Monday Morning Update 4/1/19

March 31, 2019 News 5 Comments

Top News

A two-doctor ENT practice in Michigan closes for good and its partners retire after they refuse to pay a hacker $6,500 to restore their ransomware-encrypted systems.

Some of their patients worry about starting over at new practices that can’t get their previous records.

The partners decided not to pay because they had no guarantee that the hackers would restore their data or that they wouldn’t extort them further afterward. They also didn’t want to rebuild their practice from scratch.

The doctors apparently practiced within Swedish American’s Brookside Specialty Center. They declined a TV interview, saying the FBI is now involved.

Reader Comments

From Cyrus of Persia: “Re: [vendor name omitted]. Rumor is they’re for sale after raising $80 million but failing to keep up with their valuation. The co-founder left in December for VC-land, a high-profile client ripped and replaced because the product didn’t work, and none of the company’s sales have gone live.” Unverified, so I’ve omitted their name for now, but I welcome readers to comment.

From Mawkish: “Re: [vendor name omitted]. I heard they have abandoned their development efforts to create an enterprise behavioral health EHR/PM system for the community mental health center and larger mental health / substance abuse agency marketplace after three years of signing up customers who paid deposits with promises that they would be involved in product design, with the remainder not due until go-live. This removed those customers from the marketplace for legitimate solutions. At least the company is refunding the deposits after laying off 40 developers and returning to their roots of selling EHR/PM to the small practice marketplace.” Unverified, so again I’ve left the name out until I can ask for a company response. I’m not a big fan of pre-announcing software since the only possible reason is to convince prospects to hold off buying an immediately available competing product, but then again, customers who fall for that rather obvious ploy probably would have found a way to screw up their selection and implementation anyway. Still, it’s good news that the company is providing refunds, which isn’t a given in the rough-and-tumble world of health IT.

From Irritable Cereal Bowl: “Re: opioid lawsuits. Good for the states that are suing McKesson and other drug distributors who shipped enormous quantities of opiates that they had to know were being misused.” I disagree – every dose that was sent to those states was dispensed by a state-licensed pharmacy, on the order of a state-licensed prescriber, and under the jurisdiction of the DEA, which tracks every dose of opiates that is shipped to a pharmacy. Clearly those states were asleep at the wheel in expecting the deep-pockets drug wholesalers to provide oversight of legal but inappropriate drug use. If I were McKesson, I would sue the boards of pharmacy and medicine in those states, and perhaps their attorneys general and law enforcement agencies, for failing to do their jobs in protecting the public. Maybe individual prescribers and pharmacies as well since every single transaction is readily available. Drug distributors are required to report unusual usage patterns to the DEA and they failed to do that (not that the DEA isn’t already inspecting pharmacies and prescribers), but blaming them for the immoral and probably illegal behavior of prescribers and dispensers is clearly deflecting blame long after the fact. You can’t tell me that a tiny town from which flowed millions of doses of opiates that were being dispensed to patients who lined up around the pharmacy’s block every single day was too subtle of a problem for their police departments to detect.

HIStalk Announcements and Requests

Most poll respondents say EHR design is not a major cause of physician burnout.

New poll to your right or here: How much impact will AI have on patient satisfaction, outcomes, and cost in the next five years? Click the poll’s “comments” link after voting to explain, especially if you punt with the safe “some” option.

About 20 percent of poll respondents call their PCP by their first names instead of “Doctor XXX.” Some agree with me that the PCP is working for them and therefore there’s no need for academic formality, at least once the relationship has been established, while others prefer that both patient and doctor use formal titles (Mr. Ms., etc.) One respondent says they call anyone who has earned a doctorate as “Doc,” but that’s a slippery slope when you separate a medical practice degree (MD/DO) from other medically related doctorates (PhD, DNP for nurses, PharmD for pharmacists, etc.). That doesn’t even consider saying “No fries, thanks, Dr. Jones” in answering the drive-through query of your philosophy PhD. Or, what to do when both patient and doctor have earned doctorates in any academic discipline — do they call each other “Doctor” in the exam room? Or if the poetry PhD patient is called “Mr.” or “Ms.” by their PCP, do they correct them with academic haughtiness? We’ve polluted the etymologic waters quite a bit by assuming holders of doctorates of medicine, dentistry, chiropractic, podiatry, and veterinary medicine should get an extra dose of respect beyond those who hold every other doctorate. My experience is those who are most insecure about their doctorates (usually DO’s and DC’s) are the most likely to insist on being called “doctor.”

Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre for information.

People

Medical imaging software vendor Novarad names Paul Jensen (Microsoft) as president.

Julie Flaschenreim (Fairview Health Services) joins Hennepin Healthcare as CIO.

Other

I really dislike the headline of this article from HIMSS, and not just because they misspelled “ZIP” as “Zip,” used unrelated stock photography, and pitched their recent acquisition Healthbox. ZIP codes do not “define” health outcomes, although situations that are common in the economic demographics of those who reside in a given location certainly do. As the headline fails to indicate, people who live in South St. Louis would not get instantly healthier by moving to Palo Alto since there’s no guarantee their social determinants of health would change along with the relocation to an area with a closer Whole Foods, or that their healthcare journey isn’t already set in stone to some degree. There’s also the meme-bursting phenomenon of a single ZIP code covering wildly disparate income ranges, such as parts of San Francisco and Atlanta in which multi-million dollar apartments are flanked by the homeless and working poor (if you like digging deeper, check out census department’s Gini Index measure of income concentration.) I agree with the remainder of the article, just not the simplistic concept that knowing someone’s address is all you need to understand their health.

Former Microsoft CEO Steve Ballmer gauges return on investment in healthcare by looking at the average age of death, which he says has increased only 0.6 years in the past 20 even as healthcare spending rose dramatically. He says employers should look at their prices and costs, such as whether end-of-life spending really increases overall value, but adds that a non-transparent system of healthcare management and delivery makes such analysis nearly impossible.

Sponsor Updates

Meditech produces a new podcast, “Clinical efficiency and the journey to Expanse.”
Mobile Heartbeat and Clinical Computer Systems, developer of the Obix perinatal data system, will exhibit at the BGHIMSS & INHIMSS Annual Spring Conference April 4-5 in Florence, IN.
NextGate will exhibit at the CCI Symposium April 4-6 in Greenville, SC.
Netsmart will exhibit at the LeadingAge IL Annual Meeting April 2-4 in Schaumburg, IL.
Nordic will present at the Quality of Care Outcomes Research Scientific Sessions April 5-6 in Arlington, VA.
Medhost congratulates its 19 hospital customers that earned CMS’s five-star quality rating.
Practice Velocity, T-System, Wellsoft will exhibit at the 2019 UCA Urgent Care Convention & Expo April 7-10 in West Palm Beach, FL.
Cooper University Health Care (NJ) expands its use of Access Passport’s electronic forms solution to oncology and surgical services.
The Oliver Wyman Health Podcast features Qventus CEO Mudit Garg.
SymphonyRM will sponsor the Women in Data Science Pittsburgh @CMU event April 4.
Visage Imaging will exhibit at the 2019 SBI/ACR Breast Imaging Symposium April 4-6 in Hollywood, FL.
Vocera will exhibit at the Beryl Institute Patient Experience Conference April 3 in Dallas.

Blog Posts

Surprise Medical Bills: The 6 Tools Providers Need to Prevent Them (Loyale Healthcare)
Tackling healthcare collections challenges with technology and credit data (Experian Health)
How Proper Engagement Can Turn One-Time Patient Interactions Into Lasting Relationships (PatientBond)
4 Steps for Consolidating Revenue Cycle Vendors (Patientco)
5 Keys to Simplifying Interoperability in Healthcare (Sansoro Health)
Nordic’s five guiding principles for delivering revenue improvement (Nordic)
What about human interoperability? (Voalte)
6 Keys to Branding Your PT Clinic (WebPT)

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
Get HIStalk updates. Send news or rumors.
Contact us.

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Morning Headlines 3/29/19

March 28, 2019 Headlines No Comments

Teladoc Health Launches Telemedicine Service in Canada, Expanding Portfolio of Available Healthcare Solutions

Teladoc Health will launch its services in Canada.

FDA Chief Calls For Release Of All Data Tracking Problems With Medical Devices

Departing FDA Commissioner Scott Gottlieb, MD says the agency will make good on its promise to release thousands of patient safety reports.

Hackers attempt to access Northampton General Hospital computers 240 times a day

Officials at Northampton General Hospital in England say they are fending off 240 data-breach attempts a day, and worry that the problem will only escalate as NHS facilities become paperless.

News 3/29/19

March 28, 2019 News No Comments

Top News

Medicare Advantage payer Clover Health lays off 140 employees as part of a restructuring that will eventually add more staffers with health insurance and clinical backgrounds. The company, which has touted its predictive analytics capabilities since launching in 2012, has raised nearly $1 billion. It operates in seven states including Tennessee, where it plans to open an office in Nashville.

Webinars

None scheduled soon. Previous webinars are on our YouTube channel. Contact Lorre for information.

Acquisitions, Funding, Business, and Stock

Healthcare CRM vendor SymphonyRM expands to Pennsylvania with the opening of its Health AI Center of Excellence in Pittsburgh.

Teladoc Health shares rise on the news it will launch its services in Canada.

Digital prescription startup Xealth raises $11 million in a funding round led by McKesson Ventures, Novartis, Philips, and ResMed. The company has developed software that enables providers to prescribe apps, devices, and services from their EHRs. It has raised nearly $20 million since launching out of Providence St. Joseph Health (WA) in 2017.

People

Max Hanner (HCTec) joins Pivot Point Consulting as VP of business development.

Clarify Health names Imran Qureshi (Health Catalyst) chief data science officer.

Medication tracking company Kit Check promotes Doug Zurawski to SVP of clinical strategy and MaryAnn Jensen to VP of strategic marketing; and names Amy Langan (Fresenius Kabi) CMO and Eric Bolling (Cardinal Health) EVP. I interviewed Kit Check co-founder and CEO Kevin MacDonald last December.

Sales

OSF HealthCare (IL) will use Redox’s interface capabilities to connect its clinical systems with third-party applications.

Announcements and Implementations

Sutter Health (CA) will pilot an AI-enabled digital voice assistant developed by Suki in primary care, dermatology, and orthopedics.

The multi-state Lewis and Clark Information Exchange adds PatientPing’s real-time care alerts and patient utilization details to its HIE services.

Inspira Health (NJ) implements Intraprise Health’s wayfinding technology at its three hospitals.

United Regional Health Care (TX) will go live on Epic next week.

Thirty-five bed Lackey Memorial Hospital (MS) rolls out Evident’s Thrive EHR.

Government and Politics

Departing FDA Commissioner Scott Gottlieb, MD tweets that the agency will make good on its promise to release thousands of patient safety reports after Kaiser Health News found manufacturers have for years been taking advantage of a secretive, alternate summary reporting program that kept patient safety impacts hidden from public view.

The Australian Digital Health Agency will offer qualifying vendors $30,000 to integrate interoperability standards into their clinical software so that providers using different systems can share health information. The incentive is part of the country’s larger effort to do away with paper-based communication and faxes by 2022.

Privacy and Security

Officials at Northampton General Hospital in England say they are fending off at least 240 data-breach attempts a day, and worry that the problem will only escalate as NHS facilities become paperless. They list phishing email campaigns, unpatched software, and a lack of cybersecurity expertise as their biggest concerns.

CynergisTek adds around-the-clock monitoring to its line of cybersecurity, privacy, and compliance services for healthcare.

Other

Prosecutors say the former Vanderbilt University Medical Center nurse on trial in Tennessee for a medical injection error made at least 10 mistakes that led to the death of a patient, many in line with findings from a CMS investigation. The nurse has pled not guilty despite admitting she made a mistake. Errors included:

Being distracted by an unrelated conversation with another staff member when she grabbed the wrong drug from the dispensing cabinet.
Overriding a cabinet safeguard even though it wasn’t an emergency situation and she hadn’t checked with the hospital pharmacy.
Ignoring four warnings or pop-ups about the medication being withdrawn.
Not noticing the drug in hand was a powder instead of a liquid.
Overlooking a boldfaced warning immediately before injecting the drug.

Sponsor Updates

Elsevier Clinical Solutions will exhibit at the Beryl Institute Patient Experience Conference April 3-5 in Dallas.
EClinicalWorks and Imprivata will exhibit at the AMGA 2019 Annual Conference March 28-30 in National Harbor, MD.
Ensocare will exhibit at the American Case Management Association Conference April 13-17 in Seattle.
FormFast and Iatric Systems will exhibit at the Health Connect Partners Spring 2019 conference April 1-3 in Anaheim, CA.
Hayes Management Consulting welcomes Nancy-Linn Swain as director of training and engagement, and Bo Zhang as senior financial analyst.
HGP advises Clearwave in its significant growth investment from Frontier Capital.
Healthwise will exhibit at the EClinicalWorks Enterprise and Urgent Care Summit April 1-3 in Fort Lauderdale, FL.
InterSystems releases the latest update of its IRIS data platform featuring enhanced performance and scalability, cloud support, integration capabilities; and enhanced support for Java, Python, and C# development.
Intelligent Medical Objects will exhibit at the AORN Global Surgical Conference & Expo April 6-10 in Nashville.
Spok publishes “The Non-CIO’s Guide to Interoperability.”
The local paper covers Nordic’s move to new, expanded office space.
With help from Pivot Point Consulting, Acumen Physician Solutions adds legacy data archiving technology powered by SMART on FHIR from Trinisys to its Acumen 2.0 powered by Epic software for nephrology practices.
Glytec announces that its Glucommander Outpatient insulin dosing management software is now capable of receiving data from DarioHealth’s smart glucose meter.
Lightbeam Health Solutions and AMGA have developed a collaborative to help providers maximize the effectiveness of Medicare Advantage and other value-based contracts.
Health Catalyst receives top marks for healthcare analytics in Chilmark Research’s latest report.
Cooper University Health Care (NJ) expands its use of Access Passport e-forms to oncology and surgical services.
Vail Health (CO) improves care team communication with Spok’s Care Connect solution, and continues to expand its use of the software.
The Chartis Group hires Beth Price (North Highland) as director of its oncology solutions practice.

Blog Posts

TCM: Tracking Patients to Reduce Readmissions (EClinicalWorks)
CMS 2019 Rule Creates Incentive for Remote Patient Monitoring – How to Get Started (Ensocare)
Why End-to-End Testing Will Make or Break Healthcare Integration Efforts (The HCI Group)
Artificial intelligence in healthcare – elusive, but close (Hyland)
Three Impacts of a Third-Party Security Breach (Iatric Systems)
Five key technology challenges to address in 2019 (Imprivata)
Enabling Accountable Community Care in Western Massachusetts (InterSystems)
A Picture is Worth a Thousand … Lives? (PMD)
Nordic’s five guiding principles for delivering revenue improvement (Nordic)

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
Get HIStalk updates. Send news or rumors.
Contact us.

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EPtalk by Dr. Jayne 3/28/19

March 28, 2019 Dr. Jayne No Comments

For your entertainment pleasure, ONC has released the public comment submissions received on the “Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs” document. More than 200 comments were received, with the majority being in the areas of HIT usability and clinical documentation. My personal favorites:

I believe that part of the reason that only 30 PERCENT of physicians practice independently and that most are now employed is the push for EMR usage and all the administrative burdens associated with it. Add the “click the button” game and more will leave. (Michael Richter MD)
Thank you for finally throwing a life to all physicians! One of the biggest blunders made when HER’s (sic) were approved was not mandating interoperability. This single mistake is costing the Health Care System in the United States billions of dollars every month. Please act now on this blatant oversight / mistake. The time to correct it is overdue. Also, it is time to spend some money on plane tickets to visit countries like Italy, France, Germany and Japan to name just a few, and learn how they have better outcomes at half the price we pay. Being ranked 37th in the world is not good. Our infant death mortality statistics and ranking is pathetic! (Joseph S. Testa MD)
i have not seen any reliable study that has concluded that the adoption of electronic health records in doctors’ private offices has led to improved health care or reduced costs of health care. As a frequent recipient of electronic health care records, I have found this mode of information retrieval is more often an impediment than an asset; as vital data is never highlighted and is usually either omitted or buried within a large file of irrelevant data. Within the hospital setting, I have found electronic health records to be a life threatening obstacle to patient care. When a computer monitor takes the place of a simple vital sign monitor, I’ve had to wait for as long as ten minutes for nurses to acquire the simplest of vital sign measurements. In my community, had the local hospital been motivated to spend the same money on health care that was wasted on an overly complex and inefficient computer system, our town would be enjoying the finest health care at no cost whatsoever. Instead, tens of millions of dollars leave the community to pay for a large computer service corporation. (Michael Steiner MD)
Our staff and physicians have nicknamed our system The PDS (practice-destroying software). (Howard Green MD)
The cost and complexity of EMR system maintenance and exponentially increasing regulatory requirements force doctors into large groups where we are relegated to data entry and coding tasks rather than the patient care we trained for. We are clearly expendable… End direct to consumer advertising for medications and durable medical equipment. (The author didn’t include his identifying information in his document, so once I downloaded it, I had no idea which submission it was.)
EHRs have been created for effective billing tools. CMS contractors are NOT following the CPT coding guidelines agreed to by all other stakeholders creating tremendous chaos and dissatisfaction. So adding EXTRA work to a process that was already stressed expecting a different result is insane. So payments should include costs for scribes to input the data in order to reduce physician burn out as we have aging population and will need MORE physicians to care for them. AI will not do it. (Another one that became de-identified when I downloaded it.)
The EMR was not designed with the end user in mind. It was designed with government and insurers in mind. It was never designed to help improve “quality” but rather make it easy to mine data and make insurance companies look good. I have opted not to participate in obtaining such a system because there is no compelling reason to do so. (see above) If you want physician buy in, you would have to scrap the current systems and start with the physician in mind. You would need to make the physicians job easier, not harder. You would have to be honest about the motivation to pursue an EMR. It should be made optional, and let it be bought on its own merits. If it has no merit; it won’t be bought. Remember that physicians are not stupid. Any attempt to market an EMR with hidden agendas will be discovered, and the reception lukewarm at best. Good luck. (Also de-identified on download – learn to sign your documents, folks!)
In healthcare, focus not on cure. but care. Ailing patients need care and it can even be provided by 3rd, 4th, 5th, or even any one person outside the family. Exceptional cases are there that at times like Tom Hanks in Cast Away was being motivated by a basketball which he perceives as a man talking to but its rare and it needs a healthy young man to do so but A Patient is a Patient. (Anonymized by download.)
However, the draft Strategy does not appear to recognize the investment that providers must make to train staff, procure and implement new systems, migrate and secure data, and respond to patient requests for assistance with healthcare data. For example, for the past several years my PCP requires an annual fee of $150 to help offset the cost of compliance with insurer and regulator IT standards. We just received a letter notifying us that his annual fee will raise to $1,800.00 per patient in 2019. My family of six cannot afford to spend $10,800 to be his patients. Neither can my elderly family members who were patients of the same PCP but who now struggle to find local providers who accept Medicare patients. HHS can begin to address these issues with a recognition of the costs and challenges faced by providers– and ultimately their patients. For example, the CMS fee schedules should be revised to reflect the costs of training, IT infrastructure maintenance, and patient educaton. The cost of annual IT Security training should included as directly attributable to the cost of care. (Martin O’Connor)

Most of the vendor submissions were lengthy, but I commend Epic for their two-page submission that calls out two key elements, one of which is the fact that “the electronic patient access timelines for Medicaid Promoting Interoperability are not aligned with Medicare Promoting Interoperability or MIPS, causing additional complexity for provider organizations and software developers, despite previous indications that the programs are intended to be aligned.” Whoops!

Healthfinch included the adorable Charlie on their submission as they championed the need for ONC to include delegation of routine tasks into strategic goals. They also ask for recommendations that state boards “address inconsistent and unclear “scope of practice” guidelines.” Can I have an amen from the congregation?

Intelligent Medical Objects (IMO) sent a very organized submission with a table of contents. The fact that they cited the original text then followed with their comments for each point they were making helped tremendously compared to other submissions. I was also interested to learn about an organization called the “Partnership to Amend 42 CFR Part 2” whose goal is to align various privacy rules to allow appropriate sharing of health information around substance use disorders.

One community hospital quality coordinator sent a submission that had at least seven fonts in it, which forced me to stop reading since it felt like a ransom note. I was surprised by the number of typos and grammar errors in some of the submissions, as if spelling and grammar checks weren’t run. It’s hard to take comments from a Top 3 EHR vendor seriously when the author hasn’t edited properly for its vs. it’s. Another submission was clearly written in Notepad, which is always entertaining for us IT folks.

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The only other exciting conversation this week was around the Duke University whistleblower settlement. Lung researchers were caught faking data for inclusion in grant applications to the National Institutes of Health, resulting in a $112.5 million False Claims Act settlement. The whistleblower is a former staffer in the department. He’ll receive 30 percent of the settlement, which is a good amount since his career as a research biologist is likely to be over. The US government will receive the balance. There was a fair amount of misconduct in the involved labs, with the need for retraction of 17 scientific articles to date as lab technicians either falsified data to document a desired result or sometimes failed to even conduct experiments where data was recorded.

Would you ever risk it all to be a whistleblower? How serious would the situation have to be? Leave a comment or email me.

Email Dr. Jayne.

Morning Headlines 3/28/19

March 27, 2019 Headlines No Comments

Artificial Intelligence (AI) Health Outcomes Challenge

CMS announces the AI Health Outcomes Challenge, which will award up to $1.65 million to winners who develop AI-powered technologies that can predict unplanned hospital and SNF admissions, and adverse events.

Health care leaders back Xealth with Series A funding to digitally enable patient care

Digital prescription startup Xealth raises $11 million in a funding round led by McKesson Ventures, Novartis, Philips, and ResMed.

Sutter Health, Suki Introduce Digital Voice Assistant to Support Patient Care

Sutter Health (CA) will pilot an AI-enabled digital voice assistant developed by Suki in primary care, dermatology, and orthopedics.

Centene to Buy WellCare in $17.3 Billion Health-Care Deal

Public and private payer Centene acquires WellCare Health Plans for $17 billion.

Alphabet-backed Clover Health is cutting tech jobs after realizing it needs more health-care experts

Medicare Advantage payer Clover Health lays off 140 employees as part of a restructuring that will help it focus more on healthcare rather than software expertise.

Book Review: Deep Medicine

March 27, 2019 Book Review 5 Comments

Eric Topol is one of the highest-value of the few people I follow on Twitter. He consumes information voraciously and summarizes it well without talking down to his audience. He loves technology, hates EHRs, and weighs in on the practice of medicine even though I suspect his practice isn’t very much like that of the typical doctor or even the typical cardiologist. He is quick to point out those seemingly great ideas that have had zero real-world validation in a healthcare setting. He also holds researchers accountable for proving improvement in outcomes – just making a lab value move in a seemingly good way doesn’t cut it with ET.

I have mixed feelings about this book. Topol provides an exhaustive (and sometimes exhausting) review of all the work that’s being done with artificial intelligence in healthcare. Trust me, it’s a lot. The downside is that this book was nearly obsolete the moment the first copies rolled of the presses, meaning I had better get return on investment for my $20.69 quickly.

“Deep Medicine” is a firehose of who’s doing what with AI. By nature, a lot of that work is early-stage, experimental, and unlikely to see front-line use for a long time. Most of all, we have no idea of how it will integrate with the US healthcare industry (and make no mistake, it’s an industry). We’re not really that much different than other industries no matter what we would like to believe.

I found the book somewhat of a chore to read. It has some personal stories, a bit about the history of medicine, background about companies, and of course who’s working on healthcare AI. I didn’t find it conclusive, but then again it really can’t be so early on.

Will AI Really Make Healthcare Human Again?

The subtitle “How artificial intelligence can make healthcare human again” sounds good and probably draws readers who are less interested in the nuts and bolts of AI. But to me, the book fails to deliver a convincing reason that Topol thinks that will actually happen.

I didn’t gain any confidence that healthcare will be even a little bit more human just because AI might save clinician time. If “making healthcare human again” was a business priority, we would have done it already, AI or not.

Topol expresses hope that doctors who are “given the gift of time” will be allowed to use that time to practice medicine the way they really want, to get personal with patients and to focus on their stories. That ignores the fact that most doctors these days are assembly line workers paid to treat ‘em and street ‘em in whatever way maximizes billing. It’s questionable whether the gift of time also offers the gift of higher income, and safe bets are always to assume that people do whatever it is that rewards them financially.

The other issue is that given Topol’s rigor in demanding that outcomes be proven, we don’t know that spending more time with patients in “deep medicine” actually improves outcomes. We don’t even know that patients want such attention. They seem happy with the urgent care model of dropping by with a problem and leaving with a prescription. AI could amplify the impersonal nature of those interactions, pushing patients to be triaged by chatbots or kiosk-based questionnaires. We don’t know whether that would make overall outcomes and quality of life issues better or worse.

I don’t recall any industry where the goal of automating the factories was to make workers happier or more self-actualized. Mostly it’s a reason to hire fewer of them or to restructure their work into something else that’s profitable. Assuming that healthcare is different is dangerously naive.

AI Hasn’t Been Tested on Humans

This is the most important reminder of the book. The AI work being done is interesting, but unproven. What works in a lab doesn’t necessarily work in an exam room. What works in analyzing heaps of data doesn’t necessary translate well to the frailties and idiosyncrasies of humans in their time of medical need.

It’s an easy leap to become overly exuberant when reading articles claiming that AI reads images better than radiologists, that somebody’s AI system passed a medical board exam, or that IBM Watson Health is smarter than an individual clinician. None of this has been studied and proven effective in the real world. Maybe it could improve outcomes or reduce cost, but that’s just conjecture. A lot of those systems were rigged to do one thing, like Watson winning at “Jeopardy” only because it memorized Wikpedia, which is were the show’s staffers get most of the questions.

AI Is Good at Recognizing Patterns

Topol says properly trained AI can recognize patterns better than humans. Medical work that involves pattern recognition – diagnostic radiology and some aspects of dermatology and pathology – could perhaps be performed better by machines, leaving those doctors with time to perform other value-added services (if they can find them and if someone is willing to pay for them).

How Doctors Think

Topol has interesting thoughts on the Choosing Wisely initiative to get doctors to make better-informed decisions. He says it was a noble effort to get medical societies to define low-value tests and procedures, yet they are being ordered just as often even now. He gives these reasons:

Doctors overestimate the benefit of what they do
No mechanism exists to educate them
Compliance can’t be measured
No reward is offered for complying
Doctors think it’s OK to perform questionably useful surgeries as long as they aren’t likely to be harmful

The book says that doctors are burned out by EHRs that contain inaccurate information and don’t share information. He gives those doctors a pass in simply blaming EHR vendors rather than those who select, implement, and use EHRs, often with the specific goal of not sharing information and not being willing to correct mistakes, especially those the patient could easily identify.

I’ll be honest in saying that I don’t trust the EHR commentary offered by authors like Topol and Bob Wachter, MD. They are often impatient in demanding an easy answer, like making EHRs as easy to use as Facebook, ignoring the fact that EHRs are designed to meet the requirements of our screwed-up health system.

I do like this idea from Topol – get the patient’s consent to make an audio recording of their visit, have it transcribed, and then turn that into an office note that doctor and patient review together. Key point – auto-delete the recording in 24 hours to minimize malpractice concerns.

Topol says doctors diagnose by reacting to a few patient descriptions and use internalized rules and experience to arrive at a conclusion. Their diagnostic accuracy rate is nearly perfect if they figure it out within five minutes, but it drops to 25 percent if they have to think longer. Topol also makes this point, which seems to conflict with the theme of the book – diagnostic accuracy doesn’t improve when doctors slow down and think more deeply. Clinicians who were “completely certain” about their diagnosis were wrong 40 percent of the time, based on an autopsy’s cause of death.

The #1 reason a diagnosis results in a malpractice lawsuit is that the doctor didn’t consider the diagnosis that was eventually found to be correct. Doctors say they could improve given better chart documentation.

The challenge for doctors is that they see a small number of patients, often of specific demographic composition. Personal experience can’t stack up to analyzing large patient data sets. This is an important point. Doctors don’t consistently incorporate evidence into their practice. They also can’t see their own deficiencies.

The assumption made here is that lack of accurate diagnosis is a big problem and AI can improve it. I’m not so sure from a public health perspective that it’s the most important problem to solve, although if AI can plow through the patient’s record, the literature, and data about similar patients to improve diagnostic accuracy under the doctor’s supervision, then that’s certainly a win.

Medicine versus Self-Driving Cars

I liked Topol’s comparison of self-driving cars to medicine. The steps are:

Level 1 – driver assist, such as warnings to stay in the lane
Level 2 – partial automation, such as automatic speed and steering control
Level 3 – conditional automation, where the car drives itself but with human backup
Level 4 – high automation, where human backup is not required, but it works only in limited circumstances
Level 5 – full automation, where the car drives itself in all circumstances with no human involvement

Topol doesn’t expect medicine to get past Level 3. The clinician will always be personally involved to some degree.

Where AI Could Change Physician Roles

To initially read radiology images and classify them as normal or abnormal, which given the large number of imaging studies, would save time and allow radiologists to change their role from being “the reader of scans.”
To analyze surgical, cryopathology, and possibly dermatology images, where conformity across pathologists is lacking and error rates are high. The demand for “microscopists” should decrease.

In this regard, Topol suggests combining radiology and pathology into a single discipline of “information specialists” instead of “pattern recognizers.” That’s an interesting thought, although again tinkering with the lucrative incomes of doctors who are backed by politically astute societies usually doesn’t work.

The Economic Disparity Question

My overriding feeling in reading this book is that like much of healthcare, the benefits of AI won’t be spread evenly. You have the challenge of making sure that AI is trained given a broad set of demographics to avoid bias based on location, race, economic status, etc. but those people are already underrepresented in the healthcare system. AI can’t fix that.

AI could also be like self-monitoring tools such as the IPhone’s arrhythmia detection. Not everyone can afford an IPhone, is motivated to use it for self-monitoring, or has a clinician on standby to respond to the hypervigilant monitoring of the economically well off. On the other hand, we don’t have the research to know if those tools have any effect on outcomes or cost anyway. They sound inherently good, but so does robotic surgery, which Topol notes has done nothing to improve key outcomes.

My Conclusions

This is a fairly interesting book, assuming you like deep literature and news searches summarized loosely into a sometimes unconvincing narrative about AI in healthcare. Topol doesn’t follow the Silicon Valley mantra that AI will eliminate jobs, but instead lays out ways it could help rather than replace clinicians. That’s a compelling but simplistic view of how our healthcare system works.

The underlying assumptions are far from certain. We’re a profit-driven healthcare system, and attempts to wrest that profit back in the form of reduced costs rarely work. We also don’t know what patients want or what really moves the outcomes needle, so just throwing AI at interesting healthcare problems isn’t necessarily a huge step forward.

There’s also the question of who’s willing to pay for all this technology, which is being developed by startups and tech giants that expect hockey stick growth and endless profits. What they want may be directly at odds with what patients want.

Also in play is whether Eric Topol the exuberant futurist can represent the average frontline clinician whose day looks a lot different than Topol’s. It’s nice that he has the time and resources to write a book about AI and paint a picture of medicine that incorporates it, but I’m not so sure his worldview is accurate for the industry, especially the business aspects of it. He’s made himself an expert in this narrow AI niche that may or may not make him the best person to assess its use. People with hammers are always looking for nails.

We already have a lot of problems to fix. We’re probably not choosing medical school classes optimally or training doctors the right way. We are certainly not compensating them for doing the right things, and a fee-for-service system encourages practicing medicine that is clinically unsound but financially desirable. We don’t really know what patients want, or how they see the role of a PCP (if at all). We have ample evidence already and much of it isn’t being used on the front lines to make clinical decisions.

In short, while judiciously applied AI might provide some modest diagnostic and efficiency gains, I remain unconvinced that it will transform a healthcare system that desperately needs transforming.

Morning Headlines 3/27/19

March 26, 2019 Headlines No Comments

The end for Obamacare? Trump administration says it will ask a court to throw out entire health law

The Justice Department won’t dispute a federal court’s decision that the Affordable Care Act is unconstitutional and should therefore be eliminated in its entirety.

Philips expands its radiology solutions offering with advanced teleradiology services

Philips acquires teleradiology practice Direct Radiology, whose 70 radiologists provide services to 300 hospitals, imaging centers, and practices.

‘Desperate’ risk delayed electronic medical record, meeting minutes show

Australia’s Queensland Health was so desperate to prove the financial viability of its Cerner-powered IEMR that it planned to go live at Princess Alexandra Hospital in mid-2015 even though the project was in “cannot meet objectives” status.

Alexander Says New HHS Rules Should Improve Electronic Health Records To Give Patients Better Outcomes, Better Experiences At A Lower Cost

News 3/27/19

March 26, 2019 News No Comments

Top News

The Justice Department won’t dispute a federal court’s decision that the Affordable Care Act is unconstitutional and should therefore be eliminated in its entirety.

This two-sentence announcement represents a position shift from earlier arguments in which the Trump administration advocated striking down only certain of ACA’s consumer protections, such as the requirement that insurers cover pre-existing conditions.

A group of Republican governors sued the federal government after Congress eliminated the penalty for not buying health insurance, arguing that the decision renders the entire ACA unconstitutional, a position with which the federal government now agrees.

HIStalk Announcements and Requests

Lorre found and fixed a bunch of new HIStalk email signups (over 1,000, actually) that went automatically and silently into an “unconfirmed” status in the bulk email service I use, requiring manual approval. Welcome if you got your first email today. Sign up here if you aren’t sure since you won’t get duplicate emails even if you’re already on the list.

Welcome to new HIStalk Platinum Sponsor Ensocare. The Omaha-based company’s care coordination solution includes software; a national network of post-acute care providers, services, and community-based organizations backed by 24-hour support; and solutions that help hospitals and payers succeed under value-based care. Transition of care solutions include Transition (hospital discharge software); NEMT (links hospitals to non-emergency medical transport providers); and SDoH (connects patients with community services that can help with social determinants of health). Patient engagement solutions include Wellplan (digital care plans) and Aftercare (RN-led scheduled phone calls). The company’s care coordination platform is integrated with Cerner, Meditech, Epic, and VistA to automate discharges and post-acute referrals. Its Patient Choice app allows patients and families to explore post-acute care options at the bedside. Thanks to Ensocare for supporting HIStalk.

Webinars

March 27 (Wednesday) 2:00 ET. “Waiting on interoperability: What can payers and providers do to collaborate?” Sponsored by Casenet. Presenter: Amy Simpson, RN, director of clinical solutions, Casenet. A wealth of data exists to identify at-risk patients and to analyze populations, allowing every payer and provider to operate readmissions intervention and care management programs. Still, payer and provider care managers are challenged to coordinate and collaborate to improve outcomes because of the long road ahead to interoperability. Attend this webinar to learn what payers and providers can do now to share information and to coordinate their efforts to create the best healthcare journey for members and patients.

Previous webinars are on our YouTube channel. Contact Lorre for information.

Sales

Atlantic General Hospital chooses Welltok-owned Tea Leaves Health for analyzing referral patterns and expanding its physician network.

People

Collective Medical names Jim Lacy (Waystar) as president / COO.

Announcements and Implementations

Philips acquires Idaho-based teleradiology practice Direct Radiology, whose 70 radiologists provide services to 300 hospitals, imaging centers, and medical practices.

UC Davis offers a three-month online educational program titled “Health Information Literacy for Data Analytics Specialization,” which targets technologists with no healthcare experience. Courses include Healthcare Data Literacy, Healthcare Data Models, Healthcare Data Quality and Governance, and Analytical Solutions to Common Healthcare Problems. UC Davis also offers a five-course analytics certificate program for which healthcare experience is recommended, with completion in 15 months or less at at cost of $6,125.

Netsmart will implement the 360X interoperability standards for managing referrals and sharing information between PCPs and community-based healthcare providers.

A KLAS review of 2018 health IT purchasing decisions finds that the most active areas were PACS, population health management, ERP, and secure communications. Markets are mature for EHR/PM, automated dispensing cabinets, cardiology systems, ERP, home health, PACS, patient accounting, and smart pumps. Newer and more disruptive areas are behavioral health, patient privacy monitoring, population health management, secure communications, virtual care platforms, and vendor-neutral archive. Vendors ranked at the top of KLAS’s assessment of customer satisfaction and retention are American Well (leads by far), FairWarning, Varian, BD, Protenus, Omnicell, Grifols, Workday, Nuance, and Baxter. Top reasons for replacing systems are integration, consolidation, and functionality, with price falling outside the top five.

Government and Politics

Outgoing FDA Commissioner Scott Gottlieb clarifies interview comments that some sites interpreted as his call for more EHR regulation.

Duke University will pay $112.5 million to settle federal False Claims Act charges that one of its researchers falsified pulmonary research data to win $200 million in federal research grants. Duke fired heavily grant-funded biologist Erin Potts-Kant in 2013 for embezzlement, after which she pleaded guilty to forgery and Duke retracted several of her papers. The former Duke lab analyst turned whistleblower, 34-year-old Joseph Thomas (above), will be paid $33.75 million of the settlement, while the remainder is set aside to repay the grant money involved.

HELP committee chairman Lamar Alexander (R-TN) says HHS’s proposed interoperability rules will provide a definition of information blocking, require insurers to give patients copies of their data, mandate that EHRs support API access, and require hospitals to send ADT notifications to a patient’s doctors. He quotes a Tennessee family doctor who sends printed copies of an admitted patient’s record from his EHR to the hospital for re-keying because it would cost his practice $317,000 per year to send information electronically (he didn’t say who would get that money).

Other

Fast Company looks at healthcare’s “giant patient-matching mess,” which it mostly blames on (a) EHR vendors not using a standard format for entering patient information; (b) provider consolidation that dumps the patient records of other facilities into a single database; and (c) lack of an easy way to de-duplicate records of common names that sometimes also share a birthdate. It notes CHIME’s 2015 $1 million National Patient ID Challenge that it eventually abandoned because the problem is too complex, a conclusion reached by Pew, which could only recommend that EHR vendors force standardization of addresses using US Postal Service records. It notes that other countries think the US is fighting an impossible battle to figure out which is the right Maria Garcia or John Smith given Congress’s ban on a national health ID.

In Australia, investigative reports show that Queensland Health was so desperate to prove the financial viability of its Cerner-powered IEMR that it planned to go live at Princess Alexandra Hospital in mid-2015 even though the project was in “cannot meet objectives” status. The plan was halted only when a Cerner VP and the project’s delivery director said a six-month, big-bang implementation was not possible, especially in radiology and pathology.

Bloomberg notes the increasing number of doctors who choose a telemedicine practice now that reimbursement has been sorted out and startups such as Hims and Roman need doctors to generate their lifestyle prescriptions. A startup that was founded strictly to place doctors in telehealth jobs says about 25 percent practice full time, with most of the remainder being those fresh out of school or easing into retirement. Doctors still need to be licensed individually by each state — the doctor who is the subject of the Bloomberg article spent $10,000 to gain licenses in 26 states.

Stat reports that digital health startups are struggling with how to respond to users who express suicidal thoughts using their mostly unattended platforms. Patients are threatening self-harm during video visits and people are posting suicidal comments to the Facebook pages of hospitals and practices or even to their patient portals.

Researchers retest the DNA of 49 people whose consumer genetics tests told them they are at risk, with commercial labs failing to reach the same conclusion in 40 percent of them. Some of the “increased risk” classifications were also incorrect, as the observed variants are common and benign. The authors conclude that consumer DNA testing results should be confirmed by clinical labs that understand the variants better.

Sponsor Updates

First Databank’s Meducation patient instructions creation system is added to Epic’s App Orchard.
Aprima, an EMDs company, announces integration with RavePoint.
Avaya introduces a cloud transformation program, making it easier for companies to adopt the cloud communications infrastructure that best meets their needs.
The Digital Healthcare Podcast features Collective Medical CMO Benjamin Zaniello, MD.
CoverMyMeds will exhibit at the Technology Health Experience Conference March 28-30 in St. Louis.
Culbert Healthcare Solutions will exhibit at AMGA March 27-30 in National Harbor, MD.
DocuTap will exhibit at the Pediatric Urgent Care Conference April 3-5 in Dallas.

Blog Posts

What’s an ePatient? (AdvancedMD)
Young graduates … we’re hiring! (Agfa Healthcare)
Aprima EHR Adoption Improves Neurology Practice Workflows and Communication (Aprima)
Nuance Awards Avaya ‘Top Producing Partner’ Two Years in a Row (Avaya)
Using Epic’s Signal Data to Measure Intervention Effectiveness (Bluetree)
Don’t Go It Alone: 3 Reasons to Call in the Pros for Your Secure Messaging Rollout (Spok
Will the new 21st Century Cures Act rules make a difference? (Datica)
How AI can transform customer care, for the better (Burwood Group)
Increasing the Value of Your EMR with Patient Flow Solutions using RTLS (CenTrak)
Cooking with Terminologies (Clinical Architecture)
Living with MS – Perspectives on the Patient Journey from Patients and Advocates (CoverMyMeds)
The Changing Role of the CIO: Mapping Applications to Business Tactics and Strategy (Culbert Healthcare Solutions)

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
Get HIStalk updates. Send news or rumors.
Contact us.

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Morning Headlines 3/26/19

March 25, 2019 Headlines No Comments

Judge dismisses final worker wage lawsuit against Epic Systems

A federal judge dismisses the last pending lawsuit brought by employees against Epic, finding that the 2016 suit of a group of quality assurance workers was too similar to that ruled on by the US Supreme Court last year.

Apple could combine its expertise in health and fintech to get into medical billing, experts say

Industry insiders speculate that Apple’s new credit card, combined with its Apple Pay service, could signal a pending foray into medical billing.

UA Physician and iTether Create App for Pregnant Women, New Moms, with Opioid Addiction

The University of Arizona College of Medicine is working with ITether Technologies to revamp its digital care management software for substance use disorder patients to better fit the needs of pregnant women and new moms.

Patient data exposed at 2 Toronto hospitals, privacy commissioner investigating

An anonymous computer programmer accidentally discovers the PHI of over 200 hospital patients in Toronto after intercepting unencrypted pager messages.

Curbside Consult with Dr. Jayne 3/25/19

March 25, 2019 Dr. Jayne 15 Comments

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Back in November 2017, the Epic-using world was abuzz about Share Everywhere, which was supposed to let the rest of us who are using other systems have one-time access to key patient information such as medication lists, problem lists, test results, allergies, and possibly physician notes. I remember from the announcements that the feature was version-dependent and figured it would take some time for the most current general release version to roll out to the various health systems that surround our independent urgent care.

Share Everywhere allows patients to generate an access code that allows the patient to give access to a provider, home health worker, therapist, or other member of the care team who doesn’t already have access to the patient’s Epic chart. It’s supposed to be accessible through MyChart. Since anyone in my city who has been hospitalized in the last year has been cared for on an Epic system, I figured a year would be enough for the hospitals to roll out the latest and greatest so that patients could let our urgent care providers peek behind the curtain at their records.

Now that flu season is starting to abate and I have a little more time to breathe while I’m talking with patients, I decided to make a concerted effort to ask patients about their use of MyChart in general and Share Everywhere in particular.

Patients frequently pull up information on medications, whether it’s from MyChart, the Walgreens app, or their CVS profiles. Some even access their pharmacy benefit manager, such as LDI or Express Scripts. Many patients still carry a paper copy of their medication list in their wallet, often with strike-outs and additions.

Today, I had four patients offer to pull up their account in MyChart. None of them had any knowledge about Share Everywhere or how to access it. I decided to go digging for it myself once I got home, accessing my account at Big University Hospital. Once I found the link at the bottom of a little-used tools menu, I generated a code for myself.

Despite having an accurate problem list in my patient-side account, the “share” version of my chart was lacking a problem list of any kind. It’s basically blank. The medication list contained a list of items that didn’t show any date of prescription or the name of the prescribing provider, only the person documenting it whose name I didn’t recognize. Only the items documented pre-Epic that came in with a conversion had start dates. Allergies were up to date (fortunately) but immunizations were blank. I found some useless test results that all said “see scanned report.” The family history information was clearly entered by the clinical geneticist I saw a while back, based on its specificity. There wasn’t any kind of a list of providers, which might be useful for patients that see a few more providers than the two I see each year.

Going back to MyChart, I also found a “Wallet Card” feature I had never seen before, which was supposed to have a “convenient, printable summary” of my medical information. The diagnosis list was blank, the medication list was blank, the allergies were blank, and it included a work phone number where I was last seen in 2007. I’m not sure how it’s even in the chart since I make sure to review the updates every time I’m seen at a practice, but it’s in there nevertheless. I found a handy way to print my eyeglasses and contact lens prescriptions, but unfortunately it doesn’t have my name on it or the name of the provider, so it’s not useful to try to get lenses dispensed. Good idea, poorly executed.

I’m a curious person and I was on a mission, but I wonder how many other people know these features are available to them or how to use them? Certainly Big University isn’t sending out an email telling patients that if they wind up at another place’s emergency department or an outside urgent care, here’s the best way for that competitor to access their records.

Now that I know how to tell patients how to find the Share Everywhere code generator, I’m at least able to go back to my desk and peruse their records without having to try to read them on a phone in the exam room. I’m not due to go back to Big University as a patient until at least July, so I’ll have to try to clean up the phone number issue at that point. I’ve learned from battling the billing team through the patient portal that it’s not worth trying to deal with it remotely. It hasn’t been effective in the past and I ultimately have to call a physical office.

We’re still a long was from patients being able to truly hold their records in the palms of their hands, but at least we’re taking baby steps. Maybe I’ll start a grassroots movement to have patients actually review their records and inundate the health systems with correction requests where needed. Depending on the volume, it might spur some changes in documentation habits or help providers understand that there are people outside their own system that are seeing what they are putting into charts. I’ll have to follow up with some of the more senior members of my family that have more extensive records and see what resemblance theirs bear to reality.

I’d be interested to hear from non-Epic providers whether they’ve had much utility with Share Everywhere and whether other hospitals and health systems are doing a better job keeping it accurate than mine is apparently doing. And from patients, are you aware how to generate a token for your providers to access your information? It’s only good for five minutes, so you have to do it right there, but in the right circumstances it would be useful. I’m also curious whether the other major software players have similar access for outside providers. If you can point me in the right direction, I’ll start polling patients. It’s got to be easier than watching people try to populate an intake form from memory.

When’s the last time you shared your record? Leave a comment or email me.

Email Dr. Jayne.

HIStalk Interviews Grahame Grieve, FHIR Architect and Interoperability Consultant

March 25, 2019 Interviews, Investor's Chair No Comments

Grahame Grieve is a principal with Health Intersections of Melbourne, Australia and was the architect-developer of HL7’s Fast Healthcare Interoperability Resources (FHIR, pronounced “fire”) specification that allows EHRs to exchange information.

Was it weird to see FHIR as the only universal topic of HIMSS19?

Not so much weird. Obviously it was gratifying for us to see the community investment that so many people have made becoming justified. It’s definitely worth saying that we really value HIMSS’s active participation in driving the conference in that direction. There was an organicness to the fact that FHIR became the big issue given the way the industry overall is, but HIMSS definitely actively drove that and that was an important part of the picture. I thank Hal for pushing that.

I thought there was maturity at the HIMSS meeting this year. You and I talked about bad FHIR puns and expected to see them all over the place, but we didn’t actually see anything like that. We saw instead quite a lot of maturity around the discourse and the challenges of sharing data. I thought that was really good.

I always call you the father of FHIR without asking you if you accept that title. Is it fair or unfair to call you that?

I did initially draft it and propose it and I’ve curated the passionate community input over the years. If that makes someone the father, then I guess I am. The community is the real father. I get undue attention as if it was some magic that I achieved, where actually it’s just thousands of people passionately contributing to the common values that we hold.

I’ll repeat a question that I asked you last time we spoke. Are you worried that non-experts mistakenly believe that we’ve figured out interoperability because they keep hearing about FHIR and APIs?

That definitely happens. People assume that since FHIR is now the designated answer, it is the answer to all of the problems faced. But it’s not.

As HL7, we can only take on and mandate solutions that everybody completely agrees to. This is healthcare, so there’s a very limited set of things that everyone completely agrees to. Additional agreements are required. The scope and scale of the agreements required are beyond any single organization. We’re spending increasing amounts of our time investing in collaboration with other organizations to get a seamless process around scaling up agreements and consistency across multiple organizations like IHE that are helping out with the problem.

As long as hospitals buy an EHR and then spend a $100 million customizing it to their workflows, then interoperability is going to be a challenge. On the other hand, the fact that hospitals make those kinds of investments indicates the complexity of healthcare. There is no easy win. There is no easy victory to get interoperability with some kind of tick mark against it. It’s an ongoing process that we’ll be going through for a long time yet.

It seems like every EHR vendor has at least some customers exchanging information with the EHRs of other vendors and now CommonWell and Carequality are connected. Can product shortcomings still be given as an excuse for lack of interoperability?

The vendors work really hard, and from my perspective, the vendors are committed to making patient data as easy to move as possible. On the other hand, the vendors basically fight with their old legacy code bases that are extensively customized and very had to work with. That’s the nature of any mature software product. I think that if I was a consumer, I would be unhappy with where they are, rather than if I’m an engineer looking at their problem. It’s kind of a challenge for the vendors.

But increasingly, as I observe the space, the challenges are with the providers. To what degree do the providers want to share information? To what degree are the providers prepared to standardize their record-keeping practices and their clinical practices to make it easier to exchange data and to transfer patients seamlessly? Not many of the colleges really understand that problem. I would like to call out the American College of Obstetricians and Gynecologists, which understands the problem very well and has very standardized record-keeping practices on paper. That puts them in good stead to get interoperable.

A lot of doctors I talk to think about this as a technology problem, but it’s not a technology problem. It’s an information problem, and so technology can’t solve it. It needs clinicians to make clinical agreements in order to get clinical interoperability.

There’s one more thing I’ll say, which is that interoperability is not a binary thing. We get a degree of interoperability. We can routinely exchange patient summary information. But seamless transfer of care will require a deeper agreement. We’re not there yet. We’re working on those as a community. But I believe that increasingly the load will move away from the IT side or the technical side to the clinical side as time progresses.

Efficiently accepting patient information from an outside source requires placing it into the receiving clinician’s workflow and being willing to use information that was entered elsewhere. Not that we need another interoperability frontier, but is figuring those issues out the next one?

The trust issue is really important. I’m glad you brought it up, because increasingly as I look at projects around the world, the question, is who trusts who and why? A lot of the complaints I hear from patients about poor record-keeping actually comes down to no established trust framework. If the patient provides you with a written statement concerning their medical history and you read that, are you liable for not asking them verbally? Can you rely on that written statement? If you get a written statement from another institution, can you rely on that? The interplay between trust and liability is something that we’ll have to revisit as a community and make that a fundamental part of our interoperability considerations.

What could I do as Provider A if I find that I’m regularly receiving incorrect or unreliable patient information from Provider B?

Looking around the world, I routinely hear that more than half of patient records contain wrong information about the treatment history. Some of those are really, really wrong, and you can easily find examples of that in the media. Surveys that I’ve seen show that it’s more than half the records contains something wrong, and yet we make those available to the patient without any consideration for what a patient should do if they look at it and say, that’s not right, I’m a guy, so I don’t think that a pregnancy test was actually performed. Life’s a bit more complicated than that, but what do they do?

You asked the same question about providers with each other. There’s one organization working on the policies and technologies associated with this, which is Carin Health. But we should start moving towards a culture where it’s a professional obligation that if you share your records with somebody, you have an obligation to have some sort of error detection and correction process running so that your records can be corrected. But in today’s environment, we’re a long way away from thinking like that.

What has been the impact of Apple exchanging information with EHRs using FHIR?

There’s certainly discussion happening around Apple in particular, but more generally patient access to information and what kind of difference that will make. Obviously that was a subject of the keynote at HIMSS. Apple brings a particular sharpness to that debate because of its global consumer reach, the style of its consumer reach, and the potential for Apple to disrupt health in the way they’ve disrupted other industries. I certainly hear discussion about that. Some people are wildly in favor of any disruption. Other people are very much not in favor of any disruption. Some people are concerned about what a consumer company like Apple might do.

My perspective is that getting patients their data doesn’t really make much difference to patient satisfaction or behavior, because it’s all historical data. What makes a difference to a patient is the services that you provide. You need data to support the services, but it’s the services that matter. As long as healthcare services are fundamentally delivered in the flesh in the physical world, there’s a limited degree to which the consumer electronics companies can disrupt health.

In order to provide substantial healthcare services, you have to put people on the ground. That raises all of the classic “how do you manage healthcare” problems, for which I don’t think there’s any magic bullet. I think that their impact will be significant, but ultimately limited by real-world constraints.

Joe Biden and Seema Verma have recently expressed disgust that they, even as high-ranking government officials at the time, were unable to get the medical records of their relatives, and Verma in particular seems outraged. Do you think the government sees its role now differently than it did originally?

It has become more clear across the industry that what we have is not a technology problem. We have a business and an information problem. The government laid down a whole lot of money as far as stimulus, partly to spend money — which it did effectively — and partly to move past the technology barrier to the information barrier. Aneesh Chopra has told me that what happened was relatively predictable. We’ve now solved the technology problem. We can focus on the business and the information problems, and here we are doing that. The NPRM focuses on cleaning out the technology problems and moving the business and information problems to front and center.

But as the government, the levers that you can pull have limited effectiveness. That’s even true in autocratic countries. I was in one country where they showed me that certain things were happening in a particular way. The next day, I would meet with the programmers. They would say, “This is how we do it, but don’t tell the bosses, because they’re not allowed to know.” The levers that you can pull as a policymaker and a money-spender are a lot more limited than people believe. At least the US government is acutely aware of that, much more so than other governments I deal with.

Nothing leaps out at me as any quick solution here, so since the NPRM is marginal improvements being made over time, we can look for improvements. I’m particularly hopeful that we can solve the access to healthcare records problem through thoughtful change. I already saw that happen with vendors. When I started dealing with health information exchange, vendors were suspicious about exchanging patient data. They saw that as a business threat. Now when I deal with C-level people at the vendors, they’re all like, “Well, why wouldn’t we do that? We can’t not do that. It’s part of our business. It’s a business opportunity.” Whereas if I talk to providers, I see providers very much being, “Why would we do that? Why would we spend money doing that? Isn’t that a business threat?” It’s about making that same cultural adaptation to their thinking.

That’s the key thing that we need to chase — the understanding that exchanging patient data with the patients is a business opportunity, not a business threat. But it’s a cultural transition that needs to be bedded deeply through the provider before the provider is ready to see healthcare as a different kind of business model. There are a number of institutions around the USA that are pushing that as hard as they can. Hospital in the home, seeing the hospital as part of a wider network, the whole ACO thing is pushing that. There’s a bunch of things happening, so I’m not particularly pessimistic about it.

Does anybody still care about Blue Button?

There’s a really active community around the new Blue Button work that CMS is doing with FHIR. The FHIR community is picking up and processing the data. There certainly is interest in cross-correlating data from Blue Button with data from the Argonaut interfaces that patients can get, and creating a market in that space. The White House is interested in that. It makes a lot of sense to try and leverage some efficiencies out of the system by cross-correlating payment data and payment efficiency data with individual healthcare data.

That’s the logical place to look for where you, as a funder, could seek to provide more efficiencies in the healthcare system. In the end, the providers of healthcare are not motivated to perform systemic repair to healthcare. It’s the funders who are motivated to perform systemic repair. That’s an important part of the overall picture.

Morning Headlines 3/25/19

March 24, 2019 Headlines No Comments

FDA Chief Calls For Stricter Scrutiny Of Electronic Health Records

Departing FDA Commissioner Scott Gottlieb says FDA oversight of EHRs would be appropriate “when they’re doing things that could create risk for patients” in turning into a medical device.

Healthcare Analytics Leaders Clinigence and QualMetrix Merge to Accelerate Value-Based Care and Population Health Management

Population health analytics company QualMetrix becomes a subsidiary of quality reporting software vendor Clinigence.

Wolters Kluwer provides NASA astronauts in outer space access to UpToDate clinical decision support resource

Wolters Kluwer is providing International Space Station astronauts with access to its UpToDate medical information resource.

UCLA Health System Settlement

UCLA Health System (CA) will spend $5.5 million on cybersecurity defense as part of a proposed settlement stemming from a 2015 data breach that left patient data exposed for nearly a year.

Monday Morning Update 3/25/19

March 24, 2019 News 1 Comment

Top News

Departing FDA Commissioner Scott Gottlieb — reacting to the “Death By 1,000 Clicks” article — says FDA oversight of EHRs would be appropriate “when they’re doing things that could create risk for patients” in turning into a medical device.

Gottlieb added, however, that Congress would need to define those conditions. He doesn’t expect any changes in the next several years.

Reader Comments

From Captive Cursor: “Re: Beth Israel Lahey Health. Named former Dartmouth-Hitchcock CIO Peter Johnson as interim CEO of the new entity. He would be an interesting interview.” Johnson’s LinkedIn says he’s been an independent consultant since leaving Dartmouth-Hitchcock in 2011 after 26 years and I know he has covered CIO roles since. I agree that it might be fun to interview him.

From From Athena With Love: “Re: Athenahealth. Post-acquisition layoffs are about to happen (April) according to rumors.” I’m pretty sure you can count on layoffs, especially when combining two companies that must have quite a bit of corporate overlap. The real question is how they handle the product portfolio, especially the GE Healthcare part. That’s compounded by the fact that healthcare experience, especially that obtained from somewhere other than Athenahealth, is hard to find among the executive team members.The corporate raider script, especially with hedge funds like Elliott Management, seldom wavers from: (a) create distress by criticizing the targeted company publicly and maybe applying some dirty tricks; (b) use the resulting share price drop to bully the board into selling the company at a discount; (c) cut costs mercilessly to shore up the financials while the company is sequestered away from investor oversight as a private entity; and (d) either find another willing buyer, or as is more likely with Athenahealth, expand into sexy-sounding areas with big potential, take it public again, and transport wheelbarrows of cash to the bank before the company’s long-term prospects turn out to be less impressive than the juiced numbers and creative story suggested. Vertitas Capital’s big healthcare IT score was selling the healthcare database business of Thomson Reuters, renaming it Truven Health Analytics, and then selling it to IBM for more than double the $1.25 billion it had paid just four years earlier. Athenahealth’s prospects are probably less rosy in the absence of a likely buyer (especially one as desperate as IBM), the overall sagging of the EHR market, having product that were run into the ground by GE Healthcare in its mix, and the significantly inflated company value that was purely due to Jonathan Bush’s involvement.

From Randall N’Jobu: “Re: doctors. I saw an article wondering how many people call their doctor by first name. Survey your readers?” Take a few seconds to answer and I’ll share the results. I’ve noticed than I’ve changed my practice of always calling my PCP “Dr. XXX” changed when I moved to a concierge doctor, where it’s more personal, less formal, and in my mind more appropriate to use first names since he’s working directly for me. Oddly enough, however, both concierge docs I’ve seen call me “Mr. XXX” even as I called them by their first names, so maybe I’m either faux-pas’ing or something about the situation has turned the tables (they are also younger than I, so that may play a part, as I included in the poll). Physician readers, are you put off when patients call you by your first name, do you invite it, or what do you really prefer? I remember cringing in my early hospital days with a 20-something nurse would address an 80-year-old patient as “Mildred,” but that perhaps was a signal that informality was moving from society in general to medicine in particular.

From Dollar Cost Averaging: “Re: healthcare IPOs. Are they suddenly a thing again?” I’m no expert, but it seems to me that companies see the recessionary writing on the wall and figure they need to either move now or wait years for the cycle to turn back around.

HIStalk Announcements and Requests

A third of not very many poll respondents say they saw something at HIMSS19 worth following up on. They left us to guess what that was.

New poll to your right or here: How much doctor burnout is caused by EHR design (workflows, screens, clicks, etc.)?

Webinars

Previous webinars are on our YouTube channel. Contact Lorre for information.

Sales

Iowa Health Information Network will provide real-time patient notifications to its provider members using PatientPing, replacing Iowa’s Statewide Alert Notification system.
University of Vermont Medical Center will use solutions from Loopback Analytics to identify at-risk patients and improve outcomes related to specialty medications.

People

Two ROI Healthcare Solutions executives – Founding Partner / CFO Kathy London and Managing Partner / President Jim Jancik – announce their retirement.

Other

The VA struggles with documenting care for veterans who have undergone gender reassignment surgery, as one advocate wants all EHR mentions of surgery and previous gender removed to protect them from violence, while others say providers need to know the patient’s full history.

A “Madison Magazine” columnist says the local airport should be renamed from Dane County Airport to Judith Faulkner Airport as Epic has remade the area’s economy from its Oscar Mayer heritage of making “wieners and pimento luncheon meats” (the company bailed to Chicago in 2015) and Epic saved the area from “one of the most forlorn demographics in all the world.” He notes that Epic makes it possible to take direct flights to Phoenix, San Francisco, and Los Angeles and has fueled the growth of hip venues that cater to its campus full of young adults with significant incomes.

Wolters Kluwer is providing International Space Station astronauts with access to its UpToDate medical information resource. I admit that I don’t follow low-orbit type projects, especially now that they sell seats to space tourists, but this announcement made me wonder what will happen if an occupant has a stroke, heart attack, or even appendicitis. I assume it would be like in the remote parts of the world, where doctors on the ground instruct crew members who have undergone the most basic of medical training to perform diagnostic tests or minor treatments in sort of a celestial MinuteClinic, but without the option to call an ambulance to take them to a better equipped hospital.

Warner Music Group signs a startup’s AI-powered algorithm to release 20 albums in the next year. Endel creates custom soundscapes such as “Sunny Afternoon” and “Rainy Night” that embed custom frequencies that are tailored to a particular listener’s mood, location, and heart rate. Endel’s engineers said their songs are intended to serve as tailored background music rather than album tracks, but agreed since all 20 albums can be “made just by pressing one button.” They had to hire an entertainment lawyer to figure out who to list as artists for collecting royalties, finally settling to just listing all the engineers as songwriters.

A woman sues Olive Garden for up to $1 million for failing to warn her that her “defective” stuffed mushrooms were “extremely hot,” claiming that after the first bite she staggered through the restaurant with it stuck in her throat, vomited in the restaurant’s kitchen, headed off to the ED, then called 911 on the way because she thought “death was imminent.” She was taken to the hospital, then airlifted to Parkland Hospital’s burn unit. Personally, I would be more tempted to snoop in her medical records than those of Jussie Smollet.

Sponsor Updates

Lightbeam Health Solutions, Experian Health, and PerfectServe will exhibit at the AMGA 2019 Annual Conference March 27-30 in National Harbor, MD.
MDLive and Redox will exhibit at ATA19 April 14-16 in New Orleans.
Meditech will host the 2019 Home Care Optimization Symposium March 26-27 in Atlanta.
NextGate achieves advanced technology partner status in the AWS Partner Network.
OmniSys will exhibit at the Computer-Rx T.H.E Conference March 28-30 in St. Louis.
QuadraMed’s EMPI partners with LexisNexis Risk Solutions Partners to prevent patient identification errors.
Surescripts will exhibit and present at the 2019 AMCP Managed Care & Specialty Pharmacy Annual Meeting March 25-28 in San Diego.

Blog Posts

Best Practices for Communication and Coordination in Long-Term Care (LiveProcess)
Using the cloud to ‘untether’ medicine from wired tech (Meditech)
Improving Healthcare’s $6 Billion Patient Matching Problem (NextGate)
The IT Service Management Series – Part 2: Information Security Management – Beyond Compliance (CloudWave)
How Schneck Medical Center manages denials promptly and with ease (Experian Health)
The AHA Health Motivation Platform is More Important for Your Reactive Cardiac Patients Than You Think (PatientBond)
Don’t Implement a New Patient Billing System without This Checklist (Patientco)
The Net Impact of Poor Patient-to-Provider Communication (PerfectServe)
How to Use Generated Forms Inside PV’s EMR (Practice Velocity)
ONC & CMS Proposed Rules Part 2: Interoperability (Sansoro Health)
A complete solution from smart bed to smartphone. (Voalte)
10 Emails You Should be Sending Your Patients (WebPT)

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
Get HIStalk updates. Send news or rumors.
Contact us.

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Reader Survey Results: How I Would Change EHRs

March 24, 2019 News 3 Comments

I asked readers how they would change EHRs to improve outcomes and reduce costs while still meeting the requirements imposed by the US healthcare system. That’s the basic question EHR vendors face every day. Some of the excerpted answers I received are as follows. Non-clinician responses are indicated with an asterisk.

* Keep them headed in the direction they’re on: platforms supporting standardized open APIs. The Fortune article was hysteria-feeding bias by writers who don’t understand economics, technology, or healthcare. Chopra had the best take in the article: MU was a messy process but it was a necessary down payment that will yield benefits to patients for years to come.

Create true app store-type environment being opened up by the recent mandate for FHIR APIs, a way to totally separate the data entry issue from the clutches of current vendors. The most practical complementary situation in the interoperability realm would be a timeline approach to presenting links to patient specific information for the caregiving team. There are many candidates whose product offerings could be customized to fulfill this.

* Allow doctors to create/buy their own EHRs with no regulatory restrictions on interoperability other than summary reports, lab interfaces, and pharmacy interfaces. This puts agency back into the hands of the frontline clinicians themselves and allows us to cut the complexity out of entrenched vendor products and brings e-health back to the basics, where it belongs.

* I would move EHR interoperability to something more similar to the SWIFT financial network. A cooperative would operate a set of datacenters and network. Transactions on this network would be defined by a set of standards (HL7+X12 but with a strong opinion on what that actually means.) Messages would be routed from the providers to the cooperative then onward to other providers or insurers or wherever. Failure to reply to requests with the appropriate clinical information would result in an increase in the transaction fee that the networks charge for submitted claims.

Say you don’t return a request for patient data promptly or fail to submit an HL7 ADT message when a trigger happens — some percentage of your claims for the next year will be put into a general fund that supports the network. Awards are given from the general funds to whistleblowers who point out failure and non-compliance. Additional failures or non-compliance will result in a steadily increasing withholding from each payment your org receives. Failure to join the network or repeated non compliance with the requirements will lead to loss of Medicare and other government payments. US digital service and some CMS lawyers form the initial public committee that organizations go before to submit complaints against each other, appeal decisions, etc.

* All big systems were designed around billing, and the visit is the hub. That should be tossed out and redesigned so patient is the hub.

* Phase out Meaningful Use. Halt any usability mandate initiatives (let free market decide). Pass legislation that makes it much more difficult to sue for patent infringement. For EHR software that is released and used in production at publicly funded health systems, screenshots, videos, and specific descriptions of functionality / workflow should be shareable with open public (excluding PHI stuff) i.e. greatly limit an EHR vendor’s ability to nix content from web with IP protection claims

* I would allow malpractice carriers to drive the market need for effective electronic clinical documentation through how they price premiums rather than CMS reporting requirements. That should shift the market dynamic away from a great billing product to one built around patient safety.

*Interoperability: generate rich patient records with specific variability and define a set of assertions that are associated with those cases. Send them via CCDA and FHIR and ensure that each EHR can receive, reconcile, and directly incorporate all data into their EHR.

Usability: generate a standard set of the top 10 nursing and physician workflows — give the workflow 100 points. Then for every time the user has to switch contexts from the patient to the computer, deduct seven points. Every time the user has to switch from the keyboard to the mouse, deduct five points. Every keystroke the user has to enter to do a search – deduct one point. Grade it based on standard: 90 percent A, 80 percent B, 70 percent C, 65 percent D.

Error reporting: Put the EHRs under FDA CFR and require they publish all harms with their customer notice to a Federal EHR Adverse Event Reporting System (FEHRAER?). All potential patient safety or safe use issues reported to the same system, but perhaps we would mine those for trends and allow them to remain non-public.

When someone cheats on their MU reporting or MU certification, a change in suit color is in order. Not just fines. but hard time.

* Centrally managed (decentralized storage) common health record structure that all EHR technology vendors and providers of all types are forced to contribute to. This would break up monolithic EHR vendors, stimulate creativity, and allow each provider to select the tools used to contribute to a commonly defined health record. This would solve the interoperability issues and allow the market evolve quickly. Basically we follow the ubiquitous app store approach. We could use a distributed ledger approach to record management.

* We need to focus on the paradigm that exists around our transition from paper-based, trust-based, fee-for-service charting to an electronic health archive and medical billing support infrastructure. There is no direct correlation between the two worlds. And I am not talking about the change felt by payers and providers. We have not changed the patients’ encounter as dramatically as we need to in order to support new world order in healthcare.

Patients are typically scheduled in much the same way as before. The Doctor’s office visit is mostly the same. And what is scary is the huge push and hyper focus for MORE office visits. A vastly different office visit is required. And since everyone is a consumer, we all share the same responsibility to adapt.

One very tangible change would be patients acknowledging that their visit with the physician is being recorded. Recorded sessions will be saved for 24 hours until the medical record has been appropriately updated and accurate labs and meds are ordered and prescribed. This one process change has many downstream benefits to both accuracy and integrity. There are ways to incorporate many levers to assist, however, it starts with changing the patient’s point of view of a doctor’s visit.

* Systems that you can easily dictate into via headset, for example, as you are performing assessments, “breath sounds diminished in left lower lobe, slight wheeze in left upper lobe, strong, loose, productive cough. Resp Rate 14, pulse 84”, etc.
having discussions with patients, “Mr. Gonzales indicates shortness of breath walking up one flight of stairs”. System would be smart enough to catalog information discretely in the right places in the right way to make it interoperable.
Alexa-like recall of important information or tasks “Alexa, please reconcile Mr. Jones medication list and show me any discrepancies” “Alexa, what is Mrs. Smith risk of 30 day readmission and what should we do to mitigate it?” “Alexa, what routine care items / screenings is Ms. D’Meanor due for?”

* At the health system level at a minimum, standardization of content based on evidence should be required. Utilizing 4,000 different order sets, customized care plans with zero evidence, lack of consistent clinical decision support should be disallowed. EHRs only get better when the information available at the point of care is better.

Implement National Patient Identifier, and mandate that it cannot be SSN. Get rid of the old school “funny Money” mentality of charges that all the stakeholders can get an accurate view of value in health care, and not monopoly money gross revenue nonsense that is currently what is floated out there.

* I think we need some UPS-style time and motion studies to understand how to make the EHR more natural and complementary to physician and clinician practice. Some future improvements should be possible based on this understanding, for example:

Narrowing what is on a screen based on context in the patient encounter
Narrowing what is on a pick list based on context
Improving adoption and usability of no-touch UI’s

There is a lot to be learned for the major EHR vendors from the computer gaming industry on having commands and data elements be contextual. I think we need to shatter the “project mentality” in EHR rollouts and just assume optimization never is finished. If any investment deserves the the continuous improvement process, it’s this one.

* Get rid of the need to document every single minutiae. Let the doctors decide and be responsible for what they enter in (if they start making mistakes or not entering important information, it’s on them and their insurance). Have a simpler interface for physicians, and another a complex one for “scribers” (could be the same as what’s currently offered). What’s required for simpler interface should be arrived at by a mix of EHR vendors and physicians (AMA), make this required for certified software. This you could be standardized across the US. If the doctors don’t like it, they can switch to the scribers interface and go nuts but no complaining anymore about the interface. Only the simple interface should be required for the software to be certified.

If the bean counters want something tracked and entered in, let them pay for it in the term of scribes, etc. This will easily track the true cost of of all this data entry which is currently being paid through physician time. Since they love tracking costs, they should love this, right?

Have a tool to download record from patient portal, in an open and readable format. Even better two formats, one human readable, and one machine readable. Make this required and always available if you want to be certified.

Have tool in patient portal and in EHR to submit feedback on the software. A copy goes to the vendor, one to the health system, and a copy goes to regulators, available through FOIA to anyone (once personal details are scrubbed).

Not really something that can be done on EHR side but:

Make health systems pay for failing to share patient’s records (if the above functionality fails). Make this an increasing cost based on delay and also based on the amount of money the health system generates (not profit, as they’re all not-for-profit).

Make the health system generate a single, detailed bill. If the health system is not-for-profit,” it should have both the cost of the material and how much they charge for it in the bill. If the bill goes out past a certain date, the patient doesn’t have to pay it. Let them deal with paying outside the network, etc.

* I worked in financial services technology in 90s and early 00s. If you free the data, innovation will come. We’re in generation 1. There are whole entities just forming that normalize, curate data. Better user centered design will come when SME for particular problems are able to enter at a price point commensurate with value. Add-on and systems next to the EHR will become primary home for tasks for specialized workflows. EHRs that can build and partner for these models will succeed. The ones that stay data locked will be the last system stand alone docs have before getting eaten by local mother ship. That could take decades. Ones that unlock data and become integration partners have a chance at survival.

The larger orgs that command a premium $ in their practice and have a handle on ROI and total cost of practicing will bring support for doctors into exam room. MGH in Boston has been doing this for almost a decade.

There is no perfect technology. Our ability to acknowledge data integration is key is tantamount.

Although politically undesirable, move to a unique patient identifier/set of unique keys per patient would help immensely.

Since early 2013, the Texas Medical Association has recommended to ONC that they should require all EMR data elements to be XML tagged using a single national standard, much like the accounting profession successfully uses XBRL. With a universally-understood tagged data structure, physicians and hospitals would ideally be able to pick up their databases and move them quickly and cheaply between vendors. Vendors then would be forced to compete on their user interface, including usability.

XML is just one approach for tagging. FHIR is analogous to this approach, but it’s not being used in a “pick up your database and change” way, as far as I know.

If, in 2013, the ONC had started us on the XML tag journey (or its equivalent), we would be far, far closer to true interoperability and data sharing.

* Leverage the massive amount of data that has already been collected over the past 10 years. Utilize machine learning to automate the largely repetitive tasks done by clinicians. A run-of-the mill CAP admission already gets the same order set anyway, with the same billing codes. There is no need for things like this to be done manually every single time. Machine learning should be able to take care of 80 percent of the tasks currently done by clinician end users. The other 20 percent are the unique clinical situations where we need clinicians to use their experience and critical thinking skills to solve complex medical problems beyond the capabilities of machine learning.

Mandate interoperability and provide real teeth to enforcing this with real consequences for facilities, systems, and technology that does not share all the data. This includes providing all to the patient. Don’t let perfection stand in the way of progress when it comes to interoperability – start with something and expand on it.

Relegate the EHR to a database and allow for customized solutions as an overlay for specialties and individual workflow.

Stop punishing doctors with data entry and find an alternative to capture of information and allow them to return to the art and joy of medicine.

Require justification form variation from standards of practice established and proven holding clinicians accountable for that variation when they find alternative paths and treatment protocols.

Make the technology a part of medical education and allow those individuals to contribute to rethinking the solutions, workflow, and layout. They are unencumbered by the baggage of paper notes and as digital natives would have new and innovative ideas that we could use. They are also deeply invested in fixing this unholy mess since they are forced to use this archaic solution and are often the data entry clerks of choice as the most junior clinical employee, wasting all their training time on updating the system — residents spend 70+ percent of their time in their basement room updating the EMR not seeing patients.

My notes would be minimal, perhaps even written primarily by the patient. Diagnoses would be common language and not all the absurd detail ICD-10 brings. Real-time costs would be part of ordering and someone other than me could figure out the charging in the end. Make the screens as simple as an iPad, intuitive so that they just work as expected.

Weekender 3/22/19

March 22, 2019 Weekender No Comments

weekender

Weekly News Recap

A Reddit “Ask Me Anything” with Providence St. Joseph Health EVP / Chief Digital Officer and venture fund manager Aaron Martin gets ugly with charges of layoffs and a hostile work environment for female employees
A France-based online medical appointment app vendor’s funding round values it at more than $1 billion
Fortune’s cover story, “Death By 1,000 Clicks: Where Electronic Health Records Went Wrong,” says EHRs are an “unholy mess” after taxpayers spent $36 billion on their use
Health Catalyst hires investment bankers to begin its IPO process
The payment model of England’s NHS, which is based on a medical practice’s location, raises concern as the private company behind the GP at Hand video consultation app draws 40,000 Londoners to its practice
Change Healthcare files IPO documents
A survey finds that nurses who work in a positive work environment like their EHRs better and have a higher appreciation for their role in patient care

Best Reader Comments

Having sold EHR software before the government started subsidizing buying as well as after its no surprise the monetary “savings” haven’t been realized. Most physicians under-coded visits prior to using an EHR as they feared failing an audit of required documentation. Using an EHR allows faster accurate coding, which means higher medical costs. When physicians used paper to document care, they usually made very brief notes with the patient in the exam room. Then they spent hours dictating progress or writing progress notes after business hours. This delay often led to missing information in the notes. Many charts were unreadable or missing when needed. The paper records were far from perfect and hid many more medical errors. (Matt)

No one took the time to redesign the healthcare process [before designing EHRs] and develop roles and tasks that automation could efficiently support. A quick read of the Toyota Production System’s approach to adopting new technology shows how backward EHR adoption has been. We do have great examples in health care where automation was handled properly. Voice recognition reduced radiology turn around times to minutes from days. Lab automation and electronic communication linked robotic testing results to the medical record with near instantaneous availability. Bedside MARs measurably improved patient safety. But when it came time to do the big one, we dropped the ball. (Steve O’Neill)

There’s not a Theranos story [with journalism investigating the EHR industry], but there is a story of companies that grew much too quickly, are governed largely by crisis and chaos, have an ethos of “put something out there and fix it later” (or, promise something and create it later), are operated at all levels but the very top mostly by 20-somethings, and have had plenty of lapses of both execution and ethics in the post-HITECH boom. (Fred)

Back in the very first days of the MU program, I sat in a meeting room at a state hospital association conference and heard a CMS regional administrator say, “We won’t pay for that which we can’t measure,” i.e, if you are documenting in a way that makes it difficult or impossible to collect data and compare how you’re doing with other providers, we aren’t going to pay you. Lab results, vital signs, and drug administrations are all relatively easy to collect data for measurement. Medical necessity pass/fail rates are fairly easy. Acceptable Use Criteria will make diagnostic imaging more easily measurable. CPOE made order patterns measurable. Specificity in documentation to get to the most specific diagnosis code possible is measurable. MU was in large part about making as much information as possible measurable. That it took billions of dollars to get an industry notoriously resistant to any oversight in how they function was a feature, not a bug. (MEDITECH Customer)

Physicians are in such limited supply and command such high salaries that the entire clinic or unit orient themselves around having the MD always operate at the “top of their license.” This means that the MD interaction with the patient will consist of 1.) dispensing whatever information only the MD and no one else in the clinic can dispense. 2.) doing the bare minimum to ensure that the patient is billed for number one. Doctors will not get paid >100 dollars an hour to look people in the eye, have a conversation or connection, take a clinical measurement, have an original thought, etc. All of those things can be done by a medical assistant or a nurse or someone cheap. We could assign a scribe to every physician so the wouldn’t ever have to touch an EHR; I think doctors would be marginally happier but not significantly. The reality is that physicians are now employees and no longer run the show. Like the rest of us employees, the only meaningful changes will come from unions or the legislature.(SelfInflictedWound)

I have been in the healthcare industry for years and am guilty of not having a PCP. I had never really thought about the “relationship” aspect of a physician and why it would be beneficial to have someone engaged in my care that has seen me over a period of years rather than a quick trip in when I am not feeling well. Technology continues to change how we interact and socialize with others. It will be interesting to see how the doctor-patient connections morph as technology continues to be more readily available and acceptable in new areas. (Steph M.)

Watercooler Talk Tidbits

Readers funded the DonorsChoose teacher grant request of Ms. T in Texas, who asked for 35 calculators for her elementary school class (I’m not exactly sure what kind of class, but she mentions that all students are girls who have overcome adversity). She reports, “Students today have easy access to a lot of technology, but they are not always taught how to use it correctly. One thing I have noticed in the past is that students struggle to use calculators correctly. This causes a problem as they progress in school and have more access to them and are expected to use them in Algebra. The impact of your gift is that now, students at my school have the ability to be taught how to properly use a calculator before reaching the upper level math classes. Thank you for allowing them this introduction!”

Researchers working with a woman who can detect Parkinson’s disease based on the smell of patients create a diagnostic test as a result, using mass spectrometry to isolate the four compounds that are most responsible. The former nurse can also detect cancer and tuberculosis, which will be the subject of another round of research.

A 59-year-old woman who suffers from early onset dementia is sent from a local hospital to Oregon Health & Science University for urgent heart bypass surgery and valve repair. She then developed a post-op infection that left her hospitalized for a month, after which OHSU billed her for the $227,000 part of her stay that her insurer wouldn’t cover because the hospital is out of its network. Her husband, whose Social Security payments of $1,900 per month make up the family’s entire income, says the hospital never told him about the out-of-network costs or offered a transfer to an in-network hospital. The couple is relieved that OHSU finally agreed to write off the bill under a charity waiver obtained with the help of a non-profit group, but resents getting collection calls for six months.

Bizarre: the Buffalo Wild Wings restaurant chain rolls out a March Madness “Jewel Stool” that is comfortable for men who have just undergone vasectomies, with the idea coming from data pulled from Athenahealth’s netowrk indicating that urologists perform 41 percent more vasectomies on the first Friday of March Madness compared to the typical Friday. Urology practices like the one above are even running March Madness snip specials.

A retired, Harvard-trained cardiologist whose restaurant waitress daughter asked him to cover a busboy shift saves a choking woman just five minutes into the job by performing the Heimlich maneuver.

Get Involved

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Morning Headlines 3/22/19

March 21, 2019 Headlines No Comments

BESLER Completes Acquisition of Essential Consulting LLC, a Leader in Hospital Reimbursement Services and Supporting Technology

Hospital RCM company Besler acquires competitor Essential Consulting for an undisclosed amount.

Family’s letter to Providence St. Mary leads to new telemedicine program for critically ill children

A family’s suggestion and donation leads Providence St. Mary (WA) to pilot telemedicine capabilities that enable its providers to consult with neonatologists and pediatric intensivists in Spokane.

750,000 Medtronic defibrillators vulnerable to hacking

Homeland Security alerts consumers to vulnerabilities in 16 types of Medtronic implantable defibrillators that would allow a hacker to access or modify the device’s data, and change device settings.

News 3/22/19

March 21, 2019 News 5 Comments

Top News

Providence St. Joseph Health EVP / Chief Digital Officer and venture fund manager Aaron Martin participates in a Reddit AMA (Ask Me Anything) that quickly turns ugly as participants – including claimed former employees of his Digital Innovation Group — press him about layoffs and a reported sexist, bullying, and stressful culture. I’ll paraphrase a few comments, although I’m obviously unable to verify their accuracy:

Is spending hundreds of millions of dollars on what is essentially a tech start-up consistent with the Sisters of Providence mission?
Bragging that two-thirds of the leadership team is women doesn’t reflect a culture that favors “young brogrammers.”
More than 80 employees left last year.
“People joined DIG because they were inspired by the mission and often took a step back in pay to make a difference. Then, it takes about three weeks at DIG to realize you’ve been tricked. It’s not mission-driven, it’s driven by bullies who care for no one but themselves. I think the leadership team would even turn on each other if needed.”
Participants questioned whether Martin profits personally from deals on top of his reported $1.6 million in compensation, also claiming that the sale of Circle Women’s Health Platform to Wildflower Health “involved Providence paying Wildflower $4M to take it, kind of like a dowry.”
A participant said that PSJH’s acquisition of blockchain vendor Lumedic (although not part of Martin’s group) “appears to be the hiring of a group of five executive-level ($$$) friends who used to work together at previous companies with a pointless blockchain vaporware company and no actual intellectual property (patents) or software engineers or working product. Why is PSJH throwing money at scammy, buzzword-slinging suits?”

Reader Comments

From BurbianEHR: “Re: Lahey / Beth Israel post-merger administration layoffs. Starting today.” Unverified, but not surprising.

HIStalk Announcements and Requests

I’ve received some good responses to my “how would you change EHRs” question, although respondents face the same challenges as vendors – you don’t get the pie-in-the-sky satisfaction of submitting a “world peace” type answer because the US health system defines EHR requirements, not vice versa. Your assignment, then, is to describe how you would make EHRs better while still allowing them to function in the unreal realities of our healthcare system.

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The Forbes “Death by 1,000 Clicks” article stirred some nostalgia about those heady Meaningful Use days, when EHR vendors turned into shameless used car salespeople in hawking their previously unwanted wares. HIMSS, too – my favorite insanity moment was when HIMSS launched a road show series called “Takin’ HIT To the Streets” (subtitled “The ARRA Era”) in late 2009 as a self-appointed convener of sellers and potential buyers.

My comment from November 2009:

The HIMSS Takin’ HIT to the Streets campaign (gag, even for Doobie Brothers fans) leaps that last boundary of member organization common sense — they’re paying people to attend the sales presentations of their vendor members. I’ve been watching the remake of the old miniseries “V” and I think maybe vendor visitors have taken over Steve Lieber’s body since the previously furtive and tentative vendor-HIMSS gropefest has advanced to a full-on public consummation.

Webinars

Previous webinars are on our YouTube channel. Contact Lorre for information.

Acquisitions, Funding, Business, and Stock

Unite Us, whose platform connects providers with community resources to address social determinants of health, raises $35 million in a Series B funding round, increasing its total to $45 million. Two of the three co-founders are military veterans – CEO Dan Brillman served in Iraq and Afghanistan and still flies as an Air Force Reserves major, while Taylor Justice graduated from West Point and spent time as an Army infantry officer. The company was founded in 2013 to connect veterans to resources that could help them adjust to civilian life.

France-based medical appointment app vendor Doctolib raises $171 million in a funding round, valuing the company at more than $1 billion. It recently added video visits and digital prescriptions.

Sales

LifeBridge Health will implement Artifact Health’s physician query solution to expedite accurate coding of patient records.
Hospital de la Concepcion (PR) chooses FormFast’s electronic signature system, integrated with Meditech.
Humana selects Inovalon’s analytics solution.
First Health of the Carolinas chooses HealthMyne’s imaging decision support for screening and following lung cancer patients.

People

Outgoing CVS Health EVP Meg McCarthy, who has a long background in health IT, is appointed to the board of Marriott International. She served early in her career as a Navy Medical Services Corps lieutenant at Bethesda Naval Hospital and earned an MPH focusing on hospital administration.

Announcements and Implementations

Medhost responds to a whistleblower lawsuit in which two former IT employees of Community Health Systems claim that CHS fraudulently attested for Meaningful Use and that Medhost made false statements to earn Meaningful Use Stage 2 certification for its EHR. Medhost denies the allegations, notes that the federal government has declined to get involved in the lawsuit, and says that its software is successfully used by hundreds of facilities and continues to be chosen by sophisticated clients who have analyzed and compared it extensively.

The American Academy of Family Physicians offers a Primary Care Innovation Fellowship to study EHR usability and support for primary care.

Privacy and Security

A study finds that 79 percent of medication-related Android apps share user data, most commonly their device information, browsing history, and email address. Four apps were found to share medical conditions and six sent the user’s drug list. Recipients include social media companies and two private equity firms. The study notes that HealthEngine, Australia’s most popular medical appointment scheduling app, shares user information with personal injury law firms without providing an opt-out option.

Other

NHS’s new technology group surveys clinicians on what one technology change they would make, with the #1 answer by far being integration of patient records.

A GAO report finds that two-thirds of air ambulance transports, which cost an average of around $40,000, are out-of-network for insured patients. That means they are billed for huge balances even though they didn’t make the decision to call in an aircraft instead of using ground ambulance. Air ambulance providers are prohibiting from balance-billing Medicare and Medicaid patients, but privately insured passengers are fair game.

The Kansas City lakefront estate of former Cerner CEO Neal Patterson is put up for online auction. The 13,000-square-foot house on four acres was built in 1993 by the development company owned by Patterson and Cerner co-founder Cliff Illig, which created the gated Loch Lloyd community in which the house is located. It is appraised at $3.26 million. Patterson died in July 2017.

Several board members of University of Maryland Medical System resign or take leaves of absence following investigative reports indicating that one-third of the board members have business dealings with the health system, one of them being Baltimore Mayor Catherine Pugh, who says she’s a victim of a “witch hunt” in failing to disclose her deal. She sold the health system $500,000 worth of her self-published children’s books, of which not a single copy has ever been bought by anyone else.

I missed this earlier: Rochester Institute of Technology researchers begin commercialization of a cardiovascular monitoring system embedded in a toilet seat, which they expect to sell (via their Heart Health Intelligence startup) to hospitals hoping to reduce readmissions of congestive heart failure patients. I assume it works better for women.

Sponsor Updates

EClinicalWorks will exhibit at Endo Expo 2019 March 23-25 in New Orleans.
Hayes Management Consulting will host a networking event at the 2019 HCCA Compliance Institute April 8 in Boston.
Imprivata will exhibit at Texas HIMSS March 25-26 in Austin.
InterSystems will exhibit at the AMIA Informatics Summit March 25-28 in San Francisco.

Blog Posts

What’s New in MIPS 2019 (PMD)
How to level up for a role in Data & Analytics (Nordic)
2019 Health Care Industry Reports Reveal How Technology Adoption Impacts Medication Access (CoverMyMeds)
Embrace the Evolution of Budgeting and Revolutionize Your Hospital’s Workflow (EPSi)
Preventing Provider Burnout (Formativ Health)
4 Questions with Dennis Delisle, President & CEO, Methodist Hospital Foundation (Optimum Healthcare IT)
The Rule of 40 in HIT: Should your Company Prioritize Profitability or Growth? (HGP)
Safety Review: Fluoroquinolone (Healthfinch)
Three Impacts of a Third-Party Security Breach (Iatric Systems)
2019 Update on Radiation Exposure (Impact Advisors)
Essential Metrics for Improving Access Center Experience: Delighting Patients as Healthcare Consumers (Kyruus)

Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
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Vaporware?: Mr. H, you can add this little propaganda gem to your file of Top 10 Euphemisms (emphasis mine). You have one of those f...
Fred: Epic's response to burnout is precious. Yes, everyone is happy and challenged, excluding of course the thousands who hav...
Brian Too: Any complex software that you spend a lot of time in, you'd better learn it well. Most people do that but if you invest...
AC: I don't believe they give you raw click numbers yet (only PEP/NEAT score), although I think Feb 2019 release is bringing...
Dodele: We use Cerner's Lights On and Advance data extensively. There is a wealth of valuable information and it is continuousl...
Epic User: As someone that actually tried to dig into the details of Epic's signal data, I quickly became underwhelmed. No click co...
Frustrated Patient: " suggesting that my providers don’t really want to open up a can of medical worms by asking how I’m doing overall e...
AC: That's good to hear. So the major vendors have worked on this and provided tools. The question now becomes are organizat...
Associate CIO: Re: EHR internal timers and event log monitoring Cerner has this as well, it is called the Lights On Network. A curr...
Bob: Liked - "The jammed interoperability floodgates would magically open by Labor Day if their payments depended on it."...

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