Cerner reports Q2 results: revenue is up 20 percent to $852 million and bookings for the quarter are up 15 percent to $1.08 billion, adjusted EPS $0.40 vs. $0.34.
In England, North Bristol NHS Trust will replace its Cerner Millennium EPR with CSC Lorenzo. North Bristol’s medical director says that Lorenzo “ We also have significant ambitions, and we were impressed with the vision and appetite CSC showed for working with us to build a truly world-class approach to patient care.”
Healthcare Growth Partners releases its healthcare IT mid-year review, which covers investments, M&A activity, and the expansion of the health IT footprint.
NEA Baptist Clinic and Hospital (AR) will go live on Epic across its entire organization, migrating from a previous vendor in its clinic and introducing its first EHR in the hospital.
Ever since Watson made its debut on Jeopardy, I haven’t been able to not check out what Watson was doing next. No doubt what Watson did on Jeopardy was impressive. However, it’s one thing to do what it did on Watson. It’s another thing to commercialize the Watson into something useful.
I’d long been hearing that Watson was going to be great for healthcare IT and that healthcare would really benefit from the technology. However, everything I saw felt very conceptual as opposed to practical and implemented. So, I was really interested in talking with Modernizing Medicine about their EHR integration with Watson.
You can find my interview with Daniel Cane and Dr. Michael Sherling, Founders of Modernizing Medicine, talking about Watson and some of the other cool ways they’re trying to help doctors make use of the data in an EHR in the video below. Plus, we even talk ICD-10 and MU 2 delay as well.
Note: Modernizing Medicine is a Healthcare Scene advertiser.
Cerner reports Q2 results: revenue up 20 percent, adjusted EPS $0.40 vs. $0.34, meeting estimates of both. Orders for the quarter totaled $1.08 billion, the best Q2 in the company’s history.
From Medium-Sized Data: “Re: data extraction. I challenge all of the companies promising world-changing analytics to extract all of your HIStalk posts to produce a list of hot topics by month and year, a cool infographic, or a detailed report.” That would be pretty cool. There’s a wealth of information in those old posts: tracking vendors that promised something that was never delivered, big announcements that were just hot air, and public perception items trended by vendor based on positive or negative HIStalk mentions. Companies are welcome to take a swing at it, and if they come up with something useful, I’ll toot their horn.
From Watertown Boy: “Re: athenahealth. In a recent email to clients, they announced what appears to be their problem in over counting some of the MU items. What happens to practices that already submitted this year?” A July 21 email to customers says athenahealth “identified a need to improve our calculation logic” and will complete that work by July 25, apologizing to customers whose performance numbers will drop as a result.
From WellTraveledGal: “Re: Beacon Partners. Announced mass layoffs of sales and consultants. Paul Sinclair, formerly of Cerner and UnitedHealth / Ingenix, joins as sales VP.” President and CEO Ralph Fargnoli provided this response:
We have not had mass layoffs of sales and consultants. Beacon Partners continues to grow because of the excellent work our experienced team of healthcare professionals is providing to health systems throughout North America. Recently, we have realigned some of our business development and consulting personnel to better support the operational, clinical, and financial performance engagements of our clients, and to meet our goals for continued growth. As we execute our business objectives for the second half of the year, we are actively recruiting for both business development and professional services positions.
From Boy Wonder: “Re: MU timeline for 2014. I wonder when your readers think CMS will announce a decision on the proposal to change the MU timeline for 2014? It better be quickly since many providers will be targeting Q4 as their one and only shot at MU2.”
From The PACS Designer: “Re: genome discovery. Genome sequencing will cost as little as $1,000, according to the CEO of Illumina. The company has an improved MyGenome app.” It’s a pretty amazing advance, but the really amazing one would be to figure out how we’re going to pay for treating the new problems such testing reveals. We love snazzy new diagnostic techniques and decisive interventions, but aren’t so great at making them affordable. The most amazing development would be to figure out a way to get people to lose weight, exercise, and turn off their phones and interact with others in a genuine rather than electronic way to move the population health needle. Genomic discoveries are cool, but our health problems have little to do with a lack of technology.
HIStalk Announcements and Requests
This week on HIStalk Practice: MGMA begins the search for a new CEO. Kansas Health Information Network and ICA announce a record number of HIE connections. Harbin Clinic and Cigna team up for collaborative care. ONC alludes to a specific interoperability timeline by 2015. PCC Director of Pediatric Solutions Chip Hart discusses the sometimes challenging world of pediatric HIT. The HIStalk Practice Reader Survey is live. Thanks for reading.
This week on HIStalk Connect: Dr. Travis discusses the new interest in health data aggregation from Google, Samsung, and Apple. Researchers with Cedars-Sinai have successfully tested a biological pacemaker concept in pigs. TechCrunch reports that women’s health apps are leading in the mHealth segment in both funding and consumer engagement.
My latest pet peeve: going to a company’s site and getting hit with one of those intrusive pop-up “your opinion is important” windows asking me if I want to take a survey. No, actually what I’d like to do is instantly leave any site that is clueless about annoying its web visitors with pop-ups. It’s nice to know your customer better, but nicer still to not drive them away with heavy-handed tactics whose only benefit is to make some marketing VP feel like they are contributing to business success. At least the HIMSS version doesn’t require answering before proceeding, so even though it’s annoying, I can live with it.
Listening: Phantom Planet, Southern California indie pop that’s been around for 20 years minus a hiatus or two.
Acquisitions, Funding, Business, and Stock
Quality Systems, Inc. (the NextGen people) reports Q1 results: revenue up 8 percent, adjusted EPS $0.13 vs. $0.24, beating revenue estimates but falling short on earnings. The hospital unit continues to turn in poor performance with a loss of $3.5 million. Overall, bookings were down, earnings were down, and expenses were up.
Streamline Health reports Q1 results: revenue up 7 percent, EPS –$0.16 vs. –$0.24.
The parent company of Lumeris announces $71 million in new financing from new and existing investors, which it will use to boost its population health management capabilities and expand from eight to 20 markets for its value-based care solutions. The parent company’s other companies are Accountable Delivery System Institute (accountable care education), Essence Healthcare (Medicare Advantage plan), and NaviNet (communication network).
Aspirus (WI) chooses Strata Decision’s StrataJazz to help manage costs in its six hospitals.
New Haven Community Medical Group (CT) chooses athenahealth’s PM, EHR, and patient portal.
In England, North Bristol NHS Trust signs for CSC’s Lorenzo EHR, replacing Cerner Millennium. Lorenzo was the only choice offered with the now-defunct NPfIT, but previous owner iSoft and then CSC repeatedly botched implementations and missed deadlines, which was arguably the main reason that NPfIT went up in a $20 billion taxpayer-funded mushroom cloud in 2013. North Bristol admitted that its $37 million Millennium system was nothing but trouble right after its December 2011 go-live, much of that due to its own failings in not testing and training well, shortcutting data migration, and letting IT run the project. The go-live resulted in cancelled surgeries, incorrectly assigned appointments, and patients who were sent home because doctors couldn’t access their records. The trust also admitted it had underestimated Millennium’s cost, drawing the ire of government officials demanding to know why the average trust implementing Cerner was spending three times as much as those going live on System C’s Medway, which was later acquired by McKesson and then recently sold off to Symphony Technology Group as McKesson dumped its European IT business.
Healthcare Growth Partners issues its always-insightful and downright eloquent healthcare IT mid-year review. This snippet is as brilliant that just about anything anyone has said about our healthcare challenges:
Inefficient markets typically result in a mispricing of goods and services. The cause is often due to monopolies, poor regulation, and a lack of market transparency. Each is a contributor to inefficiency in the US healthcare economy, but the primary shortcoming is the lack of market transparency, or information, needed to define the cost and quality of goods and services, otherwise known as value. In many markets, information is a tool for power and a proprietary competitive advantage. However, healthcare is not like most markets. Healthcare information is unique because it serves both a humane and a commercial purpose. At stake is the health of family, friends, neighbors, and ourselves, as well as the economy and corporate profits. Healthcare information exploited for the benefit of a few compromises the efficiency of the healthcare system as a whole. Nothing makes this clearer than the abysmal statistics of healthcare in the US. The power and profit potential for disruptive innovation in this nearly $3 trillion market is unfathomable. The advent of transparency will translate into a myriad of opportunities to drive down costs, improve outcomes, generate higher profits, and result in a stronger economy.
The report says that companies that sell out for high multiples have these characteristics:
Government and Politics
Women & Infants Hospital of Rhode Island will pay $150,000 to settle data breach charges resulting from a 2012 incident in which 19 unencrypted backup tapes containing the information of 12,000 prenatal diagnostic center patients disappeared. That’s not a federal HIPAA fine – $110,000 of the payment is a state civil penalty, $25,000 is for attorney fees, and $15,000 will fund an attorney general data security education campaign.
The GAO will release a report next week that outlines Healthcare.gov’s go-live problems, the cost to fix them, and the work remaining.
FTC Commissioner Julie Brill, concerned about a May report that showed 12 mobile health and fitness apps were sharing user information with 76 companies, says that third-party data use is where “the rubber hits the road when it comes to patient harm.” Despite expressing concerns that more consumer choice should be provided, Brill says that no new regulations are planned.
A California appellate court dismisses a class action lawsuit seeking $1,000 for each Sutter Health patient whose information was stored on a stolen computer, a suit that had exposed Sutter to a $4 billion payout. The court found that the state’s Confidentiality of Medical Information Act requires proof of unauthorized access to patient information, not just possession of the physical form of the data (a hard drive, in this case) by an unauthorized individual. One of the attorneys for the patients originally said that an unencrypted computer storing the information of 4 million patients should have been stored in a windowless room under lock and key instead the office that was broken into.
The Wall Street Journal profiles William LaCorte, MD, a Louisiana internist who has pocketed $38 million as his share of 12 Medicare fraud lawsuits he filed mostly against drug companies. He even named his newly purchased 34-foot boat Pepcid. The article also mentions a former pharmacy that found whistleblower lawsuits to be a more lucrative business, having netted it $425 million from the 20 lawsuits that have been settled out of the 35 it filed.
Former Procter & Gamble CEO Robert McDonald, in his confirmation hearings for Secretary of Veterans Affairs, says the agency needs to “continue to expand the use of digital technology to free human resources” and “create, with the Department of Defense, an integrated records system.”
UnitedHealthcare makes its Health4Me app available to all consumers, not just its customers, allowing them to perform doctor searches and review medical prices.
Allscripts receives an Intel Innovation Award for its Windows-powered Wand mobile EHR navigation system.
Google’s Google X research group will analyze genetic and molecular information from 175 volunteers to define a health human, hoping that the Baseline Study’s new diagnostic tools will allow Google’s computers to find patterns that can be used to detect disease earlier. That project may or may not be related to the company’s recently announced glucose-measuring contact lens.
The administrator of Bradley Healthcare and Rehabilitation Center (TN) says employees really like its new PointClickCare EHR, but adds that the system caused Medicare payment delays in its first two months. The system was configured to use the facility’s five-digit ZIP code instead of the required nine-digit code, and nobody knew how to open warnings from its intermediary about incorrectly formatted claims. The facility admits that it should have trained users better before going live.
A NPR report says HIPAA was created to protect patients, but healthcare organizations are intentionally or unintentionally using it to protect their own interests, such as hospitals that refuse to give patients their own medical records claiming it’s a HIPAA violation when the law intended the opposite. It also mentions that VA management used HIPAA threats to squelch potential whistleblowers.
A patient who starting shooting in the psychiatric unit of Mercy Fitzgerald Hospital (PA) is shot by the psychiatrist he wounded, who returned fired using his personal firearm despite the hospital’s policy barring on-campus weapons except by on-duty police.
EPtalk by Dr. Jayne
Jenn tweeted about this recent Washington Post piece on Maintenance of Certification (MOC). Since I now have to maintain certification in both clinical informatics and my primary specialty, it hit close to home. Although board certification is technically “voluntary,” in my market it’s a necessity – no payers will credential you if you’re not certified.
I agree with the author that merely having certification doesn’t add a lot to my actual practice of medicine. I don’t treat chronic disease or deliver babies any more, other than in an absolute emergency. I do, however, perform a mean laceration repair and reduce dislocations like a boss. None of that is on my board exam, however.
You may be asking what this has to do with healthcare IT. It’s this: nearly everything for MOC is online and some of it is a true pain. Plus, there’s not a lot of content for some of us who are largely administrative or don’t have true continuity practices.
Case in point: my Board offers a handwashing module for MOC. If you’re in traditional practice, you’re supposed to survey your patients then key in the results and analyze them. If you’re not in continuity practice, they give you mock data that you still have to key in and analyze. How hard would it have been for them to preload the data? I’m sure the argument is I need to have the experience keying in data since the others do, but that’s ridiculous.
We’re claiming that primary care physicians should be quarterbacking healthcare delivery teams and working at the top of their licensure, yet we have them manually keying in data for recertification. Physicians at my institution are burning out at an alarming rate. This is just one more thing we ask them to do. Manually keying data isn’t a good use of our time.
On the flip side, some organizations have tried to partner with EHR vendors to extract data for quality studies. My vendor used to do this for two specialties but ended up stopping it, supposedly because the burden of keeping up the code was too great and the functionality wasn’t adopted widely by customers.
I have to admit I’ve been somewhat of a slacker with regards to MOC for my newly-minted clinical informatics subspecialty. I’m in the middle of an online cultural competency module for my primary specialty that I keep having technical difficulties, with so the idea of digging into other content doesn’t excite me.
I do obtain regular Continuing Medical Education credits, typically double what is required by my Board, which is four times what is required by my state licensing board. That’s the most valuable to me as far as keeping up because I can choose CME that’s relevant to what I actually see in practice. Cramming for a test once every 10 years (even when I can listen to all the lectures on my handy-dandy iPod) doesn’t say much about my skills listening to patients or being a clinician who can actually speak with patients in a way that they understand and makes them confident in the treatment plan.
Readers may ask, if we don’t have ongoing board certification, how will patients tell if we’re quality physicians?
It’s my great hope that eventually when we are truly meaningful users of EHR technology (not the government-speak kind of MU, but the real kind) we’ll be able to show what kind of physicians we are. How many of Dr. Jayne’s patients had failure of their laceration repairs? How many had unexpected scarring? Was her documentation readable and did she provide a patient plan in a way that the average person with a fifth-grade reading level could understand? Did she communicate back with the patient’s primary physician and arrange a follow up?
A friend of mine does minimally invasive knee replacements. He puts all of his data on his website for the world to see. He’s published multiple studies on his outcomes. All he does is knees. To me, seeing his data (including infection and complication rates) is a much better marker of his skill and competency than knowing he passed a board exam that covered the rest of the realm of orthopedic practice.
Before EHRs, trying to mine paper charts for that kind of data was nearly impossible. Most of my colleagues who were doing outcomes research used separate databases and registries and there was a lot of manual entry. Now we have the ability to study our populations at a moment’s notice. As a CMIO, I provide my physicians a sheaf of reports each month that let them know how they’re doing with respect to national standards and also to their peers. That kind of data will drive behavior change far more than reading a board review book might.
I’m hopeful for the future, but meanwhile I’m stuck with the expense and tedium of MOC.
What does your CMIO think of MOC? Email me.
This is a new tamper proof drug which means if it is crushed it looses it affect, but of course people can still swallow the pills. Purdue will have to conducted follow up studies on rates of abuse, addiction and death as that’s a standard anymore for any Opioid drugs. BD
Washington • The Food and Drug Administration has approved a new combination pain pill from the maker of OxyContin that is designed to discourage abuse by painkiller addicts.
Purdue Pharma’s new drug Targiniq ER is an extended release tablet that combines oxycodone — the active ingredient in OxyContin — with the drug naloxone. FDA regulators approved the drug for daily, round-the-clock pain that does not respond to other medications.
Stamford, Connecticut-based Purdue has often been cited by public health advocates as a key contributor to the overprescribing of opioids. In 2007, Purdue Pharma and three of its executives paid $634 million and pleaded guilty to charges of misleading the public about the safety and addictiveness of OxyContin.
Is this a great story or what? Listen to the video and read below about his past, pretty grizzly so he’s off his rocker to begin with. He earned his money the old fashioned way, he inherited it. He was recognized as a regular patron at the store. BD
Police say multimillionaire Robert Durst unzipped his pants in a Houston CVS, exposed himself and then urinated on a cash register and candy before walking away from the store just after noon Sunday, Houston NBC affiliate KPRC reported.
He had left the scene by the time police arrived, but on surveillance video he did not appear to have been agitated or argumentative before the incident, police said.
Durst had been arrested in 2001, jumped bond, was found in Pennsylvania trying to steal a sandwich and a Band-Aid from a grocery store and eventually faced trial in the murder. He claimed he had shot Morris Black in self-defense during a struggle over a gun, according to the Houston Chronicle.
Flagstaff is located in northern Arizona and now the center will be closing. There has been a lot of speculation if Walgreens will stay headquartered in the US or move to the UK or Switzerland.
Last year Walgreens had 75.2 billion in revenue and 2.8 billion in profits. Remember too these folks bring in about 1 - 2 billion in revenue from selling data which would be part of of the 75 billion in revenue. In addition Senator Dick Durbin wrote a letter to the chairman of Walgreens stating they were turning their backs on the US should they decide to move. Well they have to finance their stock buy backs and reductions and cut backs are part of that as they are pretty leveraged these days if they stay in the US. The company is also suing CVS and Rite Aid over IP software patents.
In addition to save money last year all employees were moved to a private health insurance exchange for their benefits that is run by an investor relations firm. Sounds like things are headed to be a little toxic around Walgreens. BD
The community is now scrambling to do what it can to keep as many of those workers in town.
"This is the biggest one we've ever had in Flagstaff," said Coconino County Career Center Director Carol Curtis.
The distribution center in Flagstaff was once thought to be an employer that would be around for good. The city even named the road it's on Walgreens Street.
Curtis says the news made the Coconino County Career Center's rapid-response team spring into action.
The Senate Committee on Veterans’ Affairs confirms the nomination of Robert McDonald as the next VA Secretary in a 14-0 decision. His nomination will now move to Senate for a final vote. In his post-confirmation statement, McDonald said that the VA needs to prove “ that it can create, with Department of Defense, an integrated records system; (and) that it can regularly and accurately produce key data for decision-makers and oversight entities.”
A NEJM study finds that 10.3 million uninsured American’s gained health insurance during the ACA open enrollment period, with eight million signing up for private insurance and 2.3 million taking Medicaid. Enrollment variations between age, gender, and ethnicity are also included in the study.
A $4 billion class action lawsuit against Sutter Health stemming from an earlier data breach has been thrown out because patients could not prove that their data had been accessed by anyone or used in any illegal way.
We have another new one added today in the form of Wal-Mart Senior VP Leslie Dach to be Burwell’s senior counselor to help manage the health insurance exchanges. As I have said before I think HHS and CMS has nowhere else to turn with the lack of building their own models over the years. A former CMS employee told me that for years when they go stuck they just called in United to provide and create a model for them so I think this study is really true from Plos One, the fear of math gives people real physical pain:) Of course we know this doesn’t apply to Wall Street either but it could alive and well at HHS and CMS these days:)
Of course we know that we don’t have any real experts anymore either so half dozen of one and six of another, it’s modeling for inequality using segmentation anyway with the “Scoring of America’ that denies access. As I said below we are all busy as consumers being chased by corporate profit algorithms all the time with our data by all means and in time the glut will come out as it is beginning to show that all the models are not accurate and many are flawed or just cheat as what happened with the AMA and Ingenix, while the current Andy Slavitt who’s the #2 person in control now at CMS was CEO over that subsidiary. If you read the article, Andy Slavitt has officially been forgiven for anything he’s done or will do maybe. So far the focus has been on the QSSI incident, but how about the AMA suit, he was CEO then of Ingenix…
This is the guidance we can look forward to I guess as I don’t know about you but I do get suspicious about leopards changing their spots, a few do but you can base your own opinion here. There’s still a bunch of unsettled Ingenix (Optum) lawsuits out there unsettled.
Of course we all might remember Steve Larsen who left CMS to work for Optum as well a couple years ago who was responsible for a big part of the ACA law.
I said back in 2009 that these two would run over by insurers duping them and well, what do you think:) I just visualize and said what I felt in 2009 and sad but it’s what happened and we have issue at the SEC going right now too.
The mess we have right now is all credited to the insurers and their companies that’s how they make money with complexities just like Wall Street and the government sucked it all in and I’m far from the first on the web to state this fact. So we can add a new “sprinkle” of Wal-Mart here, who by the way has a pretty big technology lab up in the Silicon Valley too in case you were not aware. I like good data and it makes us smarter and we do need it but there’s so much room for one heck of a lot of Algo Duping which works well on the folks living in “The Grays” who can’t tell the difference between virtual and real world values and that’s a real problem in the US..all you have to do is recall the Facebook study a few weeks ago, and there you are:)
So it’s going to be pretty miserable indeed as the White House themselves has been caught with being duped with some junk science numbers so HHS and CMS unless something changes will as I see it keep sucking in what ever models they are presented with, and I did a post on some of that too, “quantitated justifications” for things that are not true and one by one all over today we’re seeing numbers and models fail. For an easy reference look at all the money spent with Lewin (another United subsidiary) that gave us a steady diet of of studies with “how much much money would be saved with this or with that”. You can go research and find them on the web too that claims billions and sometimes even trillions would be saved, while banks of data bases were built that scrape and sell our data for billions all the time to which we have absolutely no say or the ability to even see who they are. World Privacy Forum called that out perfectly “What going on with the secret scoring of US consumers”…we all watching. Sadly that’s what a lot of these models for better care are built around when it comes out in the wash, not better care, just more algorithms and more scoring to deny access. BD
“Leslie’s experience, which spans the business, government and civil society sectors, will further enhance our ability to deliver impact for the American people,” Burwell said. “We want to not only retain, but also recruit, talented individuals to our mission of ensuring every American has access to the building blocks of a healthy, productive life.”
Bench, Bonus and Bondage: The Sorry Side of IT Consulting
By Mike Lucey
If I could lose 20 pounds, I would be ready to model swimwear. That’s a nasty image for those who know me, but if I were serious, hiring a personal trainer would make sense. Or better yet, a personal exerciser!
Why not both? One person to tell me what to do and another to go and do it. I might not get the results I want, but much less effort. Think of what I would save in sneakers and tee shirts!
This wacky logic seems to be in play in our industry when it comes to hiring consultants. When I moved into consulting, it was because I figured I had some unique smarts and skills that a hospital would need. Once my smarts became their smarts or my skills were no longer needed, off I would go to the next guy. For this I would get a nice rate and the fun of doing new projects.
But what I am finding is hospitals have some consultants who offer guidance, and then other “consultants” who do the work, work that hospitals really need to be doing themselves. Part of why this happens can be found in the way consulting companies can market their services.
Bench: To start a consulting company, scrape up a pile of resumes, format them nicely, and throw them at every hospital problem you hear about until some of them stick. Now you have consultants working. As these consultants roll off projects, they go to the Bench. Yikes! Good news: you now have consultants ready for the next project. Bad news: every hour they sit on the bench they cost money (until you pull the bench out from under them). A way companies can lighten the bench is to give bonuses to the consultants that are still working to find work for the benchwarmers.
Bonus: Let your working consultants know that they will get a bonus for every benchwarmer they place. This is where the worm turns. Now those consultants you hired to solve a problem are to some degree degraded or distracted by the incentive to be a sales guy. The inclination to teach a hospital employee how to solve the next problem conflicts with an inclination to pull in a colleague from the company. Good for these companies, maybe not so good for the hospital.
Bondage: With each additional placement, each incremental bump in the billable hours (and bump in that bonus income), the idea of ending the engagement becomes more ugly and the motivation to extend more attractive. It is stressful to see a project end and face the uncertainty of the next job, stress that is magnified with the addition of each colleague and the bonus income they represent. Suddenly maintaining my value as a smart guy may depend on maintaining a certain amount of client ignorance and so client dependence – knowledge bondage.
This is how you end up with a consultant who is not just the captain of your hospital softball team, but the batting champ three years running.
We consultants have a great part to play as our industry continues to change. We bring real value helping hospitals make decisions, helping them act on those decisions, and providing resources when big projects need extra hands. That value is based on smarts, skills, and experience that hospitals don’t yet have, but can gain with our input.
When that value wanes, not to worry — I’m off to the next project. Or I always have the modeling gig to fall back on. (note to self: find my Ab-Master.)
Mike Lucey is president of Community Hospital Advisors of Reading, MA.
Is DIY Network Security a Good Idea?
By Jason Riddle
Patients and clients count on healthcare providers, payers, and business associates to protect their electronic health records. For optimal care, patients need to feel comfortable divulging personal information that could cause them injury—financially, emotionally, and/or physically—should it be illegally accessed or corrupted by hackers or malware.
Additionally, covered entities are required by HIPAA/HITECH laws to maintain a certain level of network security. Violation of these regulations could result in stiff fines, a disruption in operations, and a general loss of goodwill among the people who do business with them.
Many small to medium-sized organizations are managing some if not all of their network security on their own. Here is one question they often ask:
Do we have enough protection for our patients’ data, or do we need to hire outside professionals to do the job for us?
While there is no right or wrong answer to this, there are a few factors that need to be considered.
HIPAA/HITECH was designed with built-in flexibility so that organizations could make their own decisions about their level of investment in network security. For example, a large organization may choose to hire an outside cyber security firm to monitor their networks around the clock, but a three-person doctor’s office might be hard pressed to put such an aggressive solution in place. Office for Civil Rights (OCR) auditors who are responsible for monitoring HIPAA compliance recognize that organizations of various sizes make decisions based on practical restraints.
As covered entities make decisions for (or against) increasing security, the reasoning and conclusions should systematically be written down. OCR auditors generally take into consideration all well-documented justification.
One way to think about whether or not to hire an outside vendor to assist with network security is to recognize that a solution doesn’t have to be all or nothing. For example, some companies will hire an independent third party to conduct an initial security risk analysis. This gives them the objectivity where it counts—identifying vulnerable areas and obtaining guidance on how to address them.
Once the fix-it plan is set, the internal IT team can assume the responsibility of maintaining the network’s security from there on out. This hybrid solution can oftentimes save money. Cyber security professionals will likely identify problems faster and provide guidance to tools that are both free and/or low cost.
If an organization is committed to a DIY network security solution — whether starting out with the help of professionals or taking it all on independently — it takes more than someone who is just an IT whiz to manage a network security program. There are six main areas that a security officer must be well versed in to carry out the required responsibility:
A DIY network solution for healthcare organizations is not necessarily a bad idea. But it does need to be a well thought out one. Patients and clients are counting on it.
Jason Riddle is practice leader with LBMC Managed Security Services of Nashville, TN.
I briefly mentioned Dr. Oz in my recent post about NY Med (and the healthcare social media firing). It’s clear to anyone watching the show that Dr. Oz is there for the celebrity factor and not for the actual medical work. He’s always “partnered” with another cardiologist who provides the actual patient care. Of course, I don’t really care too much that he’s on it or not. If it gives them a boost in ratings, good. I like the show.
However, I don’t know a single doctor that likes Dr. Oz and I know many of them who hate Dr. Oz. With this in mind, I found this interview with a medical student whose trying to “take down” Dr. Oz quite interesting. Here’s a short take on what this med student is doing:
Last year, Mazer brought a policy before the Medical Society of the State of New York—where Dr. Oz is licensed—requesting that they consider regulating the advice of famous physicians in the media. His idea: Treat health advice on TV in the same vein as expert testimony, which already has established guidelines for truthfulness.
Although, this quote is really powerful as well, “DR. OZ HAS SOMETHING LIKE 4-MILLION VIEWERS A DAY. THE AVERAGE PHYSICIAN DOESN’T SEE A MILLION PATIENTS IN THEIR LIFETIME.”
This is absolutely one of the problems with social media and other medium like television. The person with the biggest voice doesn’t always have the best information. In fact, sometimes the wrong information is the best way to grow an audience. What’s popular is not always what’s right.
Mazer in his interview highlights the biggest problem with some of the things that Dr. Oz says. The movement in healthcare has largely been towards evidence based medicine. I think that movement will only grow stronger as we can prove the effectiveness of care even better. However, many of the things on Dr. Oz’s show go contrary to evidence based medicine. This leaves the patient-doctor relationship at a cross roads when a patient chooses to follow something they’ve seen on TV versus the advice of the doctor (even if the doctor is on the side of evidence).
Dr. Oz aside, the same principle applies to other information patients might find on the internet. Many doctors would like to just brush this aside and say that patients should “trust” them since there’s bad information on the internet or there’s a bigger picture. That might work in the short term, but won’t last long term.
Long term doctors are going to have to take a collaborative approach with patients. As patients we just have to be careful that we don’t take it too far. Collaboration means that the patient needs to be collaborative as well.
The other way for doctors to battle the misinformation out there is to provide quality sources of trusted information. One way this will happen is on the physician website. Instead of being a glorified yellow page ad, the physician website is going to have to do more to engage and educate patients. That’s part of the opportunity and vision for Physia. It’s an exciting time to be in healthcare…if you like change.
In various conversations on how to improve patient care, the importance of health literacy is often raised. Health literacy is needed as it relates to effective patient engagement and healthy habits. Information and knowledge create greater awareness of how to live healthier and interact with doctors in a more meaningful way.
Another element of health literacy needs to include health IT literacy. With about 78% of care providers now using electronic health records (EHR) and wearable technology gaining momentum, healthcare is moving into the digital age. Patients will not need go deep into the technology, but a base understanding will be required.
Although this is not a complete list, we need to begin somewhere. Highlighted below are some basic health IT elements to raise the literacy levels of patients.
Affordable Care Act: This law generates intense feelings and debate. The Medicaid.gov site defines the Affordable Care Act in this way:
“…provides Americans with better health security by putting in place comprehensive health insurance reforms that will:
Hold insurance companies accountable,
Lower health care costs,
Guarantee more choice, and
Enhance the quality of care for all Americans.”
Essentially, the Affordable Care Act expands Medicaid coverage to low-income individuals and works toward adding improvements to our healthcare system. Read more about your healthcare rights here.
HITECH / Meaningful Use: In health IT circles, most will know what Meaningful Use is and where it came from. Move outside this circle and most will just think the drive to electronic health record adoption is a part of the Affordable Care Act (Obamacare). Meaningful Use was born out of the American Recovery and Reinvestment Act of 2009 (aka Stimulus bill) in which the Health Information Technology for Economic and Clinical Health (HITECH) was buried. Meaningful Use is a part of HITECH and, together, they seek:
“…to improve American health care delivery and patient care through an unprecedented investment in health information technology. The provisions of the HITECH Act are specifically designed to work together to provide the necessary assistance and technical support to providers, enable coordination and alignment within and among states, establish connectivity to the public health community in case of emergencies, and assure the workforce is properly trained and equipped to be meaningful users of EHRs.”
Simply stated, HITECH/Meaningful Use is an incentive program to move patient records from paper to an electronic format, which will then enable secure, efficient exchange of patient data, and provide patients easier access to their records.
EHR – Electronic Health Record: According to the HealthIT.gov website:
“An electronic health record (EHR) is a digital version of a patient’s paper chart. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users.”
An important element to an EHR is it contains all relevant patient information from different clinicians involved in a patient’s care.
PHR – Personal Health Record: According to American Health Information Management Association (AHIMA),
“The PHR is a tool that you can use to collect, track and share past and current information about your health or the health of someone in your care. Sometimes this information can save you the money and inconvenience of repeating routine medical tests. Even when routine procedures do need to be repeated, your PHR can give medical care providers more insight into your personal health story.”
Patients own and manage their health data – you own it, you maintain it. Having the ability to electronically receive relevant data from care providers in a usable, efficient way is very helpful.
HIPAA – Health Insurance Portability and Accountability Act: Finding a concise definition for HIPAA is challenging. On HHS.gov, the following explanation is good:
“Most of us believe that our medical and other health information is private and should be protected, and we want to know who has this information. The Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. The Privacy Rule applies to all forms of individuals’ protected health information, whether electronic, written, or oral. The Security Rule is a Federal law that requires security for health information in electronic form.”
Even better, watch this quick video:
Your rights include saying who can see your data from clinical visits, and providers are responsible for securing your data collected during these visits.
PHI – Protected Health Information: Since protected health information was used in the HIPAA definition, we should address it. The National Institutes of Health highlights PHI as “individually identifiable health information that is transmitted or maintained in any form or medium (electronic, oral, or paper) by a covered entity or its business associates, excluding certain educational and employment records.”
Essentially, PHI is your health data.
Quantified Self: There is much more health data available because there are more tracking devices to use. Quantified Self, or wearable tech, are interchangeable terms and what it means you are proactively tracking (quantifying) your health metrics. Watches, mobile phones, apps, and other devices make the recording of your daily health information easy.
By tracking your health status, the objective is to understand your healthy habits and their impact as well as keep chronic conditions monitored and stable.
With better and timelier data, your health patterns are recognized and can be adjusted more effectively, as needed. Think diet, exercise, blood sugar, heart rate, and much more… recorded, tracked, and shared as you define.
Interoperability: Inevitably in health IT conversations, the lack or challenge of sharing patient data between providers, applications, and devices will arise. Healthcare has many data standards (e.g., HL7, X12) and different communication protocols (e.g., TCP/IP, Direct Project, Web Services).
For data to flow, each application vendor needs to open up their application or device to send and receive data. After this, the data differences need to be understood and then mapped. Integration solutions exist to orchestrate this patient data flow, but the considerations are many: application perimeters, privacy and security requirements, data specifications, workflow necessities, and more.
Interoperability is achievable and, as a patient, requesting your data in an electronic, secure way will help facilitate this requirement.
When health IT literacy works, it looks like a more fully engaged patient. The flow of health IT literacy may look like the illustration below. Pieces of the healthcare puzzle begin to fit together and patients have a broader perspective of how it all fits together, along with their important role within the healthy flow.
Healthcare has many components and, ultimately, the most essential elements are delivering high quality care in a timely and efficient manner. In the middle of this is you – the patient. Understanding what is healthy is core to health literacy. Understanding how your data is collected, stored, used, and exchanged is central to health IT literacy. We need to raise our health standards for both healthcare and health IT literacy, and this will take a community and your active participation.
What other key elements are required to raise health IT literacy? Add your thoughts and let’s expand this list to what is important for patients to grasp and use.
A recent article addressed both the diagnostic challenge and the changing presentation of diabetes mellitus. It included a description of the development of a new microchip for the inexpensive analysis of the autoantibodies that are pathognomonic of type-1 disease (see: Type 1 diabetes can be diagnosed with new microchip). Below is an excerpt from it:
An inexpensive, portable, microchip-based test for diagnosing type-1 diabetes could improve patient care worldwide and help researchers better understand the disease, according to the device’s inventors at the Stanford University School of Medicine....The handheld microchips distinguish between the two main forms of diabetes mellitus, which are both characterized by high blood-sugar levels but have different causes and treatments. Until now, making the distinction has required a slow, expensive test available only in sophisticated health-care settings....Better testing is needed because recent changes in who gets each form of the disease have made it risky to categorize patients based on their age, ethnicity or weight, as was common in the past, and also because of growing evidence that early, aggressive treatment of type-1 diabetes improves patients’ long-term prognoses. Decades ago, type-1 diabetes was diagnosed almost exclusively in children, and type-2 diabetes almost always in middle-aged, overweight adults....Now, because of the childhood obesity epidemic, about a quarter of newly diagnosed children have type-2 diabetes. And, for unclear reasons, a growing number of newly diagnosed adults have type-1. Type-1 diabetes is an autoimmune disease caused by an inappropriate immune-system attack on healthy tissue....The disease begins when a person’s own antibodies attack the insulin-producing cells in the pancreas. The auto-antibodies are present in people with type-1 but not those with type-2, which is how tests distinguish between them....The old, slow test detected the auto-antibodies using radioactive materials, took several days, could only be performed by highly-trained lab staff and cost several hundred dollars per patient. In contrast, the microchip uses no radioactivity, produces results in minutes, and requires minimal training to use. Each chip, expected to cost about $20 to produce, can be used for upward of 15 tests.
It used to be the case that type-1 diabetes with an autoimmune etiology was diagnosed in childhood and type-2 disease was diagnosed in older adults. This latter disease was often referred to as adult-onset diabetes. The age of the patient thus took the physician most of the way to the diagnosis. Now and due to the epidemic of childhood obesity, children are developing type-2 disease and some adults, for unknown reasons, are developing autoimmune disease. Type-1 and type-2 diabetes can be differentiated using an analysis for pancreatic islet cell autoantibodies but the test is slow and expensive (see: Autoantibodies in Diabetes). Researchers at Stanford are now developing a micro-chip based test for autoantibodies that is reportedly both fast and inexpensive.
Here are some additional comments about the microchip-based test and the diagnosis of diabetes from a Stanford web site (see: Researchers invent nanotech microchip to diagnose type-1 diabetes):
The microchip relies on a fluorescence-based method for detecting the antibodies. The team’s innovation is that the glass plates forming the base of each microchip are coated with an array of nanoparticle-sized islands of gold, which intensify the fluorescent signal, enabling reliable antibody detection....In addition to new diabetics, people who are at risk of developing type-1 diabetes, such patients’ close relatives, also may benefit from the test because it will allow doctors to quickly and cheaply track their auto-antibody levels before they show symptoms. Because it is so inexpensive, the test may also allow the first broad screening for diabetes auto-antibodies in the population at large. “The auto-antibodies truly are a crystal ball,” [the inventor of the chip] said. “Even if you don’t have diabetes yet, if you have one auto-antibody linked to diabetes in your blood, you are at significant risk; with multiple auto-antibodies, it’s more than 90 percent risk.”
Melissa McCormack, a medical researcher with EHR consultancy group Software Advice, recently published their medical practice management BuyerView research, which found that 63% of the buyers were replacing existing PM solutions, rather than making a first-time purchase. This mirrors the trend we’ve seen across medical software purchasing, where the HITECH Act may have prompted hasty first purchases of EHR solutions, followed by replacements 1-2 years later. For PM vendors, this means there’s a huge opportunity to market your products to practices as an upgrade, even if they’re already using PM software. I reached out to Melissa to ask her to elaborate on the implications of the trends she found in her recent research. Here’s some advice for vendors and solutions providers.
1. As EHR meaningful use requirements grow more involved, standalone billing or scheduling systems are becoming less viable. In fact, nearly 70 percent of the buyers we spoke with wanted integration between practice management and EHR. The trend of PM buyers looking for robust EHR integration grows more pronounced each year, and shows no signs of tapering off since EHR meaningful use requirements increasingly require physicians to utilize charting, billing and scheduling in tandem. Vendors who can offer seamless integration between these applications will have a clear advantage over those who cannot.
2. Another regulatory pressure influencing PM software replacement is ICD-10. Compliance with the new code set is a major driver not only of practice management purchases in general, but specifically of replacements—25% of buyers replacing an existing solution cite a concern that their current solution wouldn’t support the code set switch. Despite the implementation deadline having been extended to October 2015, we’re seeing practices give a lot of thought to preparation, and they’re realizing the software they use will play a major role in their own readiness. Vendors who are confident in their ICD-10 readiness should take care to communicate that confidence to their existing users, as well as marketing it to prospective customers.
3. The medical practice management software buyers we talk to clearly prefer cloud-based systems. Among buyers with a preference, 88% want cloud deployment. We’re hearing from smaller practices that they value the low up-front costs, as well as not needing to maintain servers and dedicated IT staff. Additionally, buyers appreciate the remote access options afforded by cloud solutions. Some buyers even seem to conflate “cloud” with “remote access” and “mobile access” (even though those features aren’t unique to cloud-based products), suggesting these are the features of cloud-based software they are most concerned with. In fact, almost 20% of buyers identified mobile access as a top priority. Vendors who offer mobile support are at an advantage and should highlight their capabilities prominently.
4. Practice management software buyers come from diverse roles within practices. We saw clinicians and administrative staff represented almost equally—46% and 40%, respectively—among our buyer sample. Vendors should consider their audiences when marketing their products and tailor communication accordingly, giving equal weight to the unique benefits for clinicians and administrators.
I’ve long been a fan of open source technologies. My blogs are run and created almost entirely on open source software. In fact, I first wrote about open source EMR on this blog back in January of 2006. We’ve come a long way since then with Vista being the top open source EHR in the hospital world and OpenEMR leading the pack in the ambulatory world.
We’re starting to see more and more application of open source technology in other areas of healthcare IT beyond EMR as well. There are some really amazing advantages to a thriving open source community. I think the key there is to have a thriving open source community behind the project. It’s not enough to just say that your software is open source. If you don’t have a great community behind the project, then the open source piece doesn’t do too much for you.
With that said, I was really intrigued by this whitepaper from Achieve Health that talks about why they are applying the popular open source Drupal framework to healthcare. While I’ve mostly used WordPress for the things I’ve done, I’ve had a chance to use Drupal for a few projects and I’m really intrigued by the idea of applying the Drupal framework to healthcare.
This section of the whitepaper describes their vision really well:
Drupal is not a replacement for legacy IT systems from EMRs, Billing, Practice Management etc., but rather an extension to these systems. Through sophisticated integrations Drupal can enhance the functionality of each system concurrently. While there is no one panacea for the trials ahead, Drupal is highly capable of rising to meet many of the existing and future challenges the industry has to offer.
In the whitepaper they mention open source success stories like Pfizer, Florida Hospitals, Amerigroup Health Services, and Alliance Imaging. I think we’ll continue to hear of more and more open source success stories in healthcare for the reasons outlined in the whitepaper Harnessing Open Source Technology to Drive Outcomes in Healthcare. It takes a bit of a different mentality to go the open source route, but those who do are usually very satisfied. I think healthcare IT could really benefit from this shift in mentality.
I’m a big fan of the online world. I love the ease of online banking, the efficiency of Zappos shoe shopping, and the simplicity of reading The Drudge Report for all the latest news. Someday I may also be a huge enthusiast for online patient portals, but that’s not quite the case today.
During the workday I rarely think about mundane tasks such as scheduling physicals or calling the eye doctor to order new contacts. I am more likely to recall that my daughter needs a follow-up appointment with the ENT when I notice her taking off her hearing aid for the night. Or, I’ll remember it’s time for a mammogram while sharing a bottle of wine with girlfriends and someone mentions the joys of her most recent scan. That last one happens a lot, actually.
I’d like to think I am the quintessential candidate for online patient portals: busy single mom who works full-time and is tech-savvy. I have little patience for being placed on hold for 10 minutes while listening to an endlessly looping recording about the importance of my call. I’d much rather schedule a doctor’s appointment with a few clicks on my keyboard while sipping my first cup of coffee. I get annoyed when my only communication option is to wait until the office opens at 9:00 a.m., navigate the automated phone system, listen to on-hold messages, and finally exchange forced pleasantries with a multi-tasking receptionist.
Recently I had a very positive experience using my primary care physician’s patient portal. One of my specialists requested a copy of my PCP’s referral form in order to schedule a new appointment. I accessed the PCP’s patient portal and in about two minutes found the referral and requested a copy to be forwarded to the specialist. The next day the specialist’s office called to say they had the referral in hand.
Other recent patient portal attempts have been a bit less successful. Typically if I need to schedule any type of medical appointment, I first go to the practice’s website and determine if they have an online scheduling option. That’s what I did a couple of months ago to schedule an appointment for my daughter and the whole process worked beautifully: the system asked for my preferred days and times; the next day I had an email informing me to check to practice’s portal for a message; the message informed me of the appointment time, which I then confirmed.
Unfortunately, a couple of days later my daughter reminded me of a conflict. So, back to the portal I went to send a new message requesting a reschedule. After several days I realized no one had responded to my message. I sent a second message. Again, no response. I ended up having to call the office, navigate the automated phone system, listen to on-hold messages, and finally exchange forced pleasantries with a multi-tasking receptionist.
Another one of my physicians uses a patient portal but its functionality is limited. For example, I am able to request an appointment with preferred dates and times, but rather than having an automated response, someone calls me back to finalize the appointment time. It beats having to call the office and being placed on hold, but if I miss the call or am driving, it’s back to the old-fashioned telephone method.
I often hear providers complain about the Stage 2 Meaningful Use requirement that at least five percent of patients view or download their personal health information via an online portal. Many argue the threshold is too high because many patients lack Internet access or computer expertise, or simply prefer communicating with a live person. However, I’d contend that providers are not doing themselves any favors by implementing poorly designed portals with limited functionality. As a patient, I wonder why I should use a portal if it doesn’t eliminate having to call the practice. I worry that my messages are getting “lost” – either due to technical glitches or office workflow issues. I get frustrated with confusing navigation and functionality that can’t hold a candle to what my veterinarian offers.
In a world where we can spend 10 minutes online and pay a month’s worth of bills, buy a pair of shoes, and read the day’s headlines, why is the healthcare industry so far behind in its efforts to provide patients with a consistently efficient online experience?
Living in Las Vegas I likely have a skewed idea of what customer service means. In the tech world, we have Zappos headquarters in downtown Las Vegas. Most of you are likely familiar with Zappos unique approach to customer service. They really have taken customer service to the next level and created an entire company culture around the customer service they provide. The same could be said for the experience that the various casinos on the strip offer their customers. They do a really amazing job at most casinos providing an amazing customer service experience.
With this background, I find it really smart of Kareo to open an office in Las Vegas. Although, that’s not really the point of this post. Instead, I want to focus on the idea that most EHR vendors need expand their idea of customer service.
As I look at the world of EHR customer service I see so many organization lacking. Certainly we see examples of terrible EHR customer service that include calling into a call center in another country where the person doesn’t speak English and has no power to actually solve a user’s problems (Disclaimer: I don’t have a problem with call centers in other countries if they are well trained and can actually solve problems). Of course, the same thing can apply to a call center in the US who can’t solve the users’ actual problems. Both are terrible customer service and a problem in the industry. However, there’s a far more painful problem that I don’t think most EHR vendors consider a part of their customer service plan and 99% of EHR vendors have done terrible at this.
Adding new features and accommodating an EHR user’s feature request is just as much a part of the EHR customer service experience as the person who answers the phone. I can assure you that every EHR vendor out there would get rated an F the past few years when it comes to this form of EHR customer service. Why do I know this? I know this because every EHR vendor has been focused on meaningful use that they haven’t had the time to add any meaningful EHR user feature requests and features outside of meaningful use.
This isn’t EHR vendors’ fault. The end users have required it and EHR vendors have had to spend the time doing it. However, EHR customer service has suffered as a consequence. Don’t believe me. Look through all the EHR press releases that have been released over the past couple years. Find me the plethora of press releases that talk about the innovations that EHR vendors have created for their end users that aren’t related to meaningful use. I get the press releases and they’re MIA.
That’s not to say that EHR vendors have done nothing for end users. They’ve made some incremental progress on a few things, but meaningful use has zapped their development time. Stage 2 was even worse. I look forward to the new day where EHR vendors can focus on great customer service and EHR features and not just MU.
Free-standing emergency rooms seem to be emerging as a new category of healthcare facilities, at least in New York City. This according to a recent article about this trend (see: E.R., Not a Hospital, Is Set to Open at St. Vincent’s Site). Below is an excerpt from the article:
The shiplike building on Seventh Avenue that used to house part of St. Vincent's Hospital is reopening in the coming days as a stand-alone emergency room and medical care center....The new E.R. [called HealthPlex], however, is part of a trend that has as much to do with a hospital’s bottom line as it does with providing acute care. Free-standing emergency rooms...have sprouted up around the country in recent years, driven by competition to capture lucrative markets, like the neighborhoods around Greenwich Village. Operators of free-standing emergency rooms....say they fill an important void in areas without full hospitals. They can bring in significant revenue, since they are allowed to charge the same high fees that hospitals charge while having lower overhead. And, since half of admissions come from the emergency room, free-standing E.R.s can funnel patient business to their parent hospitals....The first free-standing emergency room in New York State opened in the Bronx last year, and three more have opened since....Operators of free-standing emergency rooms like the HealthPlex say they fill an important void in areas without full hospitals. But the HealthPlex also appears designed to be an advertisement for the larger North Shore system, and to attract the kind of wealthy West Village residents who avoided St. Vincent’s....Ambulances will not bring patients suffering major trauma, head or spinal cord injuries, heart attacks, acute strokes, psychiatric disturbance or pregnancy-related complications, among other maladies, to the HealthPlex. But...[a hospital representative] said that if someone with any of these conditions walked through the door, the doctors at the HealthPlex would do everything that would be done in a hospital-based emergency room to stabilize the person and then transfer the patient by ambulance to the nearest appropriate hospital....Dr. Howard Mell, a spokesman for the American College of Emergency Physicians, said that in about 1 percent of cases, minutes could make the difference between a good outcome and a bad one, and the extra time for the transfer might be detrimental. But, he said, there were also cases in which getting to an emergency room sooner — because a free-standing emergency room had opened in an area that lacked a hospital — could be lifesaving.
So, like many initiatives in healthcare, the quest for increased revenue seems to be one of the main drivers in the development of free-standing ERs. The hospital systems that own them are allowed to charge the same rates for services as they do in the case of an embedded hospital ER. However, free-standing ERs don't incur the cost of expensive inpatient units such as the critical care units. They thus benefit from higher profit higher margins while, at the same time, providing the opportunity for inpatient admissions to nearby local hospitals within their system. Residents of the neighborhood benefit from rapid attention if they have a acute medical issues but suffer from the disadvantage of needing to then be transported to an inpatient facility for further treatment.
As I have pointed out in previous notes, we now have the following continuum for routine to emergent healthcare in larger cities: office visit to a PCP or visit a walk-in clinic for simple matters > urgent care clinics for minor injuries or illnesses > free-standing ERs for serious problems (these may require transport to a nearby hospital) > typical hospital ER visit with possible inpatient admission. There is also a gradient of cost across these facilities. This is important for patients with no health insurance or a high-deductible policy to understand. Urgent care facilities provide treatment at a fraction of ER costs (see: Rapid Growth of Urgent Care Clinics; Cost Competition for Hospital ERs). This complex health delivery system puts pressure on consumers who often need to perform self-triage in order to get themselves to the best facility for their problem.