not a great leap of logic to add bill issuance and bill pay to a practice’s online capabilities if it’s already “forced” to make patient clinical information available online. What’s more, the need to issue multiple paper statements that can cost around $0.70 to get paid is reduced, if not eliminated.

So be honest — what’s the hurdle that is keeping you from making a change? Are there several cases of paper invoices sitting on a shelf and you feel compelled to use them for fear someone will call you a money waster?

If you truly want to cut costs and improve profitability, throw away those paper bills and all the time consuming, error-producing manual processes associated with that antiquated and expensive process.

To be fair, the tumult of change is daunting for medical practices, but it doesn’t need to be destructive. Embrace change and employ innovative online patient billing and balance management that can be easily embedded into practice management software.

One key pressure medical practices are feeling which will make the change more palatable is the rise of patient accounts receivables; a reflection of the inexorable march from the simplicity of co-pays to high deductible health plans. One industry expert notes that, “It wasn’t that long ago that health plans covered 87 percent of medical bills. Now they cover 65 percent.” According to Aon Hewitt’s 2013 Private Exchange Survey, growth rates of high deductible health plans (HDHPs) has been averaging 10 percent per year, and as more employers promote the plans, the growth rate is accelerating.

If you still need motivation, let me share with you some research findings on consumer behavior when it comes to paying bills.

• The people who stack up their bills once or twice a month and write checks are far and few between.
• Folks who get bills in paper form tend to delay paying them versus those that arrive digitally.
• Medical bills are often not paid because they are complex and confusing and the hassle to find out what the charges are for and what’s owed translates into…delayed payment.
• Even the US Postal Service, that organization that depends on your paper bills as the bulk of what makes up first class mail today, has come to realize that 60 percent of consumers prefer to pay bills online, the result of a survey they conducted among people just like your patients.

Take a break from reading of the latest diagnostic breakthrough in a medical journal. Look at your practice’s balance sheet, particularly the A/R line. Before market forces push you to sell or close up your practice, embrace change in patient billing and balance management. Go away from paper and move toward better, more manageable profitability with online billing methods.

Tom Furr is founder and CEO of PatientPay of Durham, NC.

HIStalk Interviews Larry Garber, MD, Medical Director for Informatics, Reliant Medical Group

Lawrence Garber, MD is medical director for informatics at Reliant Medical Group (formerly Fallon Clinic) of Worcester, MA.

Tell me about yourself and the group.

I’m a practicing internist. I’ve been at Reliant Medical Group for 27 years. We are a multi-specialty group practice, about 250 physicians, covering big hunk of central Massachusetts. I’ve been working in computers since high school in 1972 with my first computer that had 8K of core memory. I’ve always continued to do computers and medicine at the same time.

You’ve said that the difference in overall cost between the cheapest and the most expensive EHR is probably five or 10 percent of the total project cost. Are practices focusing too much on the licensing cost and not looking at the long-term cost and benefits?

Yes, absolutely. A lot of practices, especially the smaller ones, don’t have time to think of the total cost of care and the long-term picture. A lot of people are just budgeting to get them live. So much needs to be spent on even the optimization that you need to continue to do after you are live.

What are the top two or three innovative ways that you’re using Epic to improve care, reduce cost, or both?

One of the best ones we’ve done is our medication refill smart tool. When our medical assistant receives a request for a medication renewal, they put in the orders for those medications. Then they pull up a smart tool that recognizes which medications are about to be reordered. It pulls in all the appropriate information that I as a physician want to see, including the last appropriate lab tests for monitoring how they’re doing on that medication, what upcoming tests are appropriate for those meds that have already been scheduled or need to be scheduled. It tells me last visits, upcoming visits. It also even suggests to the medical assistant how many refills would be appropriate for that medication.

For instance, some high-risk medication and I haven’t seen the patient for a year, it suggests that we just give them a month and tell them to make an appointment. Whereas someone who is being followed regularly and they’re getting all the monitoring tests, we’ll recommended that they get a year’s worth of refills . It’s really nice. We don’t need to have a pharmacist or a nurse staging the prescriptions. We can have a medical assistant pull it all together and I can see it all in one screen and sign it with one click.

Is that all straight Epic setup? What’s your organization’s level of expertise with Epic that you’re able to make all that work?

That one is pretty straightforward using standard Epic tools. That is why we had gone with Epic in the first place. They’re incredibly powerful and configurable and so that even using their standard tools ,you can do incredible things. We do also do some Cáche programming where we get behind the scenes since Epic does share with us their source code. There are two of us, myself and one of the other physicians, John Trudel. The two of us are able to do Cáche programming. There are about 30 routines that we’ve tweaked to be able to do some stuff so that they work perfectly for our needs.

A simple example is their standard inbasket report. For a lab result, it will show you, here are the new labs. There is a little line that says “previously viewed.” All of the results that you’ve already seen on that patient and that that were previously viewed was tiny. We went in and updated their programming point to make it a big, prominent line so it’s very easy to see what’s new versus what’s old. It’s a minor tweak. It took an hour, but it dramatically improves our usability.

Not many organizations, even hospitals, would have people available to do Cáche programming, although they could hire consultants. Would you have been happy with Epic without that ability, or would you have been happy with other products that don’t allow you to make those changes?

We’ve had a homegrown system for many years for something called Quick Chart. We were used to having the ability to put things exactly where we wanted them and exactly how we wanted them, based on what we felt was important for usability. We would probably not have been happy stepping back to a system where we didn’t have that level of control. 

That’s actually one of the big factors in us choosing Epic in the first place, because we knew we would be able to do that. I don’t know about other EHR vendors as to whether you can get access to the source code, but I would recommend any shop that’s an Epic shop, since it’s mostly large customers, try to get at least get one person who is Cáche certified.

You’ve been on Epic since 2007. Are you happy with the way that the product and the company have progressed since then and the way that you think they will progress in the future?

Absolutely. I feel they really do listen to their customers. They are trying to balance the desire for innovation against regulatory requirements. They did slow down when Meaningful Use came along in terms of their level of innovation. They’ve clearly put a focus on that. They feel now that they’ve got that under their belt they’re moving along with a lot of cool new functionality. That is why we love going to the user group meeting each year to see what’s coming. Then we come back and we say, we need to upgrade now and skip a year. [laughs]

Other than Epic, are you using any interesting technology in the group?

We have a couple of hundred patients now who use home blood pressure monitors. After they do their readings, they plug the monitor into their home computer and it uploads it automatically through Microsoft HealthVault and then loads it right down into their Epic record. We’ve set it up using standard Epic functionality to batch the readings, so that if someone is uploading their blood pressure readings twice a day, we don’t want to generate two messages a day on them. We can pick the timeframe for each patient. We might want to batch their blood pressure readings together, and then at the end of two weeks, one message is sent to my nurse saying, here are the blood pressure readings. Here is the average over this period of time. 

My nurse can decide if there is something that needs my attention or whether they can just let the patient know that they are doing great. With any of their uploads, if there is a critically high or low value, that automatically gets sent right away. It doesn’t wait for the two weeks. That works out very nicely.

You’ve had some thoughts about how to get physicians to use the technology in more than just the minimal way and to get them excited about it. What are your secrets?

Some of it has to do with feeling of ownership. Our physicians, nurses, and the clinical staff – the medical assistants — were all involved in the selection process from Day One. They felt that this wasn’t something that was being done to them, this was something that they had chosen. 

We try to give them as much control as possible. When they come up with an idea saying, hey, why doesn’t it do this or this seems to be wrong, we try to respond to those very quickly and fix things and make them better. We try to make our physicians and staff feel loved and owners of the system. When you feel like it’s your baby, you tend to work better with it.

Your group is financially at risk with 70 percent of your patients and is also a non-profit. What technology conclusions have you reached from being in that position?

That you can be successful. That using clinical decision support is important.

When we first implemented Epic, we looked at our HEDIS measures and other measurements. Not much really changed with just the implementation of the electronic health record. But turning on the clinical decision support with the alerts and the reminders, setting up interfaces to other parts of the healthcare system…  we’re interfaced to several hospitals in our area that we sent our patients to. We’re interfaced to a health plan. We load claims data on those 70 percent of patients. We load those back right into Epic, so that if a patient of mine has a mammogram done across town by some outside gynecologist and they order it, I get that loaded automatically to my record. I know who truly has had their appropriate health maintenance and disease management and who hasn’t so I can target my effort on those people who haven’t.

I think that it’s important — that you can be successful, but you need to do the whole thing in turning on the clinical decision support, getting connected to health information exchanges, interface to the rest of the healthcare system.

One of the black holes is when the patient gets discharged and nobody knows who’s doing what. You have an ADT feed to let you know that’s happened so you can initiate follow-up. What do you do?

When the secretaries see that there has been a discharge, they try to book a follow-up appointment. If it turns out that it didn’t take place, they get an alert three days after the discharge saying, it looks like this person isn’t scheduled for a follow-up appointment and hasn’t had one yet, please make sure you schedule it. Both from the actual discharge instructions that we get immediately followed up by three days later another alert saying that this doesn’t look like it’s taken place, make sure you book it – that that works well.

The nice thing is that we send the message to the right people, so that three-day alert saying this hasn’t been happening, you haven’t booked a follow up — it doesn’t come to me, it comes to my appointment secretary. I also get notices three days after discharge that the patient is on new medications that require some intervention, either that there should be some monitoring test that doesn’t appear to be taking place — whether it hasn’t been ordered or it’s not already resulted — or there seems to be a new drug interaction that I ought to be aware of and that maybe I need to adjust the dose of the medication. We wait three days on that because we use the claims data to let us know what new medications have been prescribed and that the patient went home to the pharmacy and got a new prescription. We get the claims data about a day and a half later. Then we can see what’s new and what the implications are for that.

Where do you think analytics fit in all the things a practice or hospital should be doing?

I think it’s a little bit overhyped. The reality is that analytics running on the back end in the business office or the administrator’s office does not help the patient when they’re sitting in front of me, or help me when the patient is sitting in front of me. It’s really most important to get that intelligence right there at the front line at the point of care. That’s where most decisions are being made and whether they are good or bad. It’s our opportunity to do the right thing.

I am a big advocate for first getting your front-end decision support working. Get the data to the front end, so that when I’m seeing the patient, I know what happened in the hospital, I know what happened with the specialist who saw the patient. Get those ducks in a row. After that, then you can start thinking about maybe doing the analytics on the back end to try to find sicker patients who may need more intensive care. Somewhere in between is doing the registries — finding patients who are falling through the cracks. But again, it’s being hyped as the nirvana, and there’s some very good practical stuff that people should be doing that they are not even doing right now.

Are you mining your Epic data to look for trends or evidence-based medicine opportunities?

We use the data for research studies. We also use the data to identify what we think are our higher-risk patients so that we can set them up with care managers. We are doing that sort of mining. Of course, we do look for trends. Since we are at risk financially, we look for areas where we may be doing better or doing worse financially to try to stay on top of those areas as well.

One of the other cool things I didn’t mention when we were talking about at the hospital discharge. One thing that we’re about to turn on is when one of our patient is seen at our local emergency room, we automatically get one of those ADT notifications that our patient is there. We are going to echo back a CCD summary document right back through the state health information exchange back to that hospital. They’ll be loading that into their emergency room system, so that on the big dashboard that they have in the emergency room that shows which patient is in which bed, there will be a little icon that shows that there is an outside record now available for that patient. Within a minute of the patient being registered, there will be a summary document sitting in the emergency room record and letting them know the latest information on that patient.

The SAFEHealth HIE works differently than the typical HIE. What are the lessons that other HIEs might take from how it works?

Don’t make people think. [laughs] That’s probably the most important thing.

It’s a federated health information exchange, but most important is that Massachusetts is an opt-in state, which means patients have to give consent. We make it simple for the registration person, who is doing what they normally need to do to take care of the patient, to get them checked in. As a by-product of doing that, SAFEHealth checks and sees whether a consent is necessary and whether it’s already been obtained. If it hasn’t been obtained, it just prints it out right next to the registrar. No one actually has to think about SAFEHealth or whether consents are necessary, just the consent form automatically prints. That’s a clue so the clerk can say, oh, wait, let me tell you about SAFEHealth and let me get your approval to participate in it. 

The key thing is that you have to think about workflow. You have to make things happen automatically so that people don’t have to be consciously thinking about how to do the right thing. It should just be easy and automatic to do the right thing.

Even though your group is not affiliated directly with or owned by a hospital, you seem to have a closer working relationship than a lot of practices that are. How did that happen, and what are the lessons learned?

It’s the alignment of incentives. As a group practice with a high level of risk contracts — we’ve always had a high level of risk contracts for 20 years — we’ve been incentivized to make sure that we give high quality, cost-effective safe care. We know that it’s important to get that connectivity to the hospital in order to do that.

From the hospital perspective, they know that we’re going to send our patients to them if we’re happy and we know that we’ve got good connectivity. From their perspective, they want our patients, so it’s in their best interest to keep us happy and do the connectivity. Also in part, we are lucky that we’ve had good partners. These are hospitals that didn’t feel threatened by our physician practices. They had the technological skills to be able to interface with us.

What do you see as the most important thing that you will have to address in the next five years?

As a nation, we’re going to see the evolution of what I call hassle-free HIE. That is going to be a whole new world. We’re good at our silos, but to do health information exchange is a hassle right now. What we all need to work on is making health information exchange something that is easy and automatic and part of the normal care that we give. The era of hassle-free HIE is coming.

Morning Headlines 9/4/13

Flip The Clinic

The Robert Wood Johnson Foundation launches a new project called "Flip the Clinic" committed to investigating and optimizing every aspect of the physician-patient encounter to ensure that it is as mutually beneficial as possible. In 2014, the foundation will release a toolkit of strategies and resources outlining the findings.

IBM delivers a unified health information platform for New Zealand healthcare providers

In New Zealand, the Ministry of Health launches a nationwide patient portal called the Health Identity Programme that will provide patients, providers, and pharmacists a single, centralized platform for coordinating care.

NHS to receive £240m Government funding boost as health secretary pledges to revolutionize the way it uses technology

In England, hospitals, practices, and EDs are receiving a $375 million increase in funding for new technology to help streamline scheduling processes and increase the use of e-prescribing.

With physician offices online, Novant shifts electronic health records focus to hospitals

Novant Health (NC) is preparing for an October 5 Epic go-live at its Presbyterian Medical Center facility in Charlotte. The health system recently finished bringing 300 physician offices live two years ahead of schedule.

Pay Gap for Women Doctors Increases to $50,000 a Year

Female physicians in the US earn on average $50,000 a year less than their equally qualified male counterparts according to a study published in JAMA Internal Medicine.

News 9/4/13

Top News

A new Robert Wood Johnson Foundation project called “Flip the Clinic” looks for ways to redefine the patient-provider encounter, including examples such as OpenNotes, Blue Button, and the Project ECHO telemedicine program. The program, bring run with a social innovation consulting company and a design firm, will launch a toolkit in early 2014.

Acquisitions, Funding, Business, and Stock

Quantia, the developer of physician social networking and learning platform QuantiaMD, raises $10 million in Series B financing, led by Safeguard Scientifics and Fuse Capital.

A Crain’s Chicago Business column ponders “Why is Chicago so bad in health care IT?” saying that at Merge Healthcare and Allscripts, “sales are shrinking and losses are rising at both companies; each has endured upheaval in the executive suite.” It concludes that both companies need to turn around before the HITECH well runs dry and laments that local healthcare IT startups “don’t have have better role models.”

Sales

Jamaica Hospital Medical Center (NY), Catholic Health, INTEGRIS Health, (OK) and about 40 additional provider organizations select Nuance Clintegrity 360’s computer-assisted coding platform.

Long-term care provider Nexion Health selects the Daylight IQ clinical outcomes management system.

People

Kristi Syling (Vanguard Health Systems) joins PerfectServe as compliance officer.

Announcements and Implementations

Novant Health Presbyterian Medical Center (NC) will deploy Epic October 5, the first of the health system’s 14 medical centers to go live. Novant’s 1,205 providers are already using Epic across 316 clinics as part of the organization’s $600 million EHR initiative.

The New Zealand Ministry of Health implements the Health Identity Programme, a standardized interoperable platform built on IBM’s Infosphere Master Data Management to identify patients and providers across the country’s health sector.

HIMSS names eClinicalWorks customer White River Family Practice (VT), winner of the 2013 Ambulatory HIMSS Davies Award of Excellence for its success in improving quality of care and patient safety while achieving a demonstrated ROI. In its award application, the practice hits on a point too often overlooked by providers unwilling to dedicate the time and money required for EMR success:

“Return on investment is critically dependent on how quickly the practice returns to typical patient-visit volume. To that end, investing time and resources to learn the chosen EHR system up front will expedite the office’s return to pre-EHR patient volumes, obviating the need to spend late nights trying to catch up.”

Cheyenne Regional Medical Center (WY) will pay about $50,000 a year to participate in the state’s MyWy Health information exchange, which is currently funded with a $4.9 million HHS grant and $260,000 from non-governmental sources.

Allscripts announces GA of Professional EHR 13.0.

Microsoft shows off sports-related applications that use its products, including the National Football League’s eClinicalWorks EMR and the X2 sideline concussion diagnosis system.

Truven Health Analytics announces that Micromedex NeoFax and Pediatrics now support HL7 integration with EHRs for clinical decision support and CPOE.

Merge Healthcare’s iConnect Enterprise Archive is named the leading vendor-neutral archive solution in the US and the world, accounting for 32.6 percent of all studies stored in a VNA in the US and 22.7 percent worldwide.

Government and Politics

The HIT Policy Committee will meet Wednesday from 9:30 a.m. until 3:15 p.m. in Washington, DC (with live streaming) to review the FDASIA Workgroup’s recommendations and to hear from the Meaningful Use Workgroup on progress toward Stage 3.

England’s Department of Health announces $375 million in funding for information technology for hospitals, surgeries, and EDs, raising the total money placed in the Technology Fund at more than $1.5 billion.

Other

Nine out of 10 hospitals report they experienced RAC activity in the first half of the year, according to an AHA survey of 12,000 hospitals. Requests from Medicare for medical records are up 47 percent since the fourth quarter of 2012 and complex audit denials by Medicare RACs rose 58 percent in the second quarter of 2013.

A Missouri orthodontics practice notifies 10,000 patients that their information was stored on unencrypted computers that were stolen from the practice in July.

The CIO of the Marine Corps says, without referencing the source, that 25 percent of surgery liability lawsuits are related to software.

Sign of the times? Mayo Clinic Health System announces the closing of its Blooming Prairie, MN (population 2,000) facility after the resignation of the practice’s sole provider. Mayo says the closing is temporary and encourages patients to travel 15-20 miles to other locations.

Bradford Regional Medical Center (PA) opens the country’s first inpatient treatment program for Internet addiction, which will cost $14,000 for a 10-day stay that insurance won’t pay for.

I’ve noticed several eye-catching headlines this week highlighting the continued inequities in compensation between male and female physicians. Research published in JAMA finds that the gender pay gap among healthcare workers has grown over the last decade, with male physicians earning about $56,000 (or 25 percent) more than their female peers. Researchers note that a physician’s specialty or practice type may account for some of the difference, but say more research is required to understand if specialty and practice choices are due not only to the preferences of female physicians but also unequal opportunities to enter high-paying specialties. The Gloria Steinem in me would love to hear readers’ theories for the compensation gap.

MMRGlobal not only terminates its patent infringement settlement with WebMD and refiles its original lawsuit, it also adds an additional complaint related to its newly issue patent entitled “Method for Providing a User with a Service for Accessing and Collecting Prescriptions.”

A startup called Handshake lets Internet users broker the sale of their personal data to interest companies, disintermediating market research firms and companies like Google and Facebook that grab it for their own bottom lines and instead allowing the user to negotiate their own deals. The site estimates that individuals could earn up to nearly $8,000 per year. Imagine the possibilities with health-related data.

A report by the Federation of Indian Chambers of Commerce urges the Indian government to restrict the importation of medical technology and instead encourage local innovation that will allow making services more affordable for all.

Sponsor Updates

• Etransmedia highlights a video describing how its Direct Care Coordinator software helped doctors at the Albany Med Faculty Physician Group communicate with other physicians.
• NextGen Healthcare releases an updated version of its Patient Portal, which incorporates Spanish and two dialects of Chinese.
• Beacon Partners hosts a September 13 webinar on using data analytics to improve population health management.
• CommVault reports earning a 96 percent customer satisfaction rating its support services survey.
• Xerox has processed and disbursed more than $1.7 billion in federal payments to providers for MU incentives through its State Level Registry tool.
• Jon Hamdorf, healthcare solution manager for Perceptive Technologies, participates in a panel discussion on the challenges of health information exchange at this month’s Health IT Summit in NYC.
• A Billian’s HealthDATA report lists 112 US hospitals that demonstrate positive net patient margins and 30-day readmission and mortality rates above the national average for heart attack, heart failure, and pneumonia, according to CMS.
• Divurgent co-authors a white paper with Bon Secours Kentucky Health System that provides both a client’s and vendor’s perspective on implementing an EMR.
• Wellcentive SVP Mason Beard and CMIO Paul Taylor, MD host a September 17 webinar on implementing an effective population health management and data analytics program.
• Ryan Uteg and Lyndon Neumann of Impact Advisors discuss EHR roadmap evaluation at a September 18 CHIME College Live Session.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 9/3/13

Utilization, Benefits, and Impact of an e-Consultation Service Across Diverse Specialties and Primary Care Providers

In Canada, a virtual consultation service was established for PCPs to discuss patient care with specialists. After a year, providers enrolled in the program were surveyed, with 90 percent reporting that the service was highly beneficial to both providers and patients. Specialists reported that the actual consultations usually took less than 15 minutes to complete, and almost half of the requests submitted would have required a face-to-face office visit if the service had not been available.

Launch of New Electronic Medical Record System Scheduled for September 4

A local paper covers 152-bed Sonora Regional Medical Center (CA) as staff prepares for a September 4 Cerner go-live across all of its outpatient clinics.

Pre-Pregnancy Hormone Testing May Indicate Gestational Diabetes Risk

A retrospective study conducted by searching Kaiser Permanente’s EHR dataset finds that overweight women with low levels of the hormone adiponectin prior to pregnancy are nearly seven times more likely to develop gestational diabetes.

Curbside Consult with Dr. Jayne 9/2/13

At one point or another in our careers, most of us have seen excerpts from All I Really Need to Know I Learned in Kindergarten by Robert Fulghum. For those of you who haven’t, it’s got some great tips:

• Play fair
• Don’t hit people
• Clean up your own mess
• Don’t take things that aren’t yours
• Warm cookies and cold milk are good for you

He also advises that “wisdom was not at the top of the graduate school mountain, but there in the sand pile at school.” Many of the projects I’ve worked on over the years would have gone much better had people followed his advice. General rules of niceness never go out of style.

In thinking about ways we work together, I’ve realized that specifically regarding teamwork, Everything I Need to Know I Learned on the Back of a Tandem Bicycle. A mountain bike, in particular. Those of you in the cycling community will appreciate what that means. If you’re not a cyclist, just know that you have to be a little crazy to take a bicycle built for two off-road. Here are the things I’ve learned:

The team needs to know their roles and what they have to work with. On a tandem, we call the front rider the captain. That’s who controls the steering, shifting, and braking. He or she has to know the limits of the team and equipment and how far they can be pushed. The rear rider is called the stoker. It’s difficult for people who are used to being in the lead to have to assume that role. One thing I learned along the way is that the captain can tell pretty easily when the stoker is trying to be a back seat driver because the rear handlebars are attached to the captain’s seat and having your saddle torque around is usually not appreciated. The stoker has to learn to give up some control and trust the captain.

Every team needs a captain. I think that often when teams are formed, people are under the impression that everyone is equal. Although I do subscribe to the philosophy of “leave your titles at the door” to level the playing field, someone must generally be in charge for a team to be successful. Being the captain can mean different things depending on the team. For teams that are forming or storming, it can mean helping people to align goals or figure out how to work together without fighting. For teams that are truly performing, it might be just facilitating meetings and ensuring things stay on time and that minutes are created and distributed.

Each of us needs to pull our weight. Unless you have a DaVinci tandem, both riders have to pedal at exactly the same speed. If one decides to slack off or push too hard, the other rider can feel it right away. It can result in a jerky and uncomfortable ride and can wear out the stronger rider.

Communication is essential. Especially if you’re clipped in your pedals, you have to talk to each other. Even little things such as what foot you like to use for the initial pedal stroke have to be decided and agreed upon. The captain has to communicate when more or less speed is needed and whether there are any hazards ahead such as branches, rocks, roots, holes, or railroad tracks. Coasting must be a coordinated effort. If you’re going to get into advanced skills such as trying to jump the tandem over obstacles, you better have it together.

Teams can provide efficiency, but they have to stay in control. The last time I was out on a tandem, one of the single riders was curious about what riding a tandem was like. Looking at the physics, tandems are heavier, which can make climbing tricky (especially if your frame is under-engineered and prone to flexing). The forward-moving wind resistance and amount of road friction are both similar to a single bicycle. The real difference is that tandems have twice the available power. When both riders are strong, it’s easy to get up to speeds that are nauseating. If you don’t watch the road or control your speed, the results can be disastrous. Prolonged braking from a high speed or on a steep descent can cause the rim to overheat and blow the tire off (unless you have wicked-cool disc brakes like the bike I rode today.)

Fear is not an option. I usually wind up being the stoker, and if you don’t trust your captain completely, you don’t have any business riding. It starts when you get on the bike. The captain holds it steady while the stoker mounts and clips into the pedals. Once the stoker is set, you have to make sure your pedals are in the right position. Nothing makes the captain madder than when the stoker spins the cranks without warning and slaps the captain in the shin with a pedal while he’s standing over the bike. When you’re ready to move forward there’s an uncomfortable moment when you start pedaling while the captain is getting onto the seat and you begin moving. You never quite get used to it, but you have to trust that you’re not going to fall over. (Side note – the two times I’ve actually fallen over on a mountain bike have NOT been on a tandem. Totally my own fault.) One thing that helps me with the fear factor is that most captains I’ve ridden with are bigger than me, so I can’t see what’s in front of us and I just have to go with the flow.

Working together we can perform feats that are impossible alone. The Paralympic games feature tandem pairs that often include blind or visually impaired stokers. In my situation, I don’t ride enough to have the skills to tackle some of the more challenging trails. I definitely wouldn’t venture out alone in some of the more remote areas. But clip me in behind someone who knows what he’s doing and I’m happy to help push both of us forward. Besides, I get to enjoy the view when I’m not worried about steering.

If you ever have the opportunity to ride a tandem, it’s definitely a different experience than going it alone, but it’s one I’d highly recommend. Maybe a reader or two might even spend part of Labor Day weekend on a tandem. If not, I hope you were able to enjoy the weekend with friends and family and pay homage to the achievements of the American workforce.

E-mail Dr. Jayne.

Morning Headlines 9/2/13

Electronic records conversion loss offset by investment gains for Wake Forest Baptist

Wake Forest Baptist Medical Center (NC) discloses in its 2013 annual report that its Epic implementation resulted in a $55.1 million operational loss for the year, the report says the install “did have a substantial negative impact on fiscal 2013 operating performance through both direct implementation expenses and associated indirect expenses.” Wake Forest’s stock investment gains for the year were able to offset the losses, so the overall loss for the year was reported at only $571,000.

Army Medical Program Prepares to Upgrade EMR System

The Army’s current battlefield EMR, known by the acronym MC4 (Medical Communications for Combat Casualty Care), will undergo a major upgrade between November 2013 and April 2014, that will bring the platform onto a Windows 7 operating system, replace Micromedix, the current medical reference app, with Lexi-comp, and add a new layer of information security features.

New hospital CEO updates board at his first meeting, announces new CNO

68-bed Gila Regional Medical Center (NM) eliminates its CIO position, as well as several other executive level positions, in an effort to cutback on costs at the financially struggling hospital. 67 employees were also cut from full to half time.

Monday Morning Update 9/2/13

From The PACS Designer: “Re: TPD’s back. Since development efforts on a cloud based ICD-10 solution are winding, down it allows TPD the time to post again. A significant event took place concerning Apple this week which could be of interest to HIStalkers, and that is Apple’s acquisition of software company AlgoTrim. Their software improves access speeds to large file sizes typical  and larger diagnostic imaging studies that are more prevalent than ever in today’s practices. The AlgoTrim Fast Compression Library is the fastest lossless codec (compression) on the market, with speeds four times faster than similar codecs.”

I’ve been saying for years that companies need to override their lead-happy sales and marketing people and make their advertising material (like white papers and case studies) freely available on the Web without requiring completion of a sign-up form. My survey results back that up all the way. Half of a company’s prospects run for the hills when faced with a form, and another quarter provide phony information to avoid the dreaded follow-up call. Add in the number of people who sign up but don’t return calls and you’ll see the futility of trying to drum up product interest via an intrusive data collection form. New poll to your right: if you routinely attend the HIMSS annual conference, what’s your primary reason?

Just a reminder: a couple of folks with outstanding credentials will present a free HIStalk Webinar, “The HIPAA Omnibus Rule: What You Should Know and Do as Enforcement Begins” next Tuesday, September 10 at 2:00 p.m. EDT. Their presentation is not sponsored – they just stepped up when I asked for volunteers to go over the changes for readers now that the enforcement date is upon us. Thanks to our presenters from The Advisory Board Company: Rebecca Fayed, associate general counsel and privacy officer; and Eric Banks, information security officer. I watched their practice session and it’s meaty and fluff-free in the admirable Advisory Board fashion.

Financially struggling 68-bed Gila Regional Medical Center (NM), a Stage 6 EMRAM hospital and Meditech customer, eliminates its CIO position after the departure of David Furnas (and most of the executive team) earlier this month.

Joe Miccio (Divurgent) joins ESD as regional sales VP.

A Dallas news magazine recounts the fascinating tale of a newly licensed MD-PhD neurosurgeon whose incompetence left several patients maimed or dead while the state’s medical board couldn’t stop him from practicing. Colleagues called the doctor the worst they had every seen and said his skill level was no higher than a first-year resident as he kept inadvertently slicing arteries causing patients to bleed to death, and in one case the OR team had to forcibly remove him from the OR to prevent him from killing his patient. His marketing team and his 4.5 star Healthgrades.com rating brought in plenty of new patients to his loftily named practice, Texas Neurosurgical Institute. Surgeon readers will be horrified by this recap by a peer who had to clean up one of his messes: “He had amputated a nerve root. It was just gone. And in its place is where he had placed the fusion. He’d made multiple screw holes on the left everywhere but where he had needed to be. On the right side, there was a screw through a portion of the S1 nerve root. I couldn’t believe a trained surgeon could do this. He just had no recognition of the proper anatomy. He had no idea what he was doing.” The article blames the situation on malpractice caps, laws that hold hospitals liable for damages only if their intentions are provably malicious, and a nearly powerless medical board charged more with keeping licensure records and counting CE hours than watch-guarding patient safety.

I’m constantly annoyed by websites (including healthcare IT ones) that tart up worthless “news” stories with catchy headlines, gratuitous graphics, annoying slide shows, and shameless ploys to get more clicks to impress potential advertisers. That’s all I’ll say since I can’t outdo The Onion’s eloquent criticism of CNN’s decision that Miley Cyrus is the most important news in the world, packaged as a phony confession from CNN’s editor, which is summarized as, “All you are to us, and all you will ever be to us, are eyeballs. The more eyeballs on our content, the more cash we can ask for. Period. And if we’re able to get more eyeballs, that means I’ve done my job, which gets me congratulations from my bosses, which encourages me to put up even more stupid bullshit on the homepage … Advertisers, along with you idiots, love videos.” Right now on CNN as some of its top stories: “The best cat video of all time is …”, “What Miley’s saying now”, “Twin baby pandas now fuzzy, cute,” and “Hear painful beauty pageant blunder.” You won’t find any of those stories on the BBC, although it probably gets a lot less traffic in not pandering to the average American reader. In healthcare IT, you get the added bonus of writers who have never worked in healthcare IT trying to explain it to experts or even editorializing about it, which would be like an unathletic sportswriter telling Peyton Manning how to throw a football.

The non-profit Medical Identity Fraud Alliance launches with founding members that include AARP and the Blue Cross Blue Shield Association. The group says its goals include driving policies, laws, and technology to reduce medical identify fraud.

Wake Forest Baptist Medical Center’s botched Epic implementation caused it to lose $55 million in the fiscal year on the operations side, according to its preliminary financial report. The hospital says the Epic implementation “did have a substantial negative impact on fiscal 2013 operating performance through both direct implementation expenses and associated indirect expenses,” causing a $54 million hit due to go-live disruption, deferred operational improvements, and billing problems.

The US Army is preparing for a major upgrade to its MC4 battlefield EMR that will include a move to Windows 7, replacing Micromedex with Lexicomp, adding a graphical user interface to TC2, and requiring a PKI-E certificate for security.

In England, NHS expects up to 50,000 clinicians to learn the basics of programming under its Code4Health initiative, which hopes to encourage them to develop prototypes that NHS can turn into open source tools. The program is based on the US Code for America program, which encourages government employees to learn programming. Code for America is described above in a TED talk by its founder and CEO.  

A North Carolina comprehensive clinic for the uninsured closes, blaming a loss of funding, the state’s decision not to expand Medicaid coverage, and a loss of productivity caused by its new EHR.

The Federal Trade Commission files a complaint against  Atlanta-based LabMD, claiming that a patient-specific billing worksheet with information on 9,000 of its lab test patients was found on a file-sharing network and later in the hands of identity thieves.

Vince continues his HIS-tory of Cerner, from which I learned where the name originated and how the IPO came about.

Happy Labor Day, especially to those actually laboring on healthcare’s front lines. It may seem like the end of summer, but officially you still have three more weeks to wear those snazzy white shoes and seersucker suits.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Time Capsule: Think Today’s Healthcare System is Bad? Imagine if Doctors Followed Only Their Own Best Interests

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

I wrote this piece in May 2009.

Think Today’s Healthcare System is Bad? Imagine if Doctors Followed Only Their Own Best Interests
By Mr. HIStalk

Everybody gripes about the US healthcare system’s high cost and low value. Rightly so, but it could be a lot worse. Here’s a thought I had today:

Imagine how bad it would be if doctors weren’t willing to follow the Hippocratic Oath.

I see doctors as falling into two camps. Some went to state medical schools at taxpayer expense. I figure those docs owe the rest of us, kind of like military academy students who have to repay their debt by serving in uniform once they graduate.

However, bunches of new MDs and DOs went to private med schools. They don’t owe us a thing.

Imagine the strain that doctors could place on the healthcare system if they took the course of action that benefits them the most, no different than a lawyer or accountant would do. They might refuse to:

• Treat patients who can’t pay cash upfront.
• Work for free serving on hospital committees or taking ED call.
• Work nights and weekends.
• Use someone else’s information systems, like CPOE.
• Use EMRs and interoperability technologies just because someone else wishes they would.

Doctors should be able to do whatever they damn well please and not feel guilty about it. If a doctor doesn’t want to take Medicare because it’s a money-losing pain, then blame Medicare, not doctor. If they shun using an EMR because it cuts their productivity, blame the vendor. If a hospital can’t survive without free doctor labor, then maybe it should fail or maybe the system is flawed.

If I were a cynical doctor watching my income drop, I would ditch the niceties and do whatever benefits me the most. I wouldn’t hurt patients, but I would focus on the activities that provided the most income or satisfaction, no different than most other professionals. Why not take advantage of the system that everyone plays in?

I’d start a boutique practice, cherry-pick the cash patients, and tell the insurance companies to stick it. I’d work 9 to 5 and tell patients to call the ED if they have an off-hours problem. I would get some humorless MBA to figure out how to run my practice like a factory, identifying those particular widgets that are the most profitable, then crank those out efficiently and soullessly. In any other field, this would be considered admirable and efficient.

Most importantly to this discussion, I would look at technology the same way a big company looks like plant equipment: it better pay for itself fast. Why else would I want it?

That sounds crass and cold, doesn’t it? So what? Doctors shouldn’t be expected to make sacrifices that other professionals don’t. Rightly or wrongly, we don’t have a charity-based healthcare system – it’s a business. Companies in business choose their means of production carefully. That’s why there’s a free market (or at least was until EMRs were mandated).

Doctors are soon going to be punished for using the technologies that provide them benefit if they’re not the ones Uncle Sam says are best. Next thing you know, professors will be fired for using overhead projectors instead of PowerPoint, accountants will be fined for doing calculations by hand, and lawyers will have to select only government-certified suits.

Thank goodness doctors haven’t wised up to the fact that they hold astonishing power over whether the healthcare system fails or keeps limping dysfunctionally along. Better hope the labor unions don’t whisper in their ear.

This Week in HIT 8/30/13

Tales from Encrypt: Big Breaches to Fill

Facts and Background

Major data breaches were reported this week at Advocate Medical Group (IL) and UTPhysicians (TX), both involving the theft of unencrypted computers from their premises.

Opinion

Both incidents involved somewhat unusual circumstances: Advocate’s stolen devices were desktops rather than laptops, while the stolen laptop of UTPhysicians was attached directly to a medical device and therefore not something IT would necessarily support. The bottom line of this cautionary tale: if there’s a hard drive, encrypt it.

Musings

• Computer security is only as good as physical security unless encryption is installed.
• Computers attached to medical devices may not even be on the network, making them discoverable only by physical inspection.
• It’s interesting that anyone even bothers to steal computers given their low black market value compared to cell phones or iPads. Perhaps they are intentionally stolen for more sinister purposes, such as intending to sell the medical data they may contain or holding them for ransom, but the thieves realized too late that they’re not really bright enough to pull that off.
• Government agencies like HHS and the IRS like to choose an occasional rule-breaker and flog them publicly to keep everybody else in line. Being that poster child is going to cost AMG millions in fines, investigation costs, and remediation.

Hospital EMRs: Epic and Cerner are Kicking Sand in Everybody Else’s Faces

Facts and Background

A KLAS report finds that Epic and Cerner are about the only systems being bought by 200+ bed hospitals and health systems, while Meditech and McKesson Paragon dominate small-hospital sales.

Opinion

The Epic-Cerner domination was obvious, but the staggering declines by conglomerate vendors McKesson, Siemens, and GE Healthcare may not have been.

Musings

• It has always been true that the best and best-selling products in healthcare IT are sold by companies that aren’t distracted by unrelated business lines. The worst and worst-selling products have always been marketed by international conglomerates.
• Cerner is a rare exception to another rule: publicly traded companies usually far worse in product quality and sales.
• KLAS says Cerner is narrowing the previously lopsided five-to-one sales advantage Epic has had.
• McKesson’s only potential bright spot is Paragon. If it wasn’t for that product, they would be better off just selling off their creaky legacy products (Star, Series, Horizon, etc.) and getting out of healthcare IT altogether as big companies often do once the novelty has worn off.
• Most of the laggards came with low expectations, but the zero wins and three losses for Allscripts explain why the company is suddenly steering all conversations toward population health management and away from both inpatient and ambulatory EHRs.
• The only real unanswered question, which KLAS points out, is who the Horizon and Meditech Magic customers will choose once they realize the Meaningful Use drawbacks of sticking with an also-ran EMR.
• Epic and Cerner aren’t cheap. As hospitals feel the budget pinch and swallow hard when writing their monthly maintenance fee checks, will the lower cost of Meditech and Paragon lure them in despite more limited functionality?
• Meditech should have been a better contender, but 6.0 seems to have killed its momentum just when it seemed poised to seize the opportunity to move into the Big Three of big-hospital products.
• As the hospital whales consume the smaller fish, Epic and Cerner will gain more hospitals by attrition as the incumbent vendors get the boot.

Attention Doctor Shoppers: The Database Knows You’re Hooked 

Facts and Background

New York State prescribers must check the I-STOP statewide database of filled narcotics prescriptions before issuing new narcotics prescriptions as of this week.

Opinion

It’s a good first step in identifying drug-seeking patients, but not a very elegant solution in in requiring prescribers to manually look up patients on a secure Web page.

Musings

• Pharmacists aren’t required to check the database when dispensing prescriptions, but they are required to enter their filled narcotics prescriptions into it immediately.
• The database should really be a national one, although state-specific laws always impose maddeningly archaic limitations on any kind of national effort (state-by-state medical licensure, for example).
• It would be nice if the database had the capability to integrate with EHRs to save doctors a lot of fumbling around while they’re in the room with the patient.
• What happens when a patient is identified as a doctor shopper? Most likely nothing except they walk out without a new prescription and buy their drugs on the street instead.
• While some prescription drug abusers pay cash to avoid detection, surely insurance company records (and especially Medicaid records) would already have allowed these patients to be easily identified.
• Use of the database is likely to increase drug dealer profits and drug abuser crime as the reduced drug supply pushes prices up.

Contacts

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

More news: HIStalk Practice, HIStalk Connect.

Morning Headlines 8/30/13

Regulators to investigate Advocate data breach

HHS and the Illinois attorney general announce that they will investigate Advocate Medical Group’s four million patient data breach, the second largest in HHS history.

July 2012: EHR Incentive Program

CMS releases the latest EHR Incentive Program results in which 4,051 hospitals have been paid to date, which accounts for 80 percent of eligible hospitals. Payments have reached $15.8 billion since the start of the program.

Carl Icahn Increases Nuance Stake, May Seek Board Seat

Carl Icahn increases his stake in Nuance to 16.9 and reports that he may seek to put a representative on the company’s board of directors.

Despite backlogs, VA disability claims processors get bonuses

An investigative report calls out the VA for issuing $5.5 million in bonuses to its employees in 2011 for "excellent" performances despite a 155 percent increase in the disability claims backlog. Two-thirds of the VA’s claims processors took home bonuses that year.

News 8/30/13

Top News

HHS and the Illinois attorney general announce that they will investigate the July 15 theft of four unencrypted Advocate Medical Group desktop computers that contained the medical information of 4 million patients, announced last week. An HHS spokesperson signaled the financial exposure the medical group is facing in describing the “high-profile actions that have sent clear messages to the industry that we expect full compliance with privacy and security rules.” Advocate admits that the information should never have been stored on the hard drives. Obviously encryption technology would be throwing off some impressive ROI right about now, which might be something to consider if your organization hasn’t implemented it.

Reader Comments

HIStalk Announcements and Requests

Highlights from HIStalk Practice this week include: Physicians are split when it comes to publicly sharing Medicare payment data. New York physicians are required to consult an electronic prescription database before writing scripts for controlled substances. The benefits of a practice’s ACO participation reach beyond the patients covered by the ACO. MGMA offers online scheduling tools for its annual conference. More than 90 percent of office-based physicians accept new Medicare patients, which is about the same percentage that accept new privately insured patients. The AMA urges CMS to prohibit insurers from paying physicians less than contracted amounts when reimbursing providers with plastic or virtual credit cards. Doximity says it has more physician members than Sermo. I look at the Stage 2 dilemma, highlighting the recommendations of various professional organizations and offering my opinions, namely that CMS should keep the January 2, 12014 start date but extend the deadline for meeting Stage 2 requirements. You won’t find any of these stories – and others – on HIStalk so keep reading HIStalk Practice if you like staying current with happenings in the ambulatory HIT world. Thanks for reading.

Welcome to new HIStalk Platinum Sponsor InterSystems. The company is a global leader in software for connected care. Its products empower healthcare professionals with the information they need to make the best clinical and business decisions. HealthShare is a strategic platform for healthcare informatics, enabling information exchange and active analytics across a hospital network, community, region or nation. Cáche is the world’s most widely used database system in healthcare applications. Ensemble is a platform for rapid integration and the development of connectable applications. InterSystems has more than 35 years of experience as a trusted partner serving thousands of physicians, hospitals, and health systems around the world, including Johns Hopkins, Kaiser Permanente and Memorial Care; five statewide HIEs; and the national health systems of Sweden and Scotland. The company’s technology is also used by over 100 leading healthcare software vendors in their solutions, including 3M Health Information Systems, Epic, and GE Healthcare. Thanks to InterSystems for supporting HIStalk.

A YouTube cruise turned up this video about InterSystems. I thought I knew the company pretty well, but I learned a lot about them.

On the Jobs Board: Staff Engineer (Java), Clinical Applications Consultant, Project Manager.

HIStalk Webinars

CareTech Solutions will present “Using Infrastructure and Application Monitoring to Assure an Optimal User Experience” on Thursday, September 19, 2013 at 1:00 p.m. Eastern. The presenter will be John Kaiser, senior director of the Pulse IT monitoring service. The abstract:

It’s time for hospital IT monitoring to mature – from reactive to predictive. Supporting the highly-complex healthcare technology environment with only individual monitoring tools or relying on an application vendor to identify system degradation is not the most effective means to providing users with a reliable, optimal IT experience. A comprehensive monitoring solution includes eyes on servers, network, application performance, and real user monitoring. CareTech Solutions will discuss an integrated approach to comprehensive monitoring of both the infrastructure and applications, with an emphasis on delivering a consistent solution based the hospital’s IT maturity level. The target audience is CIOs, CMIOs, CNO, IT directors, and IT analysts.

Acquisitions, Funding, Business, and Stock

The healthcare IT business unit of Tennessee-based Parallon Business Solutions, itself a subsidiary of Hospital Corporation of America (HCA), merges with Vision Consulting to form Parallon Technology Solutions, with Vision President Tim Unger taking the CEO role. Parallon Business Solutions has 24,000 employees and provides services to 1,400 hospitals and 11,000 non-acute care providers.

Carl Icahn boosts his stake in Nuance to 16.9 percent of the outstanding shares, according to an SEC filing Tuesday, saying he may want to talk to the company about adding his slate of nominees to the board. Above is the one-year NUAN share price in blue vs. the Nasdaq in red.

Sales

Blessing Physician Services will deploy Phytel’s population health management suite.

Rideout Health (CA) will roll out Perceptive Software’s Enterprise Content Management solution integrated with its McKesson Paragon HIS.

People

McKesson Specialty Health and the US Oncology Network appoints Michael V. Seiden, MD (Fox Chase Cancer Center) CMO.

Physician RCM provider MedData promotes Ann Barnes from president to CEO.

Announcements and Implementations

Australia’s Noarlunga Hospital activates Allscripts Sunrise Clinical Manager.

Novant Health (NC) reports that 343 of its physician clinics are now live on Epic’s PM platform and 316 are live on EHR. The five-year project was completed three years ahead of schedule and under budget.

Humana and Centene join Verisk Health as founding members of its pooled data initiative, which uses Verisk’s database of cross-payer information and analytics to identify illicit billing practices.

Hawaii Advanced Imaging Institute upgrades to RamSoft’s PowerServer RIS/PACS/MU radiology workflow application.

Home device manufacturer Bosch Healthcare and health content vendor Remedy Health Media announce a partnership to develop and sell products for remote patient monitoring.

Government and Politics

ONC opens the Behavioral Health Patient Empowerment Challenge to highlight existing technologies to help patients manage their mental health or substance use disorders.

A Washington Post article says that the Department of Veterans Affairs was paying bonuses to its disability claims employees despite a mammoth backlog, thereby encouraging them to game the system by pushing the tough claims aside to boost their numbers. It does point out that employees were handling high claims volumes even though the number of claims made the backlog grow.

Other

Skyline Exhibits provides trade show stats that vendors might use to justify for exhibiting: (a) 81 percent of trade show attendees have buying authority; (b) the top reason for attending is to see new products; and (c) building brand awareness is the highest marketing priority for most exhibitors. Marketing execs may very well need to look for justification considering that a 10×10 booth at HIMSS costs about $4,000. Tack on drayage, shipping, travel, trinkets, and personnel and you’re at $20K in no time.

Coming to a baby shower near you: a smart sock from Owlet Baby Care that monitors a baby’s vitals and sleep position and includes a four-sensors pulse oximeter, an accelerometer, a thermometer, and a transmitter to send data to a smartphone or computer. The company’s cofounder says the device does not require FDA clearance, though a version that includes an alarm system for oxygen levels will. Owlet is seeking $100K in crowdfunding.

Here’s a story of interest to anyone in charge of their organization’s encryption efforts. UT Physicians (TX), the medical group practice of the UTHealth Medical School, notifies 600 patients of a potential data breach after the theft of an unencrypted laptop. Unlike similar thefts at other organizations, UTHealth has a comprehensive encryption policy that covers more than 5,000 laptops. The stolen laptop was overlooked, however, possibly because it was attached to an electromyography machine in the orthopedics department and is considered more of a medical device than a standard computer. The laptop included patient names, birth dates, and medical record numbers, but no financial information.

Researchers in Canada find that the use of RFID badges raised the handwashing compliance of nurses from 33 percent to 69 percent. Their study appears in the current issue of CIN (Computers, Informatics, Nursing). I wasn’t familiar with that journal even though it’s been around in various forms since 1983, but it looks decent.

Fourteen-hospital Baptist Memorial Health Care Corp. lays off 61 employees, including pharmacists and nurses, but urges them to reapply for 500 open positions, many of those newly created to support its Epic rollout.

If you’re a fan of evidence-based medicine or Coldplay, you’ll like this video, which was tweeted by Farzad Mostashari.

Spectrum Health (MI) fires several employees after one of them takes a picture of an ED patient’s rear and posts it to Facebook with a caption of, “I like what I like.” The health system fired the employee who took the picture and all of those who gave it a Facebook Like, including an ED doctor.

Marin General Hospital (CA) asks the FBI to investigate a possible scam that shut down the phones in labor and delivery and the ED last week.

Liviam announces its Facebook-like site for long-term hospital patients, which offers the CareStream timeline, a dashboard from which the patient can request help, a blogging tool, and an events calendar.

New York prescribers issuing prescriptions for pain meds must first check an online registry of pharmacy-reported filled narcotics prescriptions as of this past Tuesday, implemented to help curb the abuse of addictive drugs.

Sponsor Updates

• Truven Health Analytics offers free access to Micromedex iPhone apps for customers outside the US and Canada. Truven also announces enhancements to its Unify Population Health Management solution, which is deployed in partnership with CareEvolution.
• Iatric Systems announces that its Meaningful Use Manager and Public Health Syndromic Surveillance products have earned 2014 ONC HIT certification.
• IHS names Merge Healthcare the leading provider of vendor-neutral archive solutions in the world and in the Americas.
• iSirona adds Singapore-based telehealth services provider myHealth Sentinel as a reseller.
• The Massachusetts eHealth Institute awards Aprima Medical a $101,000 grant to advance the interoperability of EHRs with the state’s HIE.
• Besler Consulting releases a review of the FY2014 Hospital Inpatient Prospective System final rule.
• InstaMed achieves Phase III CAQH CORE certification.
• EClinicalWorks names HealthNet (IN) the winner of its Improving Healthcare Together video contest. Auburn Medical Group (GA) and Open Door Family Medical Centers (NY) took second and third places.
• Aspen Advisors shares details of the ICD-10 preparation services it delivered to East Jefferson General Hospital (LA).
• Dearborn Advisors discusses the need for healthcare organizations to optimize their EHRs in order to thrive in today’s regulatory climate.
• API Healthcare highlights the importance of meeting the needs of an aging workforce.
• pMD announces that its mobile charge capture solution will support iOS 7, which has a possible September 10 general availability.
• Visualutions will resell Wellcentive’s Advance to FQHCs.
• RazorInsights will showcase its ONE Enterprise HIS solution at the 15th Annual HIS Pros Buyer’s Seminar next month in Rosemont, IL.
• Medicomp hosts its annual strategy update webinar September 18 and 19 and opens registration for MEDCIN U sessions November 3-5 in Reston, VA.

EPtalk  by Dr. Jayne

It’s quite a challenge to try to keep up with Mr. H and Inga in finding newsworthy items each week for EP talk. Between our day jobs and our staggered publishing schedules, it’s easy to be scooped by another member of the HIStalk crew. In the spirit of mixing things up, we’ll be taking EPtalk in some new directions. I may write up an interesting product, discuss a recent journal article, or respond to something I’ve seen in social media. Since EPtalk runs with the news each week with a slightly different audience than Curbside Consult, I may do some multi-part pieces to allow reader responses to influence the next week’s piece.

Yesterday, @ONC_HealthIT tweeted a recent Wall Street Journal Health Blog piece that asked readers what doctors use as the basis for care decisions: business or financial considerations, fear of lawsuits, or doing what is best for patients. I was gratified that with over 1100 votes, 56 percent of respondents believe we want to do right by patients. The other two options tied at 21 percent.

I’ve spent a good part of my career working in emergency departments and urgent care situations. I have to agree that fear of lawsuits can be an important driver. Financial considerations are also important, but there are many nuances other than what this survey can capture. Case in point: at one of the hospital-owned urgent care centers where I moonlight, the leadership issues a monthly report that looks at our utilization. On the surface, this aims to encourage us to provide more cognitive medicine and perform less defensive medicine.

Although thoughtful practice is a nice goal, I’d be kidding myself if I thought the report was aimed at encouraging us to use our brains rather than tests. The fact of the matter is that our population is largely uninsured, with Medicaid and Medicare closely behind. The hospital has been hemorrhaging money for the last decade despite extremely good management. It’s largely due to payer mix and other external economic factors in the community. Across our department, the Family Medicine physicians have much lower service utilization than do the Emergency Medicine physicians, and I think it’s partly due to the way we see the patient population

As a family doc, I’m used to seeing patients quickly in the office, treating their self-limited problems, and moving on. There’s a relationship between the patient and the physician. We tend to think that if the patient is becoming worse or not improving, they’ll be back. We don’t feel that pressure to try to cover all eventualities while they are in front of us, although it’s become that way with the advent of the Patient-Centered Medical Home, Accountable Care, and other initiatives where every visit has become a preventive/full-service visit as we try to cram as much as humanly possible into each encounter.

I really try not to order tests if I can make the diagnosis based on clinical history and physical examination. Not just for cost reasons, but also because tests are not without risk. Even a simple urinalysis can give false positives that lead to unnecessary follow-up, including not only financial cost but the burden of patient anxiety.

I’m also not afraid to play the bad guy with patients when it’s indicated. I don’t care if your husband’s primary doc gave him antibiotics for his viral illness. Just because you came to the urgent care and have the same symptoms, you’re not going to get them from me. I don’t care if your copay was $50, it’s not the right thing to do. It’s likely you’ll mark me down on your patient satisfaction survey, but I’ve reached a point in my career where I simply care less about satisfaction scores than I do about quality care and antibiotic resistance. You’ll get my empathy, sympathy, and some symptomatic treatment, but no Z-pack for you.

My peers that trained in emergency residency programs tend to order more X-rays for vehicular trauma even if the clinical story isn’t that impressive. Maybe it’s fear of being sued or maybe it’s just the way they’ve been habituated from working in higher acuity and trauma centers rather than the ambulatory office. Maybe because there was that one case where they missed something and it came back at them later. It’s definitely harder to try to help a patient understand why decision support rules say it’s OK to not order an x-ray than it is to just shoot a film, and sometimes I order those films too. None of us is perfect and medicine still has some art to go along with the science.

The most interesting thing about the utilization reports, though, is that over the last year, they have done very little to drive any of physicians at the high end of the test ordering spectrum into a lower bracket. Right now, the only “incentive” provided is seeing your name on the report and where you fall against your peers. Some docs may consider these reports the way I see the physician satisfaction numbers – as something that’s not on the top of their list for the many things we have to worry about when we’re seeing patients. Others may need education or potentially something more tangible before their behavior will change.

The bottom line, though, is that defensive medicine is alive and well regardless of steps towards tort reform, provider education, and other interventions. I’ve been doing some thinking about the other 21 percent as well. I’d liked to have seen the “financial considerations” choice expanded to include other options but you’ll have to tune in to the next post for those thoughts.

I’ll still throw in the occasionally newsy tidbit especially if it involves both shoes and technology. A new CT scan technology by CurveBeam called pedCAT shows what the foot and ankle actually look like when weight bearing. I was fascinated by the YouTube clip from the Royal National Orthopaedic Hospital. Since I was hobbling around this afternoon due to a loose heel on my favorite pair of pointy-toed mules, it’s a sure bet that my scan would have more than one ICD-10 code associated with it. I’m leaning toward “Unspecified soft tissue disorder related to use, overuse and pressure” and “Grief reaction” since I ultimately had to pronounce said mules dead at 6:59 p.m.

Contacts

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

More news: HIStalk Practice, HIStalk Connect

Morning Headlines 8/29/18

Telstra Buys DCA’s Healthcare Division

Australian telecom giant Telstra has acquired Database Consultant Australia’s healthcare division, which makes the Communicare EHR solution and markets a secure messaging platform for healthcare.

Announcing the Behavioral Health Patient Empowerment Challenge

ONC announces the Behavioral Health Patient Empowerment challenge, which is seeking entries from existing behavioral health apps that help patients manage mental health and substance abuse.

Novant Health Completes Rollout of Electronic Health Record at Physician Clinics

Novant Health (NC) has completed its rollout of Epic in 240 clinics under budget and three years ahead of schedule.

Aprima Medical Software Receives Grant to Advance and Accelerate Health Information Exchange in Massachusetts

The Massachusetts eHealth Institute awards a $1.3 million in grants to Aprima Medical to fund projects that increase interoperability between electronic health records and the state’s health information exchange.