Given the number of breaches we’ve seen this Summer at healthcare institutions, I’ve just spent a ton of time recently on several engineering engagements looking at “HIPAA compliant” encryption (HIPAA compliance is in quotes since it’s generally meaningless). Since I’ve heard a number of developers say “we’re HIPAA compliant because we encrypt our data” I wanted to take a moment to unbundle that statement and make sure we all understand what that means. Cryptology in general and encryption specifically are difficult to accomplish; CISOs, CIOs, HIPAA compliance officers shouldn’t just believe vendors who say “we encrypt our data” without asking for elaboration in these areas:
When you look at encrypting data, it’s not just “in transit” or “at rest” but can be in transiting or resting in a variety of places.
If you care about security, ask for the details.
If you wonder where I’ve been, I’ve, for one thing, been blogging a bit for (very little) pay over at Forbes.com and writing a lengthy cover story for the September issue of Healthcare IT News.
The Healthcare IT News piece actually breaks down into a fairly short lead story and several sidebars, which aren’t all that evident from the traditional Web version. (The digital edition has everything.) For the sake of convenience, here are links to all elements of the cover package:
Happy reading, and happy Labor Day weekend.
As most of you know, I’ve been regularly trying to feature other Health IT and EHR bloggers out there. A lot of them are creating some really great content and I’m always happy when there are more smart people joining in on the healthcare IT conversation. I hope you enjoy discovering some new blogs that might help you in your work.
Meaningful Health IT News – This is Neil Versel’s healthcare IT blog. Neil is the most prolific healthcare IT journalist out there having written for pretty much every healthcare IT publication over the past couple decades. I’ve mentioned before that Neil’s blog was one of the first ones I looked to when I started writing a blog. I modeled some of the things I do after him. I figured he was a real journalist and I wasn’t, so I should learn from him. I should disclose that Neil’s blog is part of the Healthcare Scene network of blogs. I’m lucky to be able to work with someone like Neil. I only wish he had more time to write on his blog.
Data 4 U – This is a new health IT blog by Lynn Zahner, a former obstetrician/gynecologist, who’s transforming into a health IT professional. Looking at even just the first 3 posts I’m excited to see what Lynn will bring next. It’s always great to have a clinician’s perspective on healthcare IT. I hope Lynn’s able to keep it up.
Kat’s Space – Kat’s blog is a new find for me. She’s a RN and digital marketing interested in tech and social media. It’s too bad I hadn’t found her before now. Sounds like we’d get along really well. She’s also a Google Glass explorer and so she provides some really interesting insights into the Glass and wearable technology space.
Accountable Health – I think we can all use a great accountable health blog. In fact, we can likely use more than one to try and figure out what’s happening with ACOs and other accountable care programs that are in the works. This blog is written by Fred Goldstein. Fred has a unique view of the accountable care world since he’s the Founder of the Population Health Alliance. I think Fred’s blog is one to watch if you care about where healthcare reimbursement is headed.
September arrives next Monday, signifying for most the end of summer, which means families with children are starting to settle back into a steady schedule and routine that allows for more consistent time to focus on work, on learning, and on reaching the end of 2014 on a positive note.
Here at HL7standards.com we have always operated under the principal of “Engaging conversations on healthcare and technology.” We work to accomplish this through our blog posts that span the wide swath of healthcare technology and through social media interaction that is more conversational and collaborative as opposed to a preacher with a bullhorn.
Our collaborative approach is best illustrated through our weekly #HITsm Tweetchats, which involve thoughtful discussions on topics that seemingly cover each “silo” of healthcare technology. If we’re not learning from each other through technology then we’re not social, we’re not curious, and we’re probably not very interesting, in my opinion.
It is with this collaborative and learning spirit that I am pleased to announce a new project I’ve dubbed “20 Questions for Health IT.”
We hope this project, which covers the entire month of September, will take the interaction of our social media discussions one step deeper and allow more time to discuss 20 different topics currently influencing the health IT industry.
Beginning Tuesday, Sept. 2., we will begin publishing one health IT topic per day from 20 different individuals with a deep understanding of the topic. The author of each question was generous enough to stick her or his neck out and pose a short answer to the question in the hopes it will encourage further discussion in the comments section and also on Twitter using the #20HIT tag.
So stay tuned next week as we launch into a month-long discussion that hopefully will educate and just maybe lead to a breakthrough idea that will evolve into something bigger.
Special thanks to each contributor
Sept. 2. Chad Johnson
Sept. 3. Don Fluckinger
Sept. 4. Michelle Ronan Noteboom
Sept. 5. Bernadette Keefe, MD
Sept. 8. Leonard Kish
Sept. 9. Greg Meyer
Sept. 10. Nick van Terheyden, MD
Sept. 11. Hubert Zajicek, MD
Sept. 12. Angela Dunn
Sept. 15. Rob Brull
Sept. 16. Mandi Bishop
Sept. 17. David Muntz
Sept. 18. Grahame Grieve & Rasu Shrestha, MD (Two for National Health IT Week)
Sept. 19. Scott Mace
Sept. 22. Jon Mertz
Sept. 23. Jenn Dennard
Sept. 24. Steven Posnack
Sept. 25. Vince Kuraitis
Sept. 26. Brian Eastwood
Dates subject to change
I have blogged before about the shrinking residency and job opportunities in radiology (see: Job Prospects Dimming for Residents in Radiology; Defining the Underlying Problems; Radiology Jobs Trend Downward; Blame Technology and Reimbursement). Also see this: Job Prospects Are Dimming for Radiology Trainees. This seems to be the result of a number of factors including: (1) incumbent radiologists are able to work more efficiently due to RIS/PACS support; (2) some radiologists have reportedly postponed their retirement due to the financial downturn in 2008; (3) teleradiology enabled some radiologists to find part-time or full-time positions working from home; (4) teleradiology has also enabled some hospitals to outsource their radiology departments to "nighthawk" firms (see: Dayhawk Radiology and the Decline of the General Radiologist). Below is an excerpt from a recent article on this topic (see: Radiologists Having a Hard Time Finding Residency As Teleradiology Takes Over “Day” Jobs):
Radiologists and orthopedic surgeons are still at the top of the doctor occupation chain but those jobs too are facing reimbursement cuts. In [one hospital], which is losing money, ...[radiology residents]... were given their pink slips. The hospital is ending the residency program and is going with Teleradiology that reads images remotely. So these students need to look elsewhere to finish their post graduate training. The next obstacle is getting a job as if this hospital is relying more on remote image reading....Medicare too has made cuts with radiology reimbursements in order to shift more over to primary care, which is not a bad thing, except when you have the remote services coming in and replacing them instead of less income....Anesthesiologists, facing competition from nurse anesthetists and California just passed a law to allow more use with nurses with anesthesia. Dermatology and Ophthalmology are the only two entities that are seeing an increase or staying level....For years, medical students who chose a residency in radiology were said to be on the ROAD to happiness. The acronym highlighted the specialties — radiology, ophthalmology, anesthesiology and dermatology — said to promise the best lifestyle for doctors, including the most money for the least grueling work.....Radiologists still make twice as much as family doctors, but are high on the list of specialists whose incomes are in steepest decline....On Internet forums, younger radiology residents agonize about whether it is too late to switch tracks....Though outsourcing to India grabbed headlines, the big growth in teleradiology was domestic. Now the nighthawk companies, staffed by recent radiology graduates, are competing for the daytime work, too. One hospital, McLaren Macomb, in suburban Detroit, instead offered several residents slots in its “unfunded program,” in which most radiology residents essentially pay for their own positions through donations, typically from a spouse or parents: $65,000 a year to cover a $42,000 salary and $2,000 for expenses.
There is some irony in the fact that the field of radiology, as a ROAD medical specialty (see above), is attractive to medical students for reasons of lifestyle. However, the better hours and more sedentary demands of the specialty also enabled some older radiologists to remain in their positions past the usual retirement age. One radiologist told me that he was working twice as hard to maintain the same income and that his RIS/PACS systems have enabled him to do this.
When writing this note, my mind was drawn to the field of interventional radiology that has been booming for years. I think that this continues to be the case. There is one cloud on this horizon, however, for radiologists. As intravascular approaches to certain lesions such as abdominal aneurysms becomes more common (see: Endovascular Grafts for Abdominal Aortic Aneurysms), some surgeons will be also be learning these techniques. For example, the Integrated Pathway of the American Association of Thoracic Surgery includes a rotation in interventional radiology.
A few weeks ago, I wrote about engaged patients and how they had lower healthcare costs and better health outcomes. While there is no one official definition of patient engagement, I see engaged patients as those who are interested in their health outcomes and who actively participate in their care by working with their healthcare providers to create goals.
Most healthcare professionals can attest that not all patients are necessarily engaged in their care. Some patients are very interested in achieving goals and outcomes and others don’t seem at all interested in participating in their care. How do we get those in the second group to become more participatory and invested in their care? Interactive patient care might be one way to get them on board.
Interactive patient care is a means of providing education to patients through technology like mobile devices and televisions. Interactive patient care allows patients to be active participants in their care rather than just passive recipients of information and instructions.
A June 2014 article in Healthcare Finance News, gives an example of interactive patient care at work. Boston’s South Shore Hospital and Brigham and Women’s Hospital created a pilot project that used a mobile application to connect with cardiac rehabilitation patients. The app allowed patients to check daily to-do lists, to log exercise, to remind themselves to take medications, and to interact directly with clinicians. The project appears to have improved patient engagement and interaction. In the article, South Shore nurse manager Karen LaFond explained that while cardiac rehabilitation programs have been shown to decrease mortality rates, many patients don’t take part in them. However, patient retention and compliance with cardiac rehabilitation care plans have significantly improved when using mobile applications.
Another example of interactive patient care is GetWell Network’s pediatric tool GetWell Town.It was developed to help patients and families learn and play during their hospital stay. GetWell Town can be accessed at the patient’s bedside through an iPad or television and offers age-appropriate entertainment, education and other content. The system covers information on topics like asthma, diabetes and various procedures. The GetWell website describes the presentation of information as “colorful and interactive.” It certainly grabbed the attention of my 3-year-old who saw the website over my shoulder as I was typing this and asked, “Can we play that?”
Play, while not always technology based, is the ultimate form of interactivity and one physician is combining technology with old school play to combat childhood obesity. Dr. Robert Zarr’s, a Washington, D.C.-based pediatrician, approach to managing obesity was featured on NPR in July. To get children to increase their activity, he writes prescriptions for daily play and activity. To make the prescriptions more specific, he has mapped out all of the district’s 380 parks and developed a searchable database that can be linked to patients’ medical records.
Think about ways we can make health promotion fun. Wouldn’t having a cooking contest along the lines of Chopped (where you are provided mystery ingredients and have to create a great tasting dish) for diabetic patients be more interesting than just handing them a piece of paper that tells them to keep their carbs under a certain number per day? It might inspire them to get creative and have fun in their own kitchens coming up with recipes that meet dietary requirements. And that would help them better adhere to their diets.
Interactivity, and not just technological interactivity, may be the secret to getting patients engaged. Doing is infinitely more interesting than being talked at or just handed information. That’s why we do science experiments in school. Theory is one thing but seeing an idea in action, and being a part of that action, makes the concepts so much more concrete. Making the action fun just adds to the chances of success. That’s why nursery rhymes and the ABC song have been used as learning tools for decades.
My generation was raised on video games, even if it was Galaga and Ms. Pac-Man. My daughter’s generation is being raised on smart phone apps and tablet computers. We like technology that can provide us with fun and feedback. And no matter what age you are – from 80 to 8 – when learning is fun, no matter what form it takes, the information tends to stick and this leads to better health outcomes.
The following is a guest blog post by Art Gross, Founder of HIPAA Secure Now!.
Ask any medical professional about their biggest concern for protecting patient information and they will probably tell you about the threat of a random audit conducted by the Office of Civil Rights (OCR). OCR is tasked with enforcing HIPAA regulations and has the ability to hand out fines up to $1.5 million per violation for a HIPAA breach and failing to comply with HIPAA regulations.
With recent fines of $4.8 million handed out to New York and Presbyterian Hospital and $1.7 million fine to Concentra Health Services, physicians have good reason to worry. These massive fines were levied not as the result of a random audit, but for the mandatory reporting of patient data breaches to the Department of Health and Human Services (HHS), and the investigation that followed. So physicians need to reconsider where their real concerns should lie.
The 2013 Cost of a Data Breach Study by the Ponemon Institute calculated lost or stolen patient records at $233 per record. Let’s take a look at how quickly the cost of a HIPAA breach can add up:
|# of Records Breached||Cost|
The cost of the recent Community Health Systems 4.5 million patient records breach could cost more than $1 billion!
Whether a medical provider loses 1,000 or 10,000 patient records the financial impact could easily set back the organization or even put it out of business. But the “hidden cost” of a HIPAA breach that shouldn’t be overlooked is the damage to the provider’s reputation, lost trust from patients and the resulting sharp decline in revenues.
Lost patient records sparks negative publicity. Take Phoenix Cardiac Surgery (PCS) for example. The Arizona medical practice with five physicians got slapped with a $100,000 fine for a HIPAA breach in 2012. A current search on Google returns the practice’s website plus 28 links to negative news stories related to the HIPAA fine. The consequences? A patient searching a referred cardiac surgeon from PCS finds the negative publicity and decides to continue searching for another surgeon. Or, an existing patient of PCS decides to look for another medical practice that takes every measure to safeguard his privacy.
Other Cost Factors
Beyond revenue loss and a damaged reputation are the direct overhead costs associated with a breach. The cost of discovering and stopping a breach may involve IT services, forensic investigative services to determine which systems and patients were affected, and legal counsel if patients file a lawsuit. There are also hard costs associated with notifying patients affected by the breach, including time spent to pull together their contact information, mailing out notifications and providing toll-free inbound phone numbers to handle complaints. Most organizations also provide identity and credit monitoring services for affected patients. All of these expenses add up, not to mention the cost of lost productivity due to the diverted attention of employees tasked with managing these processes.
Today it’s not uncommon for laptops, tablets and USB drives with patient records to disappear. Or, for crime rings to hack into EHR systems to steal patient information and commit tax fraud, and for meth dealers to steal patient identities to obtain prescriptions. If a large hospital system can lose 4.5 million patient records think how easy it is for a hacker to grab thousands of patient records from smaller medical practices and turn them into cash. The threat of a HIPAA breach has never been greater and all organizations should take heed.
Risk Assessment as a First Step
Healthcare organizations, particularly smaller medical practices, should perform a HIPAA risk assessment to look at where patient information is stored and accessed, and how the organization protects that information. It examines the risks of a breach and recommends steps to lower them. Without performing a risk assessment an organization may be lulled into a false sense of security, mistakenly believing they won’t suffer the consequences of a HIPAA breach. At $233 per lost or stolen record that could be a costly miscalculation.
About Art Gross
Art Gross co-founded Entegration, Inc. in 2000 and serves as President and CEO. As Entegration’s medical clients adopted EHR technology Gross recognized the need to help them protect patient data and comply with complex HIPAA security regulations. Leveraging his experience supporting medical practices, in-depth knowledge of HIPAA compliance and security, and IT technology, Gross started his second company HIPAA Secure Now! to focus on the unique IT requirements of medical practices. Email Art at email@example.com.
Full Disclosure: HIPAA Secure Now! is an advertiser on EMR and HIPAA.
During my early years in pathology informatics, I was constantly reminded of the challenge of two hospitals merging with different LISs. The problem was usually resolved in one of two ways. The first was that the two merged hospitals continued to operate the their two different LISs but with some makeshift attempt to view lab results across the two institutions. The second and more common approach was to rip out one of the LISs and replace it with the brand running in the other. All of these previous problems of IT integration are now compounded in this era of complex and expensive EHRs. Here's an article discussing how M&A costs can be boosted significantly by IT integration demands (see: Hospital M&A Cost Boosted Significantly By Health IT Integration). Below is an excerpt from it:
Most of the time, hospital M&A is sold as an exercise in saving money by reducing overhead and leveraging shared strengths. But new data from PricewaterhouseCoopers suggests that IT integration costs can undercut that goal substantially.....[T]he cost of integrating the IT systems of hospitals that merge can add up to 2% to the annual operating costs of the facilities during the integration period, according to PricewaterhouseCoopers. That figure, which comes to $70,000 to $100,000 per bed over three to five years, is enough to reduce or even completely negate benefits of doing some deals. And it clearly forces merging hospitals to think through their respective IT strategies far more thoroughly than they might anticipated...[O]ther experts feel that PwC is understating the case...[One of them said that] IT integration costs can be much higher than those predicted by PwC’s estimate. “I think 2% being very generous,” ...[he said] “For example, if the purchased hospital’s IT infrastructure is in bad shape, the expense of replacing it will raise costs significantly.” Of course, hospitals have always struggled to integrate systems when they merge, but as PwC research notes, there’s a lot more integrate these days, including not only core clinical and business operating systems but also EMRs, population health management tools and data analytics.... And what if the merging hospitals use different enterprise EMR systems? Do you rip and replace, integrate and pray, or do some mix of the above? On top of all that, working hospital systems have to make sure they have enough IT staffers available, or can contract with enough, to do a good job of the integration process.
What are the reasons why two hospitals in the same city or region decide to merge? It's often a case of the stronger system absorbing the weaker one (see: Some Hospitals Experiencing Financial Distress and Even Bankruptcy). Of course, lurking in the background of all potential hospital mergers is always the notion that substantial savings can be achieved. Such savings, at least in the past, were anticipated with the creation of single IT and HR units. Consolidated labs were often also under consideration. However, this article (and past experience on my part) suggests that the anticipated IT savings are often illusory. This point is well illustrated by the excerpt above.
Added to this IT stew is the challenge of converting the previous LIS or EHR database of the abandoned systems to the systems used by the dominant hospital partner in the merger. I know of one company, Ellkay, that specializes in such structured conversions. Below an interesting quote from the home page of another data migration company, Informatica. Of course, hiring consultants to supervise data migration activities will only add to the hospital merger costs discussed above.
Gartner has reported that 80 percent of data migration projects fail to meet expectations, running over time and budget. This is in large part due to common misconceptions about the migration data, including electronic health record data: it complies with a standardized format; users have captured it in expected fields; and it's all valid and of high quality. But the reality is, complex patient, member, and provider data exist in various formats, anticipated data is missing, and data quality is inconsistent. When healthcare organizations hand-code or write one-off processes to migrate legacy data from electronic health records and applications, they are doing so to move millions of pieces of data, likely spot-checking only a small subset. As a result, data are moved into a new application with minimal review.
About 10 months ago, we added Healthcare IT Central to the Healthcare Scene family of healthcare IT websites. It’s been a really amazing addition to the network and I’ve been amazed at the thousands of people that have been able to find health IT jobs thanks to Healthcare IT Central. I love blogging because you get the direct interaction with readers, but there’s a really amazing feeling that comes when you play some small role in helping someone find a job.
The other great part about the addition of Healthcare IT Central is the related Healthcare IT Today career blog. If you’re not reading that site, we just added it to our Healthcare Scene email subscription lists so you can receive the latest posts in your email inbox.
Just to give you a little flavor of the type of content we’ve been posting on Healthcare IT Today, we asked the questions, “Has There Been an EHR Consulting Slow Down?” and “Who’s More Satisfied – Full Time Health IT Professionals or Health IT Consultants?” Plus, we even posted really interesting data like a look at the Epic Salary and Bonus structure. Then, since it is a healthcare IT career website, we cover things like LinkedIn tips and LinkedIn as a professional or personal profile.
If you’re someone looking for a healthcare IT job or looking for a better healthcare IT job, we have hundreds of health IT jobs available. You might also check out Cordea Consulting, ESD, and Greythorn that recently posted jobs with us.
If those jobs aren’t your style we have other jobs like this Sales Account Executive at EHR vendor, gMed, or these system analyst jobs at Hathaway-Sycamores Child Family Services and Pentucket Medical.
If you’re an employer looking for amazing healthcare IT professionals, you can register for the site and post your jobs or search our database of over 12,000 active health IT resumes.
Hopefully some of these health IT career resources are helpful to readers of EMR and HIPAA. One thing that’s universal in healthcare is the need to find a job or hire the right talent. Hopefully we’re doing are part to help both sides of the coin.
It is apparent as we move toward value-based care and payments, that health care is dependent on so much more than what we would consider care. It’s not all up to the provider nor up to the individual patient, there’s a wide network of costs and influences from genetics to nutrition.
As we move toward digital health and digital payments, the relationships between spending, environment, and other health determinants are becoming clearer, affecting the choices we make at any moment. Behavioral choices are often driven by the social determinants of health, the cultural and economic contexts (including geography) of our day-to-day decisions.
Many things, of course, influence health and outcomes and our need for care, including, genetics, behavioral choices (smoking, drugs, alcohol, unprotected sex, obesity, preventative care, exercise, taking prescribed medications, sugar intake and nutrition), access to care, capabilities to care for oneself and many other risks.
While we tend to think in terms of science and individuals controlling outcomes, that’s at the very least a bit of hubris on the part of science. Zip codes were recently declared better at predicting outcomes than genetic codes (hat tip to Cyndy Nayer).
And these social influences are becoming better understood, because we are getting better at measuring them, with access to better data, as a byproduct of ubiquitous connectivity (although extent of connectivity is often correlated with zip code as well). We often assume that it’s all up to the individual, but most of what we do is a combination of many things including marketing, education, costs, and culture. As we spend more time online, those influences become both greater and more measurable. Tremendous value will be seen once we understand these decisions and why people make them, including social, economic and geographic influences in the context of vast networks of influences.
The impact numbers of personal choice and behavior related to health and health care spending, when you dig in, are pretty staggering, and perhaps, devastating for our financial outlook.
“Consumption of junk food (for example a Twinkie or a sugary drink) is akin to a financial exchange where short-term gains are privatized and long-term costs are socialized in the form of horrific health outcomes. The metabolic donkeys – consumers – pay relatively little money and turn a blind eye to the health consequences of their food choices – instead hoisting the fantastic profits of companies like Monster and opting for a shortened, diseased life.”
In the Forbes article, Munro estimates that sugar may be costing the U.S. healthcare system $1 trillion. That’s 25% of healthcare’s overall $4 trillion. Estimates are that Americans eat 70 lbs of sugar a year. Even at a rather high price of $1 a pound (commodity prices are around 15 cents per pound), that’s only about $25 billion that we spend on sugar as a country for the ingredient itself (certainly we pay much more for it when it comes in a soda or Monster beverage, or myriad of other products). So the costs of sugar to the healthcare system are on the order of 40 times higher than the price of sugar itself. Sugar, or a cigarette, is very small down payment on future health costs.
Prices and financial incentives are too often left out of the equation because we haven’t found the right mix. Offering salads at McDonald’s might not work, we don’t go to McDonald’s for salads, wrong context. Low-income women, on the other hand, might be incentivized to buy and eat vegetables, and at least in limited contexts, we do see that vouchers like this can work.
Carolyn Dimitri, an applied economist at New York University, tested whether farmer’s markets vouchers would not only encourage low-income women to buy and eat more vegetables using vouchers and measuring with surveys. They found that vouchers not only encouraged the purchasing, but also the consumption of more vegetables.
According to Pacific Standard’s write-up of the article, “..this suggests that disadvantaged families may eat fewer vegetables not because of preferences or education but because of access…(and possibly) economic scarcity and its psychological effects.”
To truly understand the health system, not just the healthcare system, we’ll need to understand decisions and incentives around food. Patient engagement has direct effects on health outcomes and health spending, as has been shown many times. How closely tied is nutrition to outcomes? Certainly it’s more long-term, but we need to understand correlations and causations much sooner.
Could providers or payers benefit by providing nutritional vouchers? Is there an app or technological solution that works for reducing sugar intake?
This is one area of mobile health and app development we hear little about, despite the fact that diabetes, prediabetes, and metabolic syndrome affect more than 40% of Americans, or over 100 million people. These are Americans that will have long-term health consequences and costs.
Why aren’t we doing more to help? Is it just too hard? Is our sugar addiction just too strong? What will Apple do now that they are including Healthkit in IOS8? What can Stikk do to improve on sugar intake?
This may be one of the most difficult, but also one of the most valuable, quests in healthcare.
Who else stands to benefit from reducing the $1 trillion in sugar-related health spending? How quickly can nutritions steer some of that money, much larger than that spent on sugar, toward better health and better nutritional decisions?
Moving just a little bit of the money we spend on sugar and on sugar-related diseases will pay enormous dividends in quality of life and cost of care. At VivaPhi, we’re rolling with the Center of Health Engagement, driving new incentive programs to drive better engagement and better health. Have an idea for how to create these kinds of incentives for healthier choices? We want to hear them.
Lab industry observers have long suggested that that the 23andMe business model ultimately involved selling anonymized client genomic data to the deep-pockets pharmaceutical industry (see: 23andMe as an Example of "Big Bang" Market Disruption; 23andMe Builds Online Sarcoma Research Community). This model required abundant capital up-front to attract clients with a relatively low lab testing cost. At some point, it's even possible for these costs to drop to zero but this might arouse suspicion and reveal more about the business model than was necessary. At any rate, a recent article discussed a new relationship between Pfizer and 23andMe to study the genetics of inflammatory bowel disease (IBD) (see: Pfizer, 23andMe Team up to Study Bowel Disease). Below is an excerpt from the article:
Pfizer is teaming up with DNA testing company 23andMe to study the possible genetic underpinnings of inflammatory bowel disease, a hard-to-treat ailment that affects an estimated 1.4 million Americans. Under the agreement, Silicon Valley-based 23andMe will map the DNA of 10,000 patients who have forms of the disease, which include Crohn's disease and ulcerative colitis. Patients will submit saliva samples using 23andMe's at-home collection kit and then fill out online questionnaires about their disease and symptoms. The companies hope to identify genetic similarities among patients with the disease, which could eventually guide development of new targeted drugs ....The cause of inflammatory bowel disease is unknown, though many scientists suspect genetics play a role....Financial terms of the agreement were not disclosed. 23andMe....has penned two similar deals with drugmakers Genentech and Janssen Pharmaceuticals (see: 23andMe and Genentech Expand Cancer Study). The agreement brings Google-backed 23andMe one step further into the medical mainstream, after a widely publicized dispute with federal health regulators last year. In November, the Food and Drug Administration ordered 23andMe to stop marketing its health-related genetic tests, warning that erroneous results could cause customers to seek unnecessary or ineffective medical care. The agency said that even after numerous meetings and email exchanges with the company, government regulators still had no assurance that the firm has analytically or clinically validated its technology....Still, the FDA sanctions haven't stopped the company from partnering with other parts of the federal government. Two weeks ago the National Institutes of Health signed a $1.4 million agreement with 23andMe to access the company's DNA database to research rare diseases.
I got the sense from this article that 23andMe will proactively seek cell samples from "10,000 patients" with IBD. Their current company database may already include individuals who have self-declared that they have this disease but some of these data will be unreliable. So the question arises as to how 23andMe will identify and obtain samples from these 10,000 patients. The company would probably need to seek them from clinics, hospitals, or physician offices in order to obtain cell samples from patients with well documented disease.
For me, the most interesting part of the article is that while 23andMe seems to be still feuding with the FDA, the company has also cut a deal with the NIH to provide access to its DNA database by the agency. If the company database contained potentially erroneous results, why would be NIH be willing to purchase access to it for $1.4M? It's possible that this question can be answered in a relatively simple way. As noted above, the FDA's beef with 23andMe is simply that "erroneous results could cause customers to seek unnecessary or ineffective medical care." In other words, the FDA believes that it is protecting consumers. In comparison, the NIH is buying access to the 23andMe DNA database which it believes to be scientifically sound. If this speculation is correct, it seems to me that 23andMe should be able to generate a report for its clients that is not erroneous nor leads them to incorrect conclusions. Here is how I summed all of this up in a note of November 2013 about how the company might be able satisfy the FDA (see: The Dispute between the FDA and 23andMe; What's Really Going On?)
In the end, I suspect that 23andMe will need to print a strong warning label on its reports to the effect that the test results have little medical significance and must not be used to make any important diagnostic or treatment decisions by consumers without confirmation by a CLIA-certified lab and a qualified physician. I don't think that such a warning will hurt its business and consumers will continue to have access to interesting and useful genetic screening test results.
One of the most popular
battles discussions we’ve had on this site since the beginning is around client server EHR software versus cloud EHR software. It’s a really interesting discussion and much like our US political system, most people fall into one camp or the other and like to see the world from whatever ideology their company approaches.
The reality I’ve found is that there are pros and cons to each side. Certainly cloud has won out in most industries, but there are some compelling reasons why cloud hasn’t taken hold in many parts of healthcare.
With that in mind, a client server EHR vendor asked me to list out the reasons why someone should go with a Cloud EHR over client server. Here’s my off the cuff responses:
No IT Support Needed beyond desktop support – This is a big benefit that many like. Plus, they add in the cost of the server, the cost of the local IT person and so they see it as a huge benefit to go with cloud software
Automatic Updated Software – Not always true with the cloud, but they like that the software just updates and they don’t have to go around updating software. Of course, this also has its downsides (ie. when an update happens automatically and breaks something)
Small Upfront Cost – Most Cloud solutions are billed on a monthly charge with little to no upfront cost. We could argue the accounting pieces of this and whether it’s really any better, but it feels better even if many cloud providers require the 1-2 year commitment. In some large organizations this type of payment plan is better for their accounting as well (ie. depreciation of equipment, etc)
More Secure – Obviously this could be argued either way, but those that believe cloud is more secure believe that a cloud provider has more resources and expertise to make their cloud secure vs an in house server where no one might have expertise
More Reliable (backup/disaster recovery) – Similar to the secure argument as far as expertise and ability to provide this reliability
Single Database – There are cool things you can do with data when every doctor is on one database and one standard data structure.
Available Everywhere – At home, office, hospital, etc. (Yes, this can be done by many client server as well, but not usually with the same experience).
I’m sure that a cloud EHR provider could add to my list and I hope they will in the comments. As I was making the list, I wondered to myself if a client server EHR vendor could provide all of the benefits listed above. Let me go through each.
No IT Support Needed beyond desktop support – Some EHR vendors will do all the IT support for the user. Plus, it’s a little bit of a misnomer that you need no IT support with a cloud hosted EHR. You still need someone to service your network and computers. More importantly though, most client server EHR vendors are offering a hosted EHR option which basically provides this same benefit to a practice.
Automatic Updated Software – More and more client server vendors are moving to this approach for updates as well. This is particularly true when they offer a hosted EHR environment where they can easily update the EHR. It’s a different mentality for client server EHR vendors, but it can be done in the client server environment.
Small Upfront Cost – We’ve seen this same offer from almost all of the client server EHR companies. It’s a hard switch for EHR companies to make the change from large up front payments to reoccurring revenue, but I’m seeing it happening all over the industry. The only exception might be the big hospital EHR purchase. In the ambulatory EHR market, I think everyone offers the monthly payment option.
More Secure – This is one that could be argued either way. Either one could be more secure. Client Server vs Cloud EHR doesn’t determine the security. A client server EHR can be just as secure or even more secure than a cloud EHR. I agree that generally speaking, cloud EHR is probably more secure than client server, but that’s speaking very broadly. If you care about security, you can secure a client server EHR as much or more than a cloud EHR.
More Reliable (backup/disaster recovery) – Similar to secure, you can invest in a client server infrastructure that is just as reliable as a cloud EHR. It’s true that a cloud EHR vendor can invest more money in redundant systems usually. However, a client server EHR vendor that hosts the EHR could invest just as much.
Single Database – This is the one major challenge where I think client server has a much harder time than a single database cloud EHR provider. Sure, you can export the data from all of the client server EHR software into a single database in order to do queries across client server EHR installs. A few vendors are doing just that. So, I guess it’s possible, but it’s still not happening very many places and not across all the data yet.
Available Everywhere – This can be done by client server as well, but the experience is often a subset of the in office experience. Although, this is rapidly changing. Bandwidth and technology have gotten so good, that even a client server install can be done pretty much anywhere on any device.
Looking through this list, it makes a great case for why client server EHR software is going to be around for a long time to come. There’s nothing on the list that’s so compelling about cloud hosted EHR software that makes it a clear cut winner.
As I thought about this topic, I tried to understand why cloud’s been the clear cut winner in so many other areas of technology. The answer for me is that in our lives portability has mattered a lot more to us. In healthcare it hasn’t mattered as much. Plus, new client server technologies have been portable enough.
Long story short, I’m a fan of cloud technologies in general, but if I were a provider and a client server technology provided me more features, functions, better workflow, etc, than a cloud EHR, I wouldn’t be afraid to select a client server EHR either.
Also worth clarifying is that this post outlines how a client server EHR can provide all of the same benefits of a cloud EHR. However, just because a client server EHR can provide those benefits, doesn’t mean that they do. Many have chosen not to offer the above solutions. Although, the same goes for cloud EHR as well.
What do you think? Are there other reasons why cloud EHR technology is so much better than client server? Is there something I’ve missed? I look forward to reading your comments.
The new classification goes into effect in 45 days. In 2008 HHS received a petition to make this change and at that time the drugs were left as a Schedule III. A year later the DEA made the request once again to be re-evaluated.
The change was made due to the extreme abuse of the pain killers and the fact that they are addictive. The Federal Register has all the details on the change. Schedule 3 drug prescriptions expire 6 months after the day they are written. There’s more drugs on the Schedule III list than you think and you can take a look here for most of them, some are actually surprising. BD
“Almost 7 million Americans abuse controlled-substance prescription medications, including opioid painkillers, resulting in more deaths from prescription drug overdoses than auto accidents,” said Michele Leonhart, DEA administrator, in a press release. “Today’s action recognizes that these products are some of the most addictive and potentially dangerous prescription medications available.”
Schedule II drugs are substances with accepted medical uses that have a high potential for harm and abuse, according the Controlled Substances Act. Hydrocodone-combination products contain both hydrocodone (a Schedule II drug) and other ingredients like acetaminophen, and were originally classified as Schedule III drugs.
Well this should come as no surprise as we have seen United with their current Medicare Advantage networks with firing MDs who see senior patients, so here’s the next level up with offering a “narrow network” to employers. This serves to further drive down doctor reimbursement of course and there’s are not enough details to fully discuss. This is being offered via the United Oxford subsidiary. Employers will still have options on other plans but of course they will be more expensive so this is the new “budget” narrowed network option for New Jersey and one could maybe wonder when this option will arrive in other states. I would be a fool to think that it would just be a New Jersey offering only and I think it’s more of a pilot to see how it works.
The savings for employers, it states here is around 10% so cash strapped small companies would have some incentive to entertain this. The article didn’t mention exactly who all the members would be here in the Garden State Network but states that it includes 18,000 doctors and 65 hospitals so it sounds pretty inclusive, but just don’t go out of state is the message I read here as they can bundle up risk assessments all within one state.
Again we don’t know what the details are here that go along with an employer offering as far as co-pays, etc. for the full story. I can say one thing though that insurers did their bit on outfoxing CMS with their quant created mathematical formulas to over bill for around $70 billion with Medicare part D, that was all math and CMS doesn’t know what to do with that matter right now. BD
Chuck Cerniglia, vice president, small business sales for UnitedHealthcare, said employers on average will see 10 percent lower health insurance premiums if they choose the new health plans in the Garden State Network, which launches Sept. 1.
“It limits access to New Jersey-only providers and it is a solution for New Jersey employers where a smaller network offers a reduction in cost,” he said.
He added that employers will continue to have the option of offering their employees the company’s larger networks alongside the more limited — but also more affordable — Garden State network. He said while a New Jersey-only network won’t work for all employers, many clearly are seeking less-expensive health care options.
I’ve long been interested in voice recognition together with EHR software. In many ways it just makes sense to use voice recognition in healthcare. There was so much dictation in healthcare, that you’d think that the move to voice recognition would be the obvious move. The reality however has been quite different. There are those who love voice recognition and those who’ve hated it.
One of the major problems with voice recognition is how you integrate the popular EHR template documentation methods with voice. Sure, almost every EHR vendor can do free text boxes as well, but in order to get all the granular data it’s meant that doctors have done a mix of clicking a lot of boxes together with some voice recognition.
A few years ago, I started to see how EHR voice recognition could be different when I saw the Dragon Medical Enabled Chart Talk EHR. It was literally a night and day difference between dragon on other EHR software and the dragon embedded into Chart Talk. You could see so much more potential for voice documentation when it was deeply embedded into the EHR software.
Needless to say, I was intrigued when I was approached by the people at NoteSwift. They’d taken a number of EHR software: Allscripts Pro, Allscripts TouchWorks, Amazing Charts, and Aprima and deeply integrated voice into the EHR documentation experience. From my perspective, it was providing Chart Talk EHR like voice capabilities in a wide variety of EHR vendors.
To see what I mean, check out this demo video of NoteSwift integrated with Allscripts Pro:
You can see a similar voice recognition demo with Amazing Charts if you prefer. No doubt, one of the biggest complaints with EHR software is the number of clicks that are required. I’ve argued a number of times that number of clicks is not the issue people make it out to be. Or at least that the number of clicks can be offset with proper training and an EHR that provides quick and consistent responses to clicks (see my piano analogy and Not All EHR Clicks Are Evil posts). However, I’m still interested in ways to improve the efficiency of a doctor and voice recognition is one possibility.
I talked with a number of NoteSwift customers about their experience with the product. First, I was intrigued that the EHR vendors themselves are telling their customers about NoteSwift. That’s a pretty rare thing. When looking at adoption of NoteSwift by these practices, it seemed that doctor’s perceptions of voice recognition are carrying over to NoteSwift. I’ll be interested to see how this changes over time. Will the voice recognition doctors using NoteSwift start going home early with their charts done while the other doctors are still clicking away? Once that happens enough times, you can be sure the other doctors will take note.
One of the NoteSwift customers I talked to did note the following, “It does require them to take the time up front to set it up correctly and my guess is that this is the number one reason that some do not use NoteSwift.” I asked this same question of NoteSwift and they pointed to the Dragon training that’s long been required for voice recognition to be effective (although, Dragon has come a long way in this regard as well). While I think NoteSwift still has some learning curve, I think it’s likely easier to learn than Dragon because of how deeply integrated it is into the EHR software’s terminology.
I didn’t dig into the details of this, but NoteSwift suggested that it was less likely to break during an EHR upgrade as well. Master Dragon users will find this intriguing since they’ve likely had a macro break after their EHR gets upgraded.
I’ll be interested to watch this space evolve. I won’t be surprised if Nuance buys up NoteSwift once they’ve integrated with enough EHR vendors. Then, the tight NoteSwift voice integrations would come native with Dragon Medical. Seems like a good win win all around.
Looking into the future, I’ll be watching to see how new doctors approach documentation. Most of them can touch type and are use to clicking a lot. Will those new “digital native” doctors be interested in learning voice? Then again, many of them are using Siri and other voice recognition on their phone as well. So, you could make the case that they’re ready for voice enabled technologies.
My gut tells me that the majority of EHR users will still not opt for a voice enabled solution. Some just don’t feel comfortable with the technology at all. However, with advances like what NoteSwift is doing, it may open voice to a new set of users along with those who miss the days of dictation.
The Chilmark Research blog had this to say about Cerner's recently announced acquisition of Siemens' EHR (see: Big Fish Swallows Another – Will it Choke?):
Much of that future value is likely found in Cerner’s rapidly growing PHM activities (HealtheIntent). One of our analysts just came back from Cerner’s PHM Summit last week and was truly impressed with how aggressive Cerner is moving on this front. There is a huge untapped PHM market among existing Cerner clients and now Siemens clients – potentially huge up-sell opportunities if Cerner does it right.
John's slant on one of the rationales for the Cerner purchase was interesting. I had posted my own opinion about it but was not aware of the HealthIntent product (see: Speculation about the Rationale for the Cerner Purchase of Siemens IT). Below is an excerpt from the Cerner discussion of HealthIntent (see: Cerner has a comprehensive vision for Population Health Management built on the HealtheIntent platform.)
HealtheIntent is a multi-purpose, programmable platform designed to scale at a population level while facilitating health and care at a person and provider level. This cloud-based platform enables health care systems to aggregate, transform and reconcile data across the continuum of care. A longitudinal record is established, through that process, for individual members of the population that the organization is held accountable for; helping to improve outcomes and lower costs for health and care.
Here is another excerpt of a discussion about the general topic of PHM (see: Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare)
The goal of population health management (PHM) is to keep a patient population as healthy as possible, minimizing the need for expensive interventions such as emergency department visits, hospitalizations, imaging tests, and procedures. This not only lowers costs, but also redefines healthcare as an activity that encompasses far more than sick care. While PHM focuses partly on the high-risk patients who generate the majority of health costs, it systematically addresses the preventive and chronic care needs of every patient. Because the distribution of health risks changes over time, the objective is to modify the factors that make people sick or exacerbate their illnesses. Such an approach requires the use of automation. Not only are there not enough providers and care managers to manage every patient continuously, but PHM also involves a large number of routine tasks that do not have to be performed by human beings.
Driven, at least in part, by the emergence of accountable care organizations (ACOs) that are designed to manage large patient populations, there are now software packages like HealthIntent from Cerner designed to automate this task. My initial instinct was to wonder whether there was a real business need for this kind of software but I will reserve such judgements for now. Time will tell as to whether they are useful. I will readily concede that the design of most EHRs, like the paper chart that EHRs emulate, is to manage and optimize the care of individual patients. The second quote above notes that one of the primary goals of PHM software is to identify "high-risk patients" (i.e., often those with chronic diseases) who generate the lion's share of healthcare costs. The reason for focusing on these patients is to determine whether their cost of care can be reduced by proactively addressing their trajectory of care. In so doing, additional down-stream costs such as hospital readmissions can possibly be avoided.