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EPtalk by Dr. Jayne 3/21/19

March 21, 2019 Dr. Jayne 2 Comments

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Several people texted or emailed links to the recent Fortune /Kaiser Health News investigative article on electronic health records. I enjoyed the video sound bites at the beginning, where various members of the US government were extolling the benefits of electronic records. The piece hooks the reader by opening with a story that details a patient’s death from a brain aneurysm, with the lack of diagnosis being influenced by failure of the head scan order to be transmitted by her physician’s EClinicalWorks EHR.

The article goes on to detail a stunning array of patient safety issues and medical errors tied to EHR use, noting the gag clauses that vendors use to keep their clients quiet. eCW isn’t the only vendor called out in the article – Epic, NextGen Healthcare, Allscripts, and Greenway Health were noted as having been the target of lawsuits and complaints.

It’s a long article, but worth the read. It reminded me of some of the industry’s antics during the push for EHR adoption that I had forgotten: the availability of eClinicalWorks systems at Walmart’s Sam’s Club and various vendors holding nationwide “stimulus tours” and “cash for clunkers” roadshow dinners that offered physicians an opportunity to switch to a new EHR.

Although there wasn’t anything truly shocking in the article, I wonder what non-industry people would think about its content and how the events unfolding in the EHR industry parallel (or don’t parallel) what might be going on in other industries. I’d be interested to hear what any non-health IT folks who read the piece think about our little slice of the economy.

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The National Resident Matching Program, a.k.a. “The Match,” was held last week. This year’s process was the largest on record, with 44,600 applicants vying for more than 35,000 residency training positions. Not surprisingly, newly-minted physicians voted with their feet and their pocketbooks. Competitive specialties that filled all available positions included interventional radiology, otolaryngology, plastic surgery, and thoracic surgery. Many of those filled more than 90 percent of their slots with graduating US allopathic (MD) seniors.

Despite the fact that primary care physicians are supposedly in demand, specialties that filled fewer than 45 percent of their slots with US MD seniors included family medicine, internal medicine, and pediatrics. The remaining primary care slots are being filled by osteopathic (DO) seniors and international medical graduates. Until things change dramatically, we’re going to continue to see medical students shy away from the parts of the workforce where they’re needed the most.

I ran across an interesting piece on how working long hours and weekends might affect men and women differently. The underlying study looked at workers in the United Kingdom and found that women are more negatively impacted by long hours. Working on the weekend impacts both subgroups, but in different ways. Women working long hours were more apt to show depressive symptoms than those who worked fewer full-time hours or part-time. Men working long hours didn’t show a significant rise in depressive symptoms.

My family lives in an “opt in” state for data sharing on the state’s health information exchange. Fortunately, the big players in their town all participate. When my uncle was recently hospitalized at Big Health System, my dad was excited to find a pamphlet on the value of opting-in to HIE sharing while going through the admissions documents. Since he understands the value of having multiple clinicians be able to share data, he went to the nursing station to obtain the appropriate forms to opt his brother in. The person he talked to seemed surprised to learn about the pamphlet and didn’t have any idea what forms were needed. He was redirected to the medical records department deep in the bowels of the hospital, and they didn’t have any idea either. He was forced to call the number on the pamphlet to try to get information, which wasn’t terribly fruitful. Documentation 1, Patient 0.

Walmart is taking advantage of domestic medical tourism by sending patients across state lines for consultations and second opinions. The company’s Centers of Excellence Program matches patients with a short list of hospitals, including Mayo Clinic and Geisinger Medical Center, for certain surgeries and treatments. While it was optional for the first six years it was in existence, participation has been required since 2018. Geisinger plans to expand similar programs to other companies besides Walmart. This approach is quite a change from what many of my patients experience, where they can’t find specialists who even accept their insurance.

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Maybe your mom was right: going out and getting some fresh air can be a game-changer. A study recently published in the International Journal of Environmental Health Research shows that spending 20 minutes in a park can improve wellbeing. Participants visited urban parks in Birmingham, Alabama during the summer and fall. From experience, being outside in the summer in Alabama can be a challenging mélange of heat and humidity, so I’m glad they included another season. Subjects weren’t told what to do in the park or how long to be there, but were monitored with fitness trackers and questionnaires. Wellbeing scores rose in park attendees.

Washington DC-area pediatrician Robert Zarr has been a fan of sending patients outdoors for a long time, founding ParkRxAmerica to help providers “prescribe Nature” as a way to decrease their patients’ burden of chronic disease and increase health and happiness. Zarr believes that writing the prescription in the EHR just like a medication makes it more specific and motivates patients to actually follow the instructions. This has also been done by National Health Service GPs with good outcomes. The US National Park Service has a Health Parks Healthy People program to advance the idea that “all parks – urban and wildland are cornerstones of people’s mental, physical, and spiritual health, and social well-being and sustainability of the planet.” People who know me know I’m a huge fan of the US National Park Service, and after paying my recent tax bill, I’ve decided to visualize 100 percent of my federal taxes going to support it. I made it to Redwood National Park last summer and would be happy to write a script for anyone who’s interested.

What’s your favorite National Park? Leave a comment or email me.

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Morning Headlines 3/21/19

March 20, 2019 Headlines No Comments

CMS Awards IMPAQ Contract to Support Patient Safety Measure Development and Maintenance

Impaq International signs a five-year, multimillion dollar contract with CMS for the development, implementation, and maintenance of patient safety measures used in the the Hospital Inpatient Quality Reporting program, Hospital-Acquired Condition Reduction program, and the Promoting Interoperability program.

ZOLL Reports Recent Data Security Incident

Critical care device and software company Zoll notifies customers and patients of a data breach that occurred when a third-party vendor left emails exposed during a server migration late last year.

SA Health upgrades to latest version of Allscripts EMR

SA Health in Australia upgrades its Allscripts Sunrise software after a report found numerous problems with the health system’s EHR and patient administration project.

Morning Headlines 3/20/19

March 19, 2019 Headlines No Comments

Primus Capital Provides Growth Investment in Harmony Healthcare IT

Health data archiving company Harmony Healthcare IT secures an unspecified amount of funding from Primus Capital.

Unite Us Raises $35 Million to Bridge the Gap Between Health and Social Care

Healthcare and social services coordination software vendor Unite Us raises $35 million in a Series B funding round.

Teladoc Health to Expand Global Reach with Acquisition of MédecinDirect

Teladoc acquires French telemedicine company MédecinDirect.

News 3/20/19

March 19, 2019 News 6 Comments

Top News

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A Kaiser Health News – Fortune article titled “Death By 1,000 Clicks: Where Electronic Health Records Went Wrong” says the federal government’s Meaningful Use program cost $36 billion, yet 10 years later, the system is an “unholy mess.” It makes these points:

  • Malpractice and whistleblower lawsuits have exposed an underreported number of cases in which patients were potentially harmed by EHR problems.
  • EHRs remain a “sprawling, disconnected patchwork” of systems that now-unhappy users bought quickly to collect incentive payments.
  • Doctors aren’t allowed to publicly talk about observed safety issues because of “gag clause” requirements of either their employer or their EHR vendor.
  • A survey found that 20 percent of consumers found mistakes in their EHR records, most often involving medical history.
  • User customization makes it hard to compare safety records across health systems and sometimes the site’s own configuration creates the problem.
  • Experts note that while the EHR solved several problems, it created a big one lacking visual cues to assure clinicians that they are working in the intended patient’s record.
  • A MedStar usability study found that an ED doctor ordering Tylenol is faced with a drop-down that lists 86 options, many of them inappropriate for a given patient.
  • The article includes a brilliant comment from WellSpan SVP/CIO Hal Baker, MD: “Physicians have to cognitively switch between focusing on the record and focusing on the patient … I have yet to see the CEO who, while running a board meeting, takes minutes, and certainly I’ve never heard of a judge who, during the trial, would also be the court stenographer. But in medicine … we’ve asked the physician to move from writing in pen to [entering a computer] record, and it’s a pretty complicated interface.” 
  • The urgency to dump money into the Meaningful Use program in 2009 – it was part of an economic stimulus program that targeted  “shovel-ready” projects – left too little time to consider interoperability or broader improvements an instead rewarded only widespread adoption.
  • EHR vendors rushed out aggressive sales tactics to get their place in the EHR Meaningful Use land grab, figuring they could fine-tune implementations afterward, leading to customer complaints and lawsuits over shoddy software and patient harm.
  • An unknown number of doctors and hospitals falsely attested to EHR use to earn incentive payments.
  • Patients still can’t get copies of their own medical records easily and inexpensively from hospitals.
  • Some patients who are suing for malpractice claim that hospital employees changed EHR entries after the incident and refused to turn over audit logs that would prove it.

Thoughts on the “Death By 1,000 Clicks” Article (And Your Chance to Weigh In)

This article was a good rehash of how we went from the first glimmers of Meaningful Use to today’s “unholy mess.” It doesn’t contain much of anything new for industry followers, but it will reach a mass audience as the Fortune cover story.

The Past, Which By The Way, Can’t Be Changed

  • Healthcare was slower than most industries to adopt technology.
  • Meaningful Use was an ill-conceived, rushed stimulus project that paid EHR-resistant doctors to use (not necessarily buy) EHRs in government-mandated ways with the vague hope that patient care and cost would improve once they were in place.
  • The short payment timelines discouraged innovation as providers were forced to buy the same outdated systems they didn’t want before the government offered bribes.
  • EHR vendors fought for their share of the resulting taxpayer-funded windfall with aggressive sales tactics and over-the-top marketing that were a lot more sophisticated than the old EHRs that were gathering dust on their shelves.

Provider Greed Made Today’s Undesirable EHR Situation Possible

  • Hospitals and practices bought whatever inexpensive, quickly implemented system would get their faces into the government trough as quickly as possible.
  • They did the bare minimum required to earn incentives.
  • The government used the honor system of unverified attestation to trigger checks, leading some providers to lie.
  • In the case of larger practices and most hospitals, they didn’t ask (and didn’t really care) what physician users thought of the systems they considered before buying.
  • They customized new EHRs to work like paper charts and their old systems.
  • They under-invested in training, physician support, and optimization, opting instead to push the decisions of committees – often with minimal user involvement – to the front lines.
  • Freshly armed with the technical means to allow easy sharing of patient data, they have refused to do so.
  • They didn’t allow doctors to publicly share EHR-related patient safety information because of malpractice concerns, competitive worries, and the lack of incentive to help someone else’s patients.

The Challenges to Making It Better

  • Doctors and hospitals don’t believe in standardizing processes, either within their own organizations or across competing ones. They all believe they have a self-developed secret sauce that is better than everyone else’s. The same patient will receive different care depending on where they go in the absence of “one best way.” You don’t want to be the developer that has to code around that.
  • Doctors and other clinicians are the only professionals who are expected to perform their own clerical work and to perform data entry during professional encounters. Hospitals are willing to force their doctors to perform tasks that other professional employers (law firms, accounting practices, and even dental practices and veterinary practices) would find not only insulting, but a waste of highly-paid resources when lower-skilled employees could do the work.
  • The executives who require doctors to use computers generally don’t use them themselves.
  • Only a tiny part of what is entered into an EHR directly contributes to patient care and the user of that information is often not the person who enters it.
  • Doctors don’t like to have bosses or to have their decisions questioned, yet ancillary departments and EHRs catch and prevent their mistakes regularly, creating tension between doctors and almost everyone else, especially when the doctor is not a hospital employee. Everybody thinks they understand patient care – or at least their particular pet aspect of it — better than everyone else.

The Big Question: What Would An EHR Look Like If Clinicians Designed It For Themselves?

We will never know because clinicians don’t drive our healthcare system. It’s mostly overseen by hospital and practice executives, insurers, regulators, and the government. I would also wager that getting consensus would be impossible since nearly every doctor mistakes their opinion for irrefutable fact.

There’s also the question of whether clinicians have enough of a broad view to design software that will be used by thousands of users. EHR design is the de facto consensus of a broad swath of users in the most heavily represented specialties and user configuration options are the safety valve for practice deviations (which is why EHRs are so deeply configurable).

It’s also a pie-in-the-sky fantasy that a clinical system should be as easy to use as Facebook, Amazon, or an IPhone. It’s true that those systems empower their users with smart design, but their functionality is comparatively simple and users are motivated because their purpose is largely recreational.

The Bottom Line

EHR vendors are incented to create the systems that customers will buy. Companies selling well in a contracting EHR market Cerner, Epic, EClinicalWorks, etc. – are delivering what customers want (“customers” not necessarily being synonymous with “users.”) They have no incentive to build products that everybody hates, and given the competitive environment, they would do whatever they can to gain market share.

The underlying business model drives EHR design, and that’s what a lot of clinicians don’t like (and especially their place in it). That resentment gets pushed both down and up.

There’s still an immediate need for not only allowing, but encouraging system users to publicly and anonymously report patient-endangering software bugs. Vendors have not done a good job in pushing these notices out, and even in cases where they do, word doesn’t always filter down from the hospital’s IT department to end users.

Now Comes Your Part

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Enough griping about EHRs or leaving laypeople to draw their own conclusions about them. What would you change? Tell me here,  be specific, and assume (as EHR vendors are expected to do) that our screwy US healthcare system is off the table.


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.


Acquisitions, Funding, Business, and Stock

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Health Catalyst hires bankers to initiate its IPO.


Announcements and Implementations

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Apple quietly rolls out new models of the IPad Air and IPad Mini. The former has a larger display, a processor that’s three times faster, and support for the Apple Pencil, while the latter hasn’t changed much except to add Pencil support (and thus supports high-margin Pencil sales). Apple seems more focused on the impending announcement of its video streaming service and other high-margin, non-commoditized services.

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Sopris Health claims that its chat-powered digital assistant app allows clinicians to create a visit note in 45 seconds, or the time required to walk from one exam room to the next. Co-founder and CEO Patrick Leonard previously worked for Aetna’s consumer technology group and was CTO of the symptom-checking app ITriage that Aetna acquired in 2011 along with its developer, Healthagen.  

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A new KLAS report on the medical oncology technology needs of community cancer canters finds that Flatiron Health leads the pack, as Cerner, Epic, and McKesson Specialty Health lag in supporting workflows. Cerner and Epic also score poorly in connecting with EHRs of other vendors.


Government and Politics

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A whistleblower lawsuit brought by two former IT employees of Community Health Systems accuses the for-profit hospital chain of submitting fraudulent attestations for Meaningful Use, reaping $544 million in incentive payments in 2012-2015. It adds that CHS acquired 60 hospitals of Health Management Associates that attested to Meaningful Use payments even though their Pulse EHR was poorly integrated and require printing paper at multiple stages during a patient’s stay. The lawsuit also claims that Medhost made false statements to get its EHR certified under Meaningful Use Stage 2. The former employees also say that CHS used Medhost partially because of illegal kickbacks in the form of providing free Medhost Financials with the purchase of its clinical applications.

The White House’s US Digital Service says the VA’s newly developed online eligibility tool for veterans who seek private care under 2018’s MISSION Act is so flawed that it should be scrapped. warning that it will be slow, will cause errors, and will require an extra 5-10 minutes for each appointment booked. The report says VA contractor AbleVets isn’t the problem – it’s the VA’s poor oversight and a rush to bring the system live in June without adequate testing or integration with six existing VA systems. VA doctors are already pushing back, with one saying, “These people are out of their minds. We aren’t housekeepers, doorkeepers, or garbage men.” The VA says it needs $5.6 million to finish work on the system, which it says will cost $96 million in this fiscal year. An inefficient approval and scheduling process caused major delays in the VA’s 2014 rollout of a similar program, creating the need for this new project.


Other

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Samuel Shem, MD – who in 1978 wrote what might be medicine’s most enduring novel in “The House of God,” which is a lot like MASH except more clinical and more cynical– calls EHRs “the new bullying to all of us in medicine.” He calls EHRs “an epic intrusion and frustration in our doctors’ lives” that require more time than actually delivering care, He also notes that EHRs are billing machines that have not been proven to improve safety or quality of care. I’ve read “House of God” many times and hereby give you some teasers to encourage you to do the same:

  • “The delivery of good medical care is to do as much nothing as possible.”
  • “It’s an incredible paradox that being a doctor is so degrading and yet is so valued by society.”
  • “Gomers (Get Out Of My Emergency Room) are human beings who have lost what goes into being human beings. They want to die, and we will not let them. We’re cruel to the gomers, by saving them, and they’re cruel to us, by fighting tooth and nail against our trying to save them. They hurt us, we hurt them.”
  • “To do nothing for the gomers was to do something, and the more conscientiously I did nothing, the better they got.”
  • “It ain’t easy to do nothing, now that society is telling everyone that their body is fundamentally flawed and about to self-destruct. People are afraid they’re on the verge of death all the time.”

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For more insightful medical wit, check out retired ED doc and author Rada Jones, MD, who describes herself as, “I speak like a vampire since I lived most of my life in Transylvania” and who just relocated to Thailand with her husband. She offers “47 Tips to Keep You Away From My ER” (which actually contains 49), one of which is, “NEVER EVER stand around minding your own business. It’s the most dangerous thing known to man. 90 percent of my assault victims were doing just that.”

Glen Falls Hospital (NY) reaches a confidential settlement with Cerner over the $38 million of revenue it lost due to billing problems after go-live.

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A study finds that implementing EHR-generated severe sepsis alerts didn’t improve treatment performance measures or patient outcomes. Two-thirds of the alerts were true positive, but only eight percent of those doctors used the EHR sepsis order set, with two-thirds saying they would rather enter their own orders and 58 percent expressing skepticism about whether the alert captured a meaningful change in clinical status.

Stat notes that despite the hype associated with Stanford’s widely reported study of the Apple Watch’s ability to detect atrial fibrillation, it’s hard to look at the overall effects since the study was not a randomized controlled trial and instead just observed what users experienced. It did not look at false positives, how many doctor visits resulted, the conclusions from those visits, and whether wearing the Watch can actually improve the health of a large population.

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Doctors in England express concern about fast-growing online visit provider Babylon, which NHS has embraced under its GP at Hand program. Local NHS cost have skyrocketed as 40,000 Londoners have joined Babylon’s program, which as a medical group requires people to leave their local practice (which patients often don’t understand), creating economic upheaval under NHS’s per-patient payment model that looks at where the practice – not the patient – is located. Doctors also complain that Babylon attracts the most easily managed patients, sticking them with the more complex ones under the fixed payment. Insiders also raise questions about the company’s AI-powered chatbot, which sometimes delivers flawed results and has not  been peer-reviewed.

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At least 48 adult strangers find that they are half-siblings after taking home genetic tests and sharing their results, their newly discovered father being an Indiana fertility doctor who admits that he used his own sperm instead of that of donors in the 1970s and 1980s. Meanwhile, some former writers for “The Onion” launch a home DNA testing parody site called “DNA Friend.”


Sponsor Updates

  • AdvancedMD will exhibit at NATCON March 25-27 in Nashville.
  • Aprima will exhibit at the AIMSVAR Annual Conference March 21-22 in San Antonio.
  • EClinicalWorks publishes a case study of the implementation of ECW’s population health management tools at Adult Medicine of Lake County (FL).
  • Avaya announces further integration with Google Cloud Contact Center AI.
  • Bernoulli Health becomes an Affiliate member of the Intel IoT Alliance; its Bernoulli One solution has been named an Intel IoT Market Ready Solution.
  • Culbert Healthcare Solutions will exhibit at AMGA March 27-30 in National Harbor, MD.
  • Divurgent launches a data and analytics approach to address physician burnout.

Blog Posts


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Contacts

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

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Morning Headlines 3/19/19

March 18, 2019 Headlines No Comments

Malfunctioning billing system leaves scars on Glens Falls Hospital

Glenn Falls Hospital (NY) reaches a confidential settlement with Cerner after a $38 million loss attributed to its faulty billing system.

Beware the hype over the Apple Watch heart app. The device could do more harm than good

STAT points out that the highly-publicized results of an Apple Heart Study on a-fib detection conducted by Stanford University should be taken with a grain of salt, given that it was an observational study without a control group of non-Apple Watch users.

The messy, cautionary tale of how Babylon disrupted the NHS

Babylon’s GP at Hand telemedicine clinic in London offers NHS patients a tech-friendly alternative to traditional clinics, but is placing an unexpectedly burdensome strain on local resources and staff.

$1 billion Sequoia-backed Health Catalyst has picked lead banks for its IPO

Sources report that Health Catalyst has selected Goldman Sachs and JPMorgan to handle its IPO.

VA’s Private Care Program Headed for Tech Trouble, Review Finds

A US Digital Service review finds that private-care eligibility software developed by AbleVets on behalf of the VA should be scrapped due to numerous flaws resulting from a rushed development timeline.

HIStalk Interviews Cedric Truss, DHA, Director Health Informatics Program, Georgia State University

March 18, 2019 Interviews No Comments

Cedric Truss, DHA, MSHI is director of the health informatics program and clinical assistant professor of Georgia State University of Atlanta, GA.

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Tell me about yourself and your program.

I’ve been at Georgia State since August 2017. We offer a bachelor’s of interdisciplinary studies and health informatics. With that program, we partner with the College of Business, so students take courses under the College of Business and within the College of Nursing and Health Professions.

A reader who ran across your students at HIMSS19 said they were engaged, asked great questions, and were enthusiastic. How would you describe their participation? What impressions were they left with?

I’ve gotten a lot of great feedback from some of the students. For some, it was their first time going, Some went last year in Las Vegas. They enjoyed both of the conferences. They said that they were able to connect with some of the companies and to talk with them about some of the things they have been learning in the program.

For instance, we talk about all of the EHR companies throughout the program, so students talked with individuals from Cerner, Epic, Athenahealth, and Allscripts. They were able to get feedback from those who are actually doing the work and to see how it applies to their learning in the program.

How do you cover the theoretical parts of informatics while also exposing students to the real-world aspects that they saw at HIMSS19?

We have a curriculum that’s set around the different areas of what encompasses health informatics. Throughout those different courses, we talk about the theory of why things are the way they are and how to actually make them work in practice.

We have a local Georgia HIMSS chapter and individuals come in to the program and talk to students in the different courses. They explain how what they are learning is applied. This past year we started doing something new. We’re participating in the academic organization affiliate program that HIMSS offers, so we provided all the students with memberships this year. This was the first time that we’ve done this and it is a success, so we will continue doing it.

Were students surprised at the size of the conference and the level of activity around the industry?

Yes, they were, especially for those for whom it was their first time going. I’m glad that it was in Orlando, because it was much closer. They came back and said, OK, now I know what I want to do, or I can pinpoint it. Being able to see this, I can decide what I really want to do and what I want to go into long term.

Yours is a professional program, where students are required to complete pre-requisites and then apply. What kind of applicants do you typically get?

We mainly get students who know they want to do healthcare, but they don’t want to deal with patient care or have hands-on patient care. That’s the majority of the students that we get. We’ve had some that were in the nursing program, and after seeing what they would have to do, they decided, “I don’t want to do this.” They come check out health informatics and fall in love with it.

We’ve also had a couple of students come from the business school. After looking at some of the CIS majors that they offer, they decide this is a better fit for them and the type of career they’re looking to go into.

What careers do they want to pursue?

A lot of students mention project management and analytics, whether it’s data analytics or performance analytics.

Many informatics programs target people who have earned clinical degrees. How does the science aspect of informatics fit with the caregiver side?

You’re not providing direct patient care, but you are providing patient care. You’re making sure systems are working properly so the caregiver or provider can provide you care. If it’s a nurse or a physician at Clinic A but you’re going to Clinic B, that provider can go into the system to see what you have had done, be able to provide the care that you need, and not do something that’s unnecessary, like maybe give you another vaccination that you’ve already gotten or diagnose you with something that you’ve already been diagnosed with.

You’ve worked in different parts of the industry. Is the academic setting different?

[laughs] It is completely different working in academia versus working in the industry. I did enjoy the industry. I loved it. I don’t get to participate as much now in the industry, but I’ve been able to develop new partnerships with those who are in the industry so I can create the pipelines for students to talk with those individuals who are practicing, do internships at these organizations, and even gain employment at these organizations after graduation. It’s been a great fit for me here in academia.

Is there a recognition among your students that Atlanta is such a stronghold of health IT?

There is. We have a lot of health IT companies here in the state of Georgia. Actually, Georgia is considered the health IT capital. A lot of the students are aware of what’s here and the many different opportunities that they can have. We have a lot of health IT startups here as well. That makes the area stand out quite a bit. It gives students an opportunity to say, if I go through this program and I have this idea, I can have my own startup here as well.

How do your students view their future work life differently than the generations that preceded them?

A lot of them are wanting to do different things. Some of them would like to develop their own business. Some of them are interested in traveling and consulting.

I have a master’s in health informatics, so when I went into that program, my idea was that I wanted to be a CIO. But once I got towards the end of that program, I decided that’s not what I wanted to do any more. The opportunities I have had expanded my knowledge and my interest in different areas. The students see what I’ve done and talking with them gives them an outlook that they can do many different things, whether it’s to start their own company, work for other organizations, or travel and be consultants.

Your doctoral dissertation was on hospital ransomware attacks. What are your takeaways from that?

A lot of hospitals were not focusing on security when they were implementing the EHR. I think they figured that they were covered since they had software and a vendor that potentially had them protected from all of that. But I think they need to take steps and have their own policies and procedures in place to prevent that from happening.

How could someone get involved to help your program?

They can go to healthinformatics.gsu.edu. There’s a lot of information on there and it has some contact information as well. Or if they want to reach out to me directly, ctruss@gsu.edu or 404.413.1222. They’re welcome to call me directly and we can discuss options.

Curbside Consult with Dr. Jayne 3/18/19

March 18, 2019 Dr. Jayne 5 Comments

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There was another big story about telemedicine in the news this week, this time about a young man who had to undergo what sounds like a competency evaluation via video prior to signing a “do not resuscitate” document. Regardless of the telemedicine situation, the story is heartbreaking. A young man with testicular cancer is dying. His wife did not have power of attorney, and it sounds like the hospital was concerned about his ability to legally sign the document.

The focus of the story is the telemedicine angle, whether it’s poor connectivity, level of compassion, etc. I haven’t seen a news piece, however, that addresses the other issues that are brought to light by the situation. Namely, how it got to that point in the first place.

This was a patient with a recurrence of testicular cancer, which is a serious situation. Of course, we don’t have all the medical details of the case, but there are some non-medical issues at play here. For an oncology patient with a young family, we should hope that a comprehensive advance care planning session should include not only discussion of end-of-life wishes, but also the need to have the appropriate legal documents in place. These discussions need to happen early in treatment, while the patient can discuss with their family and make good decisions and before events unfold that put decision-making capacity in question.

Seeing the pictures of his young daughter made me wonder if he had a will, and if so, did the attorney involved (if there was one) also advise on advance directives and power of attorney documents? We always think about healthcare organizations supporting patients in these situations, but what about legal organizations? Are there channels for attorneys to volunteer services to families like this to ensure they have the supports they need? Why is it always the physicians and hospitals that bear the brunt of responsibility for failure in these heart-wrenching situations?

I know I’ve covered this topic before, but everyone needs to have these conversations, whether you’re sick or well. We never know what is going to happen, what illness or speeding car might strike us down. However, in the situation where someone potentially has a terminal illness, it should be happening without fail.

I don’t know about the laws in the jurisdiction where this story occurred, whether a psychiatrist specifically was needed for the determination of capacity or whether anyone else in the hospital could have done it. We don’t know if this was the middle of the night or the middle of the day. Perhaps the video consult was offered up as a way to speed things, if it would have taken longer to bring the appropriate clinician into the hospital. There aren’t a lot of facilities that keep psychiatrists in-house at all times, so maybe the choice that was made was the best one at the time even if it didn’t play out as the family expected. Approaching end of life is challenging enough even when all the paperwork is in place and the family is supportive of the patient’s wishes. 

My thoughts go out to everyone involved. I encourage everyone out there, young or old, healthy or not, to have these conversations with your family members and to make sure you have the right paperwork in order to make the best of a terrible situation when the time comes. Eventually, death comes for us all.

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Another situation I ran across this week that demonizes technology without addressing other “comorbid conditions” was an interview with Eric Topol. This time, EHRs are the bad guy, but artificial intelligence is going “make healthcare human again,” at least according to his newest book. I don’t know Dr. Topol other than by what I have ready in his books and in various interviews, but I’m awfully tired of people who seem to have all the answers to what are undoubtedly very complex problems.

Topol lists EHRs as “the single worst part of the deteriorating doctor-patient relationship.” Although I agree they’re a factor, I personally think the worst part of the deteriorating relationship is the devaluation of the relationship itself. Because our medical system in the US is so broken, people no longer value the concept of a lifelong primary care physician who is going to know you as a patient and understand what optimal health means for you. We’ve sacrificed it on the altars of cost and convenience because those elements are more important for many of the people in our society. We’ve decided that it’s more important to treat populations (numbers) than people (outliers) and have incented people to behave in a way that supports that. Providing clinical expertise has become transactional and commoditized.

I feel this acutely every day that I see patients, especially on those days when I am part of a story that starts with a seemingly minor medical problem and ends with, “I went to the urgent care and now I have cancer.” I never dreamed that as an urgent care physician I would diagnose the number of life-threatening conditions that I see on a regular basis. It falls to us because people don’t have primary care physicians, they can’t get in to see them, or they can’t afford to get medical care. Once I diagnose people and refer them to the appropriate subspecialists, they’re generally lost to me unless they follow up with a card or a note. However, they don’t leave my mind and their stories haunt me every time I see a patient with a similar presentation.

Fixing EHRs isn’t going to fix the fragmentation in care. First, we have to decide as a society that unfragmented care is important. We have to decide that primary care and public health are important and we have to support those decisions with our pocketbooks.

I have a friend at a large health system that just spent half-billion (with a “b”) dollars on an EHR rip-and-replace. How much was she able to get as a grant for a school-based health clinic to serve children who never see a physician or other clinician? Zero. She had to pull together a coalition of community organizations to fund it despite her non-profit employer sitting on one of the largest cash reserves in the nation.

Topol says EHRs are “uniformly hated” and that’s just not the case. Sure, we dislike clunky interfaces and click-happy screens, but we sure love being able to process a drug recall in 90 seconds and notify 10,000 patients with a dozen clicks. We never loved our paper charts (and some of us hated them), but in reality, how many people “love” the tools they use for their work? Do mechanics love their tools? Do bankers love their tools? Do teachers love smartboards more than they loved chalkboards or whiteboards? Talking about the dynamics of love/hate just raises emotions and makes it harder for us to rationally evaluate what we’re really working with and how we are able to use it well vs. struggle with it.

Topol does at least give a passing mention to the healthcare disparities in the US, noting that increased use of AI and data “could make things much worse if these tools are only provided for affluent people.” We’re already at that point, where people struggle to pay for basic healthcare. If we can’t universally deliver vaccines (proven cost effective) to all people, are we really going to be able to afford gathering and analyzing all their data (not yet proven to be as spectacular as some people think)?

Fixing the EHR might make the day smoother, but it’s not going to fix the major underlying issues in healthcare. It’s not going to fix a hospital system that lowballs physician salaries in the name of value-based care, but turns around and builds a multi-million-dollar imaging center. It’s not going to fix an insurer that will pay $30,000 for a gastric bypass for a teenager after it wouldn’t pay $2,000 for an intensive weight management program that might have prevented or delayed the need for bariatric surgery. It’s not going to fix nursing ratios on patient care floors that are inhumane, not to mention unsafe.

I don’t have all the answers, but I’m pretty good at stirring up a discussion. What do you think is the worst part of the deteriorating patient-physician relationship? Leave a comment or email me.

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Morning Headlines 3/18/19

March 17, 2019 Headlines No Comments

Change Healthcare on deck for IPO

Change Healthcare, valued at up to $12 billion, files IPO documents for a $100 million IPO.

Signify Health acquires start-up TAV Health in multimillion-dollar deal

Mobile health evaluation company Signify Health acquires TAV Health, which offers a platform to connect community and health partners to address social determinants of health.

Doctors Create an iPad Program to Help NICU Babies Get Home Faster

Doctors at University of Virginia Children’s Hospital develop an IPad-based system that allows NICU babies to go home earlier, replacing a pen-and-paper and call-in system for parents to report their baby’s feedings and weight.

A huge trove of medical records and prescriptions found exposed

EHR vendor Meditab leaves a server unsecured for nearly a year, giving anyone the ability to read the content of medical faxes in real time.

Monday Morning Update 3/18/19

March 17, 2019 News 2 Comments

Top News

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Change Healthcare files IPO documents for a $100 million IPO. Analysts estimate the company’s value at up to $12 billion.

The company, of which McKesson owns 70 percent with two private equity groups holding the remainder, reports adjusted net income of $281 million on $3.3 billion in revenue in 2018.

Change took on $6.1 billion in debt to create the business last year in merging the former Emdeon with McKesson’s IT business, after which McKesson was paid $1.25 billion and PE firms Blackstone and Hellman & Friedman received $1.75 billion.

Shares will trade on the Nasdaq under the symbol CHNG.

CEO Neil de Crescenzo’s 2018 compensation was $8.3 million; former CFO Al Hamood (now president of ATI Physical Therapy) was paid $13.3 million; EVP Rod O’Reilly earned $5.6 million; former sales EVP Mark Vachon was paid $6.4 million; and EVP/CIO Alex Choy’s compensation was $3 million.

The six non-employee board members were each paid cash and options worth $400,000 to $573,000.

Seventeen of the 19 company directors and executive officers are male.


HIStalk Announcements and Requests

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Last week’s poll is a toss-out since responses were evenly spread and few in number, so let’s move on.

New poll to your right or here, for HIMSS19 provider attendees: did you discover an interesting product or service that you will follow up on? Click the poll’s “comments” link if you vote yes to tell us what piqued your interest.


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.


Acquisitions, Funding, Business, and Stock

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Mobile health evaluation company Signify Health acquires TAV Health, which offers a platform to connect community and health partners to address social determinants of health. Signify’s CEO is former Athenahealth SVP/Chief Product Officer Kyle Armbrester.

For-profit hospital operator HCA acquires a majority ownership in for-profit Galen College of Nursing, which offers instruction on five campuses and online.


People

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Chris Belmont (Intelligent Retinal Imaging Systems) joins The HCI Group as EVP of strategy and operations.

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ROI Healthcare Solutions hires Brent Prosser (Infor) as SVP of sales.


Announcements and Implementations

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Peterson Regional Medical Center (TX) goes live on Meditech Expanse with patient accounting and supply chain help from CereCore.


Privacy and Security

Singapore’s Health Sciences Authority reports yet another healthcare-related breach in that country after discovering that one of its contractors failed to secure an online database of blood donors containing the information of 800,000 people. The website of the contractor, Secur Solutions Group, has gone offline.


Other

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A large RN survey finds that a hospital’s work environment plays a big part in whether nurses are satisfied with the hospital’s EHR and how they perceive its contribution to patient care and safety.

The Canberra, Australia newspaper reviews the 40 patient safety bulletins issued to EHR users in 2018 by the Cerner project team at Queensland Health, many of related to software updates. They include problems with children’s weights, unexpected drug name changes, switching to the wrong record when multiple patient windows are open, and creation of duplicate encounters.

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A Virginia woman complains that her dying husband had to endure a low-quality, 35-minute telemedicine encounter with an Inova psychiatrist who needed to evaluate his “do not resuscitate” request. She complained, “I hope there’s a real reflection in the medical community about the ethics of these teledoctors.”

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Doctors at University of Virginia Children’s Hospital develop an IPad-based system that allows NICU babies to go home earlier, replacing a pen-and-paper and call-in system for parents to report their baby’s feedings and weight. The system sends data immediately to Epic. It was developed by Charlottesville-based Locus Health and its use has been expanded to 15 children’s hospitals. The designers are a pediatric cardiologist and his NICU pediatrician wife.

Ontario, Canada scraps a $500,000 public health vaccination reporting system and goes back to paper forms after finding problems caused by incompatibilities with physician EHRs, one of which was that the vaccine names don’t match.

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The Atlantic covers the “uniquely American phenomenon” of medical debt, as 60 percent of people who file bankruptcy say medical bills played a major part. It says medical debt will probably increase as fewer people buy insurance, deductibles are raised, sales of poor-coverage junk plans increase, and out-of-network bills increase as insurers narrow their networks. The article focuses on how to negotiate a bill with a hospital:

  • Ask about financial assistance, including charity care if uninsured
  • Ask to be billed at the same rate Medicare pays
  • Ask for a payment plan or full payment discount

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A study finds that applying deep learning to just a few hundred patient EHR records can accurately predict the outcome of chronic diseases (rheumatoid arthritis in this case). The same model then works fairly well across other hospitals. The authors believe that decision support should involve training models on aggregated patient data from multiple healthcare systems, then extending the model to other providers.


Sponsor Updates

  • NextGate and Nordic will exhibit at Texas HIMSS March 25-26 in Austin.
  • Clinical Computer Systems, developer of the Obix Perinatal Data System, will exhibit at the AWHONN Virginia Section Conference March 17-18 in Charlottesville.
  • Flywire and Experian Health will exhibit at the HFMA Revenue Cycle Conference March 20-22 in Austin.
  • Recondo Technology and MedeAnalytics partner to create a single, powerful revenue cycle management platform.
  • PatientPing publishes a new case study, “Houston Methodist Coordinated Care Achieves Savings of Over $680,000 Within First Year of PatientPing Partnership.”
  • PatientKeeper will exhibit at Hospital Medicine 2019 March 24-27 in National Harbor, MD.
  • SymphonyRM releases a new e-book, “Competing in an Amazon World: Four-Step Action Plan for Health Systems.”

Blog Posts


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Mr. H, Lorre, Jenn, Dr. Jayne.
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Weekender 3/15/19

March 15, 2019 Weekender No Comments

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Weekly News Recap

  • Rutland Regional Medical Center (VT) experiences its second email-related breach
  • Australian imaging software vendor Mach7 fires its CEO and eliminates the CTO role as part of a restructuring and cost-cutting program that it hopes will propel its US growth
  • An investment analyst thinks Apple will expand the Watch’s medical sensors and then sell the data of wearers to their doctors for $10 per patient per month
  • Hill-Rom announces that it will acquire mobile clinical communications vendor Voalte for up to $195 million
  • An investigative report finds that medical device manufacturers have been able to hide widespread patient safety issues by using the FDA’s alternate summary reporting program

Best Reader Comments

The thing that gets me about the Theranos story was that even at the peak of their hype, everyone I spoke with in the healthcare field could see that it was fishy as heck and no one I know was surprised when it turned out to be BS. (Dr. Herzenstube)

I hadn’t thought of Amazon serving up order sets, but they’re actually doing some of the most sophisticated order sets out there. (Mike Z)

You’re right on the money. There is no magic bullet to burnout but this type of article that talks real / no frills techniques that can be done today. This is exactly what our teams should be focused on. (TX Trainer)

I’m sure there are plenty of physicians, regardless of specialty, who could speak to a patient via a telemedicine “robot” and convey empathy. So please blame any outrage on the individual purveyor of bad news and not on all physicians or all robots. (Compassionate cyborg)

It will be fascinating to monitor Cerner’s encounter-based EHR’s acceptance as well as how they will decide to address functional nuances in the VA (and DoD). Cerner’s EHR is designed for a “clinically driven revenue cycle” – a help or hindrance to the VA and DoD? (Art_Vandelay)


Watercooler Talk Tidbits

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Readers funded the DonorsChoose teacher grant request of Ms. P in Virginia, who asked for books that emphasize individuality and tolerance, lap desks, and camp tables for her first grade class. She reports, “It was wonderful to be have these read-aloud titles in the classroom. I frequently turn back to the books when I feel my students needed a reminder about how to treat others with empathy and tolerance. The books’ message also reached first graders in other classes, as I loaned the titles to other teachers on my teaching team. Thank you for allowing me to bring these resources into my classroom!”

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Turkey’s government opens a 3,810-bed, $1.15 billion hospital in Ankara, with the country’s medical association expressing concerns that “central hospitals are not cost effective and they impact public health quite negatively.” The medical association notes that European cities have mostly moved away from building mega-hospitals in favor of building several smaller ones. They have mostly abandoned the public-private partnership model that is being used to open 30 new hospitals in Turkey, in which a contractor pays the construction cost, then rents the building back to the government. Armchair geographers take note – Turkey is in both Asia and Europe and Istanbul is the only city in the world that straddles two continents.

A North Carolina hospital warns employees that using legal but unregulated CBD oil could get them fired because some products contain traces of THC that will trigger a positive drug test.

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A New York Times article notes that doctors “disappear without a word” when they leave a practice with a non-compete agreement in which the old employer refuses to tell their patients how to contact them. The CEO of Iowa Clinic, which is being sued by three urologists who argue that their termination makes their non-compete agreement unenforceable, says such agreements are “good for the patients because they help to provide stability within a practice and ensure continuity of care.” One of the clinic’s patients disagrees, saying that, “somehow they lost sight of patient care and were more concerned about the bottom line.”

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OnMed rolls out a phone booth-like telemedicine station that allows online consultations via a a video consultation that includes remotely-controlled vital signs measurement and automated drug dispensing. In-session privacy features include automatic door locking, windows that turn opaque, and speakers that can’t be heard from outside. Patients are identified using 3D facial recognition and the doctor’s credentials are displayed on the screen. UV lighting sterilizes the booth between visits.

A University of Miami Health System fires a sex-change surgeon for posting pictures of his cases on Instagram under the account @sexsurgeon, including a Valentine’s Day post showing a removed penis shaped into a heart labeled, “There are many ways to show your LOVE.”


In Case You Missed It


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Morning Headlines 3/15/19

March 14, 2019 Headlines No Comments

More than 72,000 possibly affected by hospital data breach

Rutland Regional Medical Center (VT) notifies 72,000 patients of a breach after discovering that the email accounts of nine employees had been hacked late last year.

Aldrich Capital Partners Invests in eHealth Technologies

Medical record retrieval and image-sharing company EHealth Technologies secures $41 million in financing.

Theranos employees struggle to put scandal behind them

As HBO’s Theranos documentary gets set to air, former Theranos employees recount the ways in which their time at the company has stigmatized them and severely curtailed their career trajectories.

News 3/15/19

March 14, 2019 News 9 Comments

Top News

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Rutland Regional Medical Center (VT) notifies 72,000 patients of a breach after discovering that the email accounts of nine employees had been hacked late last year.

Hospital officials believe the hack originated outside of the US.

RRMC did similar damage control in 2017 after an employee exposed patient information by sending a bulk email to patients using CC: instead of BCC:.


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.


Acquisitions, Funding, Business, and Stock

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Health research network TriNetX raises $40 million in financing, earmarking the funds for enhancing its analytics software and further expanding in Asia, Europe, and South America.

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Medical record retrieval and image-sharing company EHealth Technologies secures $41 million in financing.


People

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Haven hires Sandhya Rao (Partners Healthcare) as VP of clinical strategy.

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PatientPoint names Wes Staggs (Blue Ridge) as its first EVP of customer success.

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Australia-based Telstra Health names former New Zealand National Health IT Board Director Graeme Osborne, who also spent seven years leading New Zealand’s EHealth Program, to run its hospital software business unit, which includes the EHR it acquired along with Emerging Systems in 2014.

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Wendy Hill (Cerner) joins Netsmart as its first chief people officer.


Sales

  • In Australia, SDS Pathology will replace its Triple G Ultra lab system with SCC Soft Computer.
  • Val Verde Regional Medical Center (TX); Bayamon Medical Center (PR); Puerto Rico Women’s and Children’s Hospital; and Massachusetts Health Collaborative members Harrington Healthcare, Holyoke Medical Center, and Heywood Healthcare will implement Meditech Expanse.

Announcements and Implementations

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Johns Hopkins Health System (MD) goes live with Bluetree’s Service Center for Epic users.

Partners HealthCare leverages Appriss Health’s PMP Gateway interface to become the first health system in Massachusetts to integrate its EHR with the state’s PDMP.

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OhioHealth goes live on Epic.


Privacy and Security

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Emerson Hospital (MA) notifies patients of a data breach that occurred last May when an employee of its billing vendor, MiraMed Global Services, sent electronic patient files to an unauthorized third party. The hospital’s forensics team found the files to be of such poor quality that the data was likely not used in further malicious activity.


Other

 
Documentarian Alex Gibney shares his experience developing “The Inventor: Out for Blood in Silicon Valley,” a Theranos documentary that will debut on HBO Monday night. A few highlights:
  • The overriding theme, beyond company paranoia, is the willingness of Holmes to “fake it until you make it.”
  • Gibney likens Elizabeth Holmes to Thomas Edison in that both invented larger-than-life celebrity personas to sell themselves and their inventions. His footage of her in-house interviews shows that she worked hard to present that contrived version of herself. “[T]hat was precious to us,” he says, “because, if you’re talking about the psychology of deception, now we had an opportunity to show from the inside out how that deception was manufactured.”
  • After a team member interviewed Holmes in 2017, Gibney concluded that, “Elizabeth perceived herself to be a victim. Not somebody who was contrite, but somebody who was brought low by forces who were out to get her because she was a woman.”
  • After acquiring footage of Holmes and her boyfriend and company executive Sunny Balwani jumping in a bouncy house to MC Hammer’s “U Can’t Touch This” in celebration of FDA’s marketing clearance for one of its tests, Gibney admits, “It was jaw-dropping to see the delusional behavior inside the company.”

Sponsor Updates

  • Nordic names Michael Malecha (Huron) senior director of ERP solutions.
  • Elsevier adds new assessment capabilities to its ClinicalKey Student medical education platform.
  • EClinicalWorks and InterSystems will exhibit at the Rise Nashville Summit March 17-19.
  • HBI Solutions will present and exhibit at the Population Health Colloquium March 19 in Philadelphia.
  • The University of Florida recognizes The HCI Group CEO Ricky Caplin as one of its outstanding young alumni.
  • HGP publishes the results of its 2018 health IT private equity survey.
  • Imprivata will exhibit at Texas HIMSS March 25-26 in Austin.
  • Medhost recaps its 2018 business growth.
  • Spok releases a new case study featuring Vail Health (CO).
  • EHealth Exchange expands its use of InterSystems solutions by selecting its HealthShare unified care record to power its HIE.
  • Meditech releases a video showing how its solutions deliver real results to executives, providers, and patients.

Blog Posts


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Contacts

Mr. H, Lorre, Jenn, Dr. Jayne.
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Contact us.

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EPtalk by Dr. Jayne 3/14/19

March 14, 2019 Dr. Jayne 1 Comment

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Today was a Google Cloud kind of sock day, and I have to say these made me smile with their stethoscopes, microscopes, and miniature DNA. These beauties (along with many of the other socks given out at HIMSS) are from Sock Club, which designs their socks in Austin, Texas and manufactures them in North Carolina using cotton sourced from the southeastern US. Perhaps I see some locally-sourced HIStalk socks in my future.

CMS has released an updated version of its Security Risk Assessment tool. Many organizations I’ve encountered fail to appreciate the importance of the Security Risk Assessment, which is required under HIPAA. Some clients think that SRA is something their EHR vendor does for them and don’t understand that it’s not just about the technology, but also about compliance with physical, administrative, and technical safeguards. CMS has always had free tools, but they hadn’t been updated in a while. This one was release in October 2018.

Speaking of CMS, there is less than one month remaining for eligible clinicians to submit their MIPS Year 2 data for the Quality Payment Program. The system closes at 8 p.m. ET on April 2, 2019. CMS Web Interface users must report their Quality performance category data by 8 p.m. ET on March 22, so that deadline is even shorter. Good luck to everyone who is making the final push before submission.

It’s also time for the annual Call for MIPS Quality Measures. CMS is looking for measures to consider for future years of the Merit-based Incentive Payment System (MIPS). Recommendations can come from the domains of: patient safety, person / caregiver-centered experience and outcomes, communication / care coordination, effective clinical care, community / population health, and efficiency / cost reduction. Measures can be submitted through the ONC-JIRA system. You can learn more about the measure selection process here.

Congratulations to the 178 physicians who recently became board certified in clinical informatics, bringing our overall number to more than 1,800. There are yet more physician practicing in our field who are unable to be certified because they may have let their primary board certifications lapse. I’m looking forward to the day when we can be either primarily certified in clinical informatics or when we will be allowed to recertify without a current primary board certification.

As a former family medicine physician with a traditional practice, I realized all too quickly in practice that a good portion of my job was sales – trying to convince patients to “buy” something they didn’t want, such as healthier behaviors or medication compliance. Even in the urgent care setting, I’m constantly trying to sell patients on the benefits of symptomatic treatment for their viral illnesses rather than throwing antibiotics at anything that sneezes, runs, or coughs. I enjoyed this Health Affairs article  that looked at the idea of rewarding patients financially when they choose lower-cost alternatives.

The study looked at more than two dozen employers with almost 270,000 eligible employees and dependents. It was in play for more than 100 elective procedures, including advanced imaging (MRI, CT) and joint replacement surgeries. Patients who chose lower-cost alternatives received between $25 and $500 cash depending on the nature of the procedure and the relative cost of the provider. Although the savings only translated to a 2.1 percent reduction ($8 per patient), it resulted in an overall $2.3 million in savings annually. The largest effects were in MRI and ultrasound imaging. There was no savings seen with surgical procedures. The authors note that “this structure is appealing to employers, because compared to alternative programs such as high-deductible health plans or reference pricing, it encourages patients to price shop without exposing them to increased out-of-pocket spending.”

Until recently, I received my mammograms at an independent physician-owned imaging center that delivered high-quality services at a fraction of the cost of the local hospitals. Some quirky genes led me to enroll in a local medical center’s high-risk breast cancer surveillance program, which includes alternating mammograms and MRIs with increased frequency along with input from genetic counselors, surgeons, and other members of the support team. The cost is certainly higher than the independent imaging center and I’m able to understand the risk/benefit equation better than the average patient, for whom this could be challenging. Data is evolving so quickly it’s difficult at times to make these choices. I’m still not sure about the risk of gadolinium contrast deposition in my brain and whether it’s making me wacky, so if anyone is a neuroradiologist and has an opinion, let me know.

A team from Harvard University is partnering with the US Department of Health and Human Services to better understand attitudes towards health data, accessing it, and what patients know about their rights. Take a minute to complete their survey. Thanks to Amy Gleason @ThePatientsSide for sharing.

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Not all tech is good: The US Food and Drug Administration issues an alert that patients and providers should be cautious regarding robotically-assisted surgeries for mastectomy and other cancer-related surgeries. The FDA has not granted marketing authorization for any cancer-related surgeries and states that “survival benefits to patients when compared to traditional surgery have not been established.” Robotically-assisted surgeries use small surgical site incisions and can reduce pain, blood loss, and recovery time compared to open surgeries. The FDA goes on to say it “is aware of scientific literature and media publications reporting poor outcomes for patients, including one limited report that describes a potentially lower rate of long-term survival when surgeons and hospital systems use robotically-assisted surgical devices instead of traditional surgery for hysterectomy in cases of cervical cancer.”

Hospitals love to use the robotic devices for marketing campaigns because being high tech is sexy. As a physician, it’s more important to me to make sure I have a surgeon who has a high-volume practice in a particular procedure and performs that procedure at a facility which also has a high volume of those procedures. Those two factors have been shown to improve outcomes compared to lower-volume surgeons and facilities. The amount of training that providers receive on robotically-assisted procedures can be highly variable and is an important question for patients to ask as well.

Medscape released its 2019 “Family Medicine Physician Lifestyle, Happiness, & Burnout Report” last month. Here are the takeaways that caught my attention:

  • Plastic surgeons are the happiest, at 41 percent
  • Family physicians are nearly twice as happy (52 percent) outside of work than they are at work (23 percent)
  • We cope with burnout by eating junk food (35 percent), drinking alcohol (22 percent), and binge eating (19 percent) but we’re not using marijuana (0 percent)
  • We drive reliable, economical cars: 23 percent Toyota, 18 percent Honda
  • Nearly one-fifth of us don’t have spiritual or religious beliefs
  • 17 percent of us have had suicidal thoughts and 1 percent have attempted suicide

The last item is particularly sobering and weighs heavy on me as I approach a milestone reunion for my medical school class. We lost one of our dear classmates during the last semester of our fourth year. The American Foundation for Suicide Prevention has resources specifically for health professionals. If you are in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or text the Crisis Text Line by texting TALK to 741741.

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Morning Headlines 3/14/19

March 13, 2019 Headlines No Comments

TriNetX Secures $40 Million in Series D Funding

Analytics-enabled global health research network TriNetX raises $40 million in a financing round led by Merck Global Health Innovation Fund.

ImagineSoftware Acquires RCM Software Company ProviderAlly

Medical billing company ImagineSoftware acquires healthcare payment automation and analytics vendor ProviderAlly.

Mental health providers, others ask for delay to electronic health record requirement

Citing high EHR costs and lack of selection, behavioral health providers in North Carolina are pushing for more time to connect to the statewide HIE ahead of the mandated June 1 deadline.

Readers Write: To Douse the Flames of Physician Burnout, Target the Four Biggest Time-Wasters in the EHR

March 13, 2019 Readers Write 9 Comments

To Douse the Flames of Physician Burnout, Target the Four Biggest Time-Wasters in the EHR
By David Butler, MD

David Butler, MD, is principal at Calyx Partners and interim CMIO at Guthrie Health in Sayre, PA.

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There’s no question that physician burnout is one of healthcare’s most pressing problems: Forty-four percent of physicians report feeling burned out. It affects everyone to varying degrees: specialties, employed vs. self-employed, men and women.

The Number 1 contributor? Too many bureaucratic tasks such as charting and paperwork. The bottom line, according to Mayo Clinic Proceedings, is that physicians who aren’t comfortable using EHRs are more likely to reduce their working hours or leave the profession altogether.

We all agree on the challenge, but what’s not as obvious is the solution. Many hospitals are investing in scribes and assistants like they’re a sustainable solution. Individual providers have stated they have higher satisfaction, but the evidence isn’t showing that this is always the case.

Other organizations are placing the burden on other docs, creating physician-led training teams to improve EHR efficiency in their facilities. This can provide some level of peer-to-peer efficiency when thoroughly implemented with the correct support staff, in-room support, and focused curriculum based on user specific metrics. Otherwise, instead of slowing one doc down, you’ve merely doubled your inefficiency.

Mindfulness, yoga, and other self-care strategies are problematic. They take time—of which physicians are already short – but more importantly as this recent whitepaper on burnout points out, they fail to address the root cause and put the responsibility of burnout on individual physicians.

We’re all responsible for burnout. In my experience as a CMIO and EHR implementation and optimization strategic advisor to various healthcare delivery systems, the key to reducing frustration with the EHR and physician burnout is practical tactics that actually give doctors time back in their day.

These are the four biggest time wasters in the EHR and how to address them.


1. Searching for Clinical Data

When you think about search in the consumer world, companies like Netflix and Amazon may come to mind. They use various degrees of artificial intelligence (AI) to serve up what you’re likely to be interested in based on your past searches to streamline what you see.

Unfortunately, EHR search isn’t quite that intuitive yet. Searching for clinical data will happen during every patient visit, making it one of the biggest EHR pain points for physicians. Until the leading vendors incorporate focused AI and machine learning, the average physician should use these tips to filter through the sea of patient data more easily:

  • Default to search over navigation. I just described that EHR search is far from perfect. However, it is infinitely better than browsing and clicking your way through the interface. Sure, I know how to navigate to a WebEx site to join the meeting. Do I ever do that? No. Not when typing “Join WebEx Meeting” into Google gets me there much faster. Similarly, I always tell docs to search the chart. Let the system look for you by using the search bar. Once the page loads, typically Ctrl+F will open another more specific search box to find keywords within long patient reports of clinical data. Remember to use quotation marks around words that you want an exact match, i.e. “chest pain” versus just typing chest pain. Most EHRs will not suggest a correction like Google and ask, “Did you mean: chest pain” (correct spelling). So, learn your search tricks like: quotations, NOT, OR, AND, parentheses around multiple terms, etc.
  • Save your filters. When you listen to music on your app of choice via your phone or in the car, in order to rapidly get to what you want to listen to, you still have to either download albums, bookmark your favorite playlists, and/or save your top radio stations as presets. If you’re looking for the same type of data over and over again, be certain to treat the EHR in the same manner by saving your most common searches as a filter in chart review (labs, notes, imaging, etc.). Treat the filters like playlists. Create a cardiac playlist for all lipids, cardiac enzymes, and any other labs that brings the patient’s cardiac status into full view for the way you practice medicine based on your specialty and training.
  • Create disease- and symptom-specific reports. The majority of physicians in the U.S. are specialists and routinely need to zero in on the same disease, condition, or symptoms. Your EHR teams can easily create elegant patient summary reports that will pull data to you, i.e. all diabetes-related meds, labs, studies, referrals, etc. Most of the time you will have to agree on this with a group of clinicians within the same department, but roughly 20 percent are customizable at the individual level. Remember, just use newly created Maroon 5 “Sugar” playlist for the rest.

2. Managing the Inbox

Have a full Outlook inbox or an IMessage app with a permanent notification icon or badge? The EHR inbox is like that for physicians, but on steroids. InBasket is the name for the inbox for Epic users, but regardless of your EHR vendor, managing the flood of messages can be a struggle, and with greater interoperability, it will only get worse. Here’s what I tell physicians (and IT folks who want to help them) to personalize the InBasket to their workflow and get it under control:

  • Rearrange and sort. Many docs don’t realize that there are filters and sort logic available to always keep their most critical messages at the top (for example, abnormal test results, patient calls, refills, etc.). Fight your OCD and move to the top only the folders that you need to address to get the heck out of the office: results, patient messages, billable chart co-signs, refills, etc. Deal with the rest later, as they likely are not important and are just automatically sent to you because they always have been.
  • Remove and relocate buttons. Healthcare can take a lesson from the airline industry here. Just like in the cockpit, buttons and alerts should be presented in a logical, easy-to-read, color-coded format. Just like in other programs you use, such as Microsoft Office, you’re able to customize your user interface to increase your focus with no IT team required. Kick the clutter by deleting buttons that are never used and move ones that are frequently used to more convenient locations. Just look for any sort of wrench, bolt, pliers, or other icon on your screen, which typically means you can move things around.
  • Maximize your view. Treat your EHR view like you would your physical office and Marie Kondo the heck out of it until it’s most comfortable for you. Adjust the preview panes, sidebar, and the even the order that the report displays in to see as much information as possible at one time. For example, you may have the top half of your screen display your messages and the bottom half display reports about the particular patient to save you time from going to chart review. Maybe the EHR won’t quite spark joy for you, but it will definitely be less painful.
  • Create macros / QuickActions. I’ve encountered very few physicians who have created InBasket macros. These are simple, rote tasks / words / clicks that one does over and over based on a specific type of message. These are worth investing in as they offer significant time savings, a 60 to 70 percent time savings per message type for some. For example, you can create a macro that notifies a patient via the patient portal that (1) your labs were abnormal, yet not serious; (2) my office will contact you; (3) route to your nurse/team; (4) add a small note to yourself; and (5) close the lab message–all in ONE CLICK. Spend a few days watching for things that you do over and over, then try one. I suggest refill and normal result labs to start. They’ll give you hours back in your life over time.

3. Entering Orders

Does Amazon have order sets? Sure it does. When you order a new smart TV, it will automatically suggest the recommended HDMI cable, remote keyboard, etc. That’s an order set.

I’ve always wanted an Amazon-oid EHR. When I order the latest back pain (chief complaint) for my patient, I would like for the EHR to then make recommendations based on my patterns, my colleagues’ patterns, and other patients like this one. I’d like to see it display useful information that says something like “other internists like you who have seen patients with similar complaints have done X, Y, and Z.” I’m smart enough to know if I care to follow the pack or click and see what the latest evidence-based data is from the literature.

Until this occurs, here are a few tips you can use today.

  • Save your faves. Not saving your favorite orders is like not using bookmarks for your favorite websites when browsing the internet … not cool! Similar to the above macros and filters, these are key to faster ordering common things. Record dosage tapers and save multiple preferences for the same med, lab, or imaging with pre-fills. These are common, especially with chronic diseases, so save yourself from typing it or searching for it an infinite number of times. Some techie docs may already have these saved and may be willing to share with you if you ask nicely. Meds: refills 0, 30, 90 day refills, narcotics. Labs: A1c in three months, A1c in six months, etc. Imaging: CXR – chest pain, CXR – pneumonia.
  • Use portions of the name of the order. Google might say, “Did you mean?” when your search isn’t perfect, but the EHR won’t. However, you can use shorthand to look up med, lab, or imaging orders. For example, here’s an Epic trick that’s been around for at least 10 years that many don’t know. When searching for an order or diagnosis, try typing small pieces of the word (in any order), i.e. “CT Abd Con” will return a short list of “CT of Abdomen and Pelvis with Contrast.” Just remember, when it comes to searching for orders in the EHR, less is more! Check with your training team for more tips.

4. Documenting the Encounter

Physicians likely spend the most time here, inputting all of their notes into the EHR. Documentation takes a lot of time, whether it’s documenting visits, sending thank-you notes for referrals, or fielding follow-up questions in the patient portal. If you have to type, then create templates for things you say over and over. There’s no predictive text a la Gmail yet, but we can emulate it until we’re there.

  • Leverage SmartText and SmartPhrase templates. These are Epic system-specific names for their tools, but all EHRs I’ve used have the same type of documentation tool. Again, it’s all about making the EHR work for YOU.
  • Speak now. In the age of Siri and Alexa, it’s simply bewildering how many physicians don’t leverage speech recognition software like Nuance Dragon or MModal. Add in voice navigation macros and you can rattle off your notes to your computer with incredible speed and accuracy. For example, “Show me last CBC,” or “order amoxicillin 500.” etc. And be concise! Despite what we learned in med school, verbosity doesn’t mean better care.
  • Create SmartLinks. One of my favorite tricks to teach is how to pull data into your note for review, then delete (Ctrl+Z is undo). Don’t type values—learn tricks to pull into your note when appropriate (without pulling in too much in creating note bloat). As you look at others‘ notes, you’ll notice that they are pulling these labs, etc. into their note. Just find out from them how they are doing it, get the link, then you do the same yet with no need to leave it in the note. This is faster than search or filters.

Those four areas of the EHR compose about 80 percent of “pajama time.” Anything that you can do in one of those areas that can shave off a little time, you’ll see time come back in the long run—it adds up over many patient visits. Until the EHR vendors incorporate the functionality from consumer technology noted in the above examples, you must do these things to survive and stay optimistic.

By targeting these areas with these tried and true tips and tricks, I guarantee you’ll feel like you have more control over something that once felt like it was uncontrollable. Keep these fire extinguishers handy and you’ll douse some of the flames of burnout and take back your time.

HIStalk Interviews Mike Mardini, CEO, National Decision Support Company

March 13, 2019 Interviews 2 Comments

Mike Mardini is founder and CEO of National Decision Support Company of Madison, WI, which is part of Change Healthcare.

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Tell me about yourself and the company.

I’m a healthcare IT veteran. I’ve gone through three companies in the utilization management and documentation space. We were acquired by Change Healthcare about a year ago.

How will the acquisition change your business?

We had been working with McKesson for two years and they were acquired by Change. We had a good relationship. We knew what we were getting into when the conversation about them owning us started. We knew the people and we knew what the synergies were. We lived together before we got married. That was a big advantage, not only for us, but for them, too. It happened the right way.

It’s content integration and connectivity to impact care. To share data between providers and payers. A lot of assets come together.

How do you balance the big picture of growing the business, raising money, and considering who might acquire you or who you might acquire, all while you are still running the company day to day?

I’ve done it three times and I’ve asked myself that question. Each time was a little different. The first time was the first time. The second time, the strategic buyer was different. But it is a balance. You have to be true to the company and the company’s mission as opposed to a personal type of mission.

Some would say it was harder or easier for me since I never raised money. I never had a bank or a VC dictating what they wanted out of it. It was always personal. Whether it’s running the business or finding a partner, you’re in it every day. You have to be true to the mission of the company and to evaluate how the company is better off, whether it is run independently and we keep on going, or whether we’ve found the right partner to advance the mission. It becomes easy.

Change wasn’t the only one that wanted to us. From the day that we got started, I would say inside of a year, we were courted. We found the right partner.

CEOs have told me that instead of the champagne corks flying once the deal was done, the due diligence was like a colonoscopy and then it was second guessing about whether it really is the right partner, the right price, and the right thing for the company and its employees. Is it hard to balance the negatives and positives of multiple offers?

It was a lot easier this time around than the other two times, whether it was experience or that we had been working with them for two years. It is difficult. It is the colonoscopy. It’s all of that. But this time around was a lot smoother. We knew what to expect, we knew the people, and everybody’s heads and hearts were in the right place.

How hard would it be for a health system to set up and maintain ordering appropriateness checks on their own?

It’s a huge project. They all have a few dozen alerts and advisories. When we install our imaging product, it’s 15,000. Maintaining and managing with native EHR tools is a huge task. That’s why they only do dozens. All the content is managed locally.

Governance is an issue. Tracking the impact and the effects. It is a huge undertaking for sites to do it alone. I’m not sure they even realize how big the problem is. But as the market starts to evolve, they’re starting to ask all the right questions. We want an enterprise partner. We want to understand your analytics. We want to understand all the components, not just whether you put this alert in my EMR.

How do doctors react to that extra level of review or entry that is required to ensure clinical appropriateness?

The docs who are complaining about alert fatigue are primarily correct. When you install your EMR, you have people putting all these alerts. There’s not a lot of thought that goes into it, and even if there is on the front end, there’s not a lot of thought on an ongoing basis. They’ll add five alerts, then two years later, they add another five without taking a look at the original five. A doc does something in the EMR and three boxes pop up with kind of related, yet unrelated alerts. All they do is X through it. There’s no response, there’s no impact, it’s just these things that pop up and they pop up all the time. Nobody says anything, because they’re just X-ing through it.

Thoughtful implementation of guidelines to where they really have an impact, and putting them in place where we’re using the data from the EMR to fire guidance when it’s appropriate. When the end user connects, you understand what the value of it is.

That being said, we still see see doctors who don’t want to see them because they don’t want to see the EMR. They don’t even want to work inside the EMR. There needs to be an improvement in the thought process and the implementation of these advisories to ensure that they’re optimized so we’re not wasting people’s time.

The “revenge of the ancillaries” must play a part, where anyone in any department who wants to collect more information or make their own job easier dumps a new documentation requirement into the newly installed EHR. Is it easier to sell the idea that your recommendations were created by the societies to which those physicians belong?

It all depends on the use case. Sometimes the information is from societies. Sometimes it’s a local rule that a facility wants to implement. Sometimes it’s a payer rule. We try hard to make sure that the guidelines that are actually put in are relevant and respected by the end users.

Imaging is particularly hard. We took on the absolute hardest part of it. An entire service, in some cases 3,000 orderables, 7,000 clinical reasons for why you would want to use those 3,000 orderables, as well as variants used by every specialty in healthcare. It’s not something like, let’s put an alert in there for blood management if the patient’s hemoglobin level is above seven. Everything that we do beyond imaging is much easier for us to hit the target.

Why does CMS keep pushing out the mandatory date for implementing advanced imaging appropriateness rules?

This next date is set in stone, short of a big lightning strike. But I think the market is constantly making CMS aware of just how huge this implementation is. Everybody orders imaging, so they are communicating to CMS that it’s going to impact everybody. They’re getting a lot of push-back. They’re getting a lot of blowback from the market. They want to get it right.

It’s not just that they pushed it back, they have refined it, too. It is not all imaging, it’s certain clinical scenarios. But beyond just that, it’s figuring out how the data gets on the claim forms. There’s a whole process, not just on the provider’s interaction with CMS, but how all this data is going to flow and how they’re going to keep track of it all.

Do I think that they could and should have gotten this done faster? Yes. Am I surprised that it has taken this long? No.

Hospitals get paid well for imaging that best practices say it is inappropriate. Are they interested in ensuring the appropriateness of imaging until CMS forces them to?

That is almost the norm. They want to use it for the stuff that they’re at risk for, but they’re not as excited about it for the stuff that they’re not at risk for. We have seen that.

But the market is moving in a different direction. As the risk shifts to providers, this concept of a standard of care and making sure that there is no waste becomes tantamount. Not just to patient care, but to profit as well. As the risk shifts, everything looks like a DRG. Everything looks like a bundle. We are starting to definitely see a shift in wanting to adopt more and more as this risk shifts. They start acting like payers.

How is Choosing Wisely, which is endorsed by Consumer Reports, being implemented and what results are we seeing?

It’s another set of criteria. Some of it is really good. Some of it is impacted by evidence. The single greatest thing that Choosing Wisely did was create a market awareness that it’s workable to put guidelines in place to impact decision-making. It’s possible and it should be put into place. It has created an awareness.

Many of the Choosing Wisely guidelines are obvious. There’s no debate on them. So it has done a great job of creating an environment where the market is willing to accept putting guidelines in work flow to impact decision-making. The guidelines themselves are good, some better than others, but the awareness that it created is the impact that it has had.

What causes the gap between what a competent practitioner wants to order versus an insurer or hospital that thinks they need to tell them they might be wrong?

There is new data out there that docs may or may not be aware of. The average CME credits that docs get every year can’t begin to cover and keep docs updated with the latest knowledge. One of the points of implementing an EMR is to solve this gap in data. This ability to shed a light to docs on data that is available that would help them in their decision-making. I don’t think anybody could reasonably argue that doctors can’t benefit by being made aware at clinically relevant times that guidelines out there are proven or should be followed. It’s not for every case, but this is science, and information is being found all the time.

We talked about how risk shifts. Let’s go to the extreme and say you have a full-risk model on a provider’s side. Now, when a third part is paying, it’s the third party’s money and they are trying to save on unnecessary testing. Once the risk shifts to the provider, the issue is reversed. How do we prevent the provider from cutting corners? How do we prevent the provider from doing things to save money? It’s not based on bad things or evil or greed. It’s about keeping the lights on.

The only thing that protects providers from liability around cutting corners is to reduce variation in care, to establish a standard set of “this is what we do in this clinical scenario.” It doesn’t mean that somebody can’t veer off of it if there is a variant that exists. But it’s a standard that everybody follows. That ultimately will have to happen to give the provider not only protection from liability, but credibility. Why should the same type of patient with the same scenario walk in and get two different protocols?

Do you have any final thoughts?

I want to go back to the synergies with Change Healthcare and what we’re actually doing here. NDSC came to the table with a content management solution that is designed to deliver provider-focused guidelines seamlessly integrated into EMRs. In a standard way, extract data, calculate that data against guidelines, and then send that clinical data wherever it needs to be sent. We have a large provider footprint and success in the market. Change brings a host of criteria through its InterQual asset, a dominant product in the market that is used by health plans. They also have advanced business intelligence, a large investment in AI and machine learning labs, and a very large network of payer connections with a whole host of claims information.

We are working together to close the loop on delivering guidelines into the physician workflow, then being able to share that information with payers or whoever is financially risk to insure that the right things are done and to mitigate waste.

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March 12, 2019 Headlines No Comments

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Reader Comments

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