Since Lipitor has come off patent, Pfizer has been facing very serious competition from the manufacturers of generic copies of its former cash-cow (see: Pfizer Lipitor Sales Are Threatened by Ranbaxy Generic Copy). But the company continues to try to breathe new life into the product by now proposing an OTC version (see: Lipitor Down, But Not Out: Pfizer Plans an OTC Version). Here are some of the details:
I've been following Lipitor's "demise" ever since Pfizer vowed the drug would maintain a 40% share of the total U.S. atorvastatin market. In May 2012, we all thought Pfizer Threw In the Lipitor Marketing Towel when the Lipitor co-pay card/PBM discount plan failed to meet its goal of maintaining the aforementioned 40% share of the combined market for Lipitor and its generic equivalents for at least 6 months after generic brands were launched. At that time Lipitor's U.S. market share was 33%. Guess what Lipitor's U.S. market share versus generic atorvastatin is today. As reported in the WSJ (here), global sales of Lipitor plummeted in 2012 and 2013 to about 20% of what it was in the blockbuster heyday....
...Pfizer is preparing to sell an over-the-counter (OTC) version of Lipitor. According to the WSJ, "Pfizer recently started a 1,200-patient clinical trial to test if consumers taking a nonprescription Lipitor get their own blood tests to see if the medicine is improving their cholesterol and then make the right decisions based on the results." The FDA has to approve the switch to OTC status. Keep in mind that FDA already has "rejected proposals by Merck & Co. to sell an OTC version of the statin Mevacor, amid doubts that consumers could correctly choose to take a statin on their own or sufficiently monitor themselves for changes in cholesterol levels and side effects."
Will consumers "undertreat" their cholesterol because the proposed OTC version of Lipitor will come in a 10 milligram dosage form versus the 40 to 80 milligram Rx dosage forms?...[I]t all depends upon the price consumers will have to pay out of pocket -- medical insurance doesn't cover OTC medicines. Most people would think a little bit of cheap OTC Lipitor...is better than no treatment at all -- and surely better than generics that lack brand "personality." And because it is OTC, consumers will think it is as safe as aspirin and won't cause any problems that require monitoring. Pfizer can then market it like aspirin without mentioning any of the potential problems/side effects.
This is very interesting--a proposal by Pfizer to sell Lipitor OTC with the assumption that consumers will monitor their own cholesterol levels and thus treat themselves effectively and appropriately even with only a low-dose OTC product available. This will be a particular challenge for those with high levels who may not be diligent in seeking medical advices. I agree with the author of this blog note in that consumers frequently consider OTC drugs as "safe as aspirin" which, by the way, is not all that safe.
I am fascinated by the idea that an OTC drug could potentially be accompanied by a recommendation that the consumer should periodically monitor cholesterol levels. I suppose that such an OTC statin could be sold with a test kit for measuring cholesterol levels at home (see: Cholesterol Home Test Kits). However, this involves a finger-stick with a lancet and I suspect that this would be a challenge for many people. Sounds much too complicated so I doubt that it would be approved by the FDA.
::Update on 3/08/2014 at 9:15 a.m.
This year I’m chairing a healthcare IT event series called HealthIMPACT — it’s what I’m hoping will be some of the best places for healthcare technology enthusiasts and buyers to get actionable advice on what’s real, what’s BS, what to buy, what not to buy, and perhaps most importantly, which guidance is worth following. In order to make sure we cover the right topics, we have created a very short survey so that we have some evidence-driven approaches to proving we’re focusing on the right areas.
The survey should only take a couple of minutes to take and includes the following questions:
If you have a few minutes, please take the survey and help us make sure that these events are as filled with actionable advice as possible.
A week after the craziness that is HIMSS (there’s a reason the #HIMSSanity hashtag has done so well), I’m kicking around an idea that came to my mind on my flight home from HIMSS. Overwhelmed by the 5 days of in depth discussions, I closed out my HIMSS talking about healthcare IT with the lovely lady sitting next to me. It just so happened that she was a HIE coordinator at a hospital in California and was heading home from HIMSS as well.
We had a far reaching discussion on the 5 or so hour flight home from Orlando. At one point we started the discussion of personalized medicine. I think I freaked her out a little bit when I mentioned the concept of every organ having an IP address.
Our discussion prompted to me to consider this really interesting an important question:
Can we abolish a disease because we’re so good at predicting that disease that we prevent it from ever happening?
When I considered this idea, it reminded me of Bill Gates (and many others) efforts to literally eradicate Polio from off the face of the earth. They’re doing so using vaccines and I can’t remember the exact timeline, but they’re only a few years out from this goal. It’s so empowering to think about eradicating a disease. Could health IT have a similar impact?
I haven’t thought through all the diseases and all the technology that could benefit from this concept, but I’m quite certain this is the real future of healthcare IT. How wonderful would it be to work on a project that determined the cause of diabetes early enough that we no longer had diabetics? What if we no longer had coughs and colds because we could identify the warning signs early enough that we could stop them from ever happening? We just need to get past the beauracracy and regulation and on to solving these major problems. No doubt this will take an enormous effort and resources and people beyond the traditional health IT.
This is a lofty concept indeed. However, I don’t think these ideas are that far away. What do you think? Could healthcare IT be used to abolish a disease?
Moody’s recaps the EHR-related credit downgrades that took place at US hospitals during 2013.
A Commonwealth Fund study finds that nursing homes that used telemedicine to provide after-hours care significantly reduced hospitalization rates for their residents, compared with facilities not using this service.
ONC publishes a dashboard that consolidates 2010-2013 literature focused on MU related outcomes changes.
KLAS rates HIE solutions and finds that Epic, Orion, and Siemens are doing the best. Researchers note that “What is surprising is that despite the millions of dollars HIE vendors invested to add needed functionality, only about half of them are seeing their provider satisfaction scores improve."
The Defense Health Agency, established in October 2013 as a successor to TRICARE, requests $1.6 billion to support its health IT systems in 2015. It also wants $91 million for R&D to develop a new EHR by 2017 and $68 million to integrate its systems with those of the VA. Meanwhile, the VA’s 2015 budget requests include $269 million for EHR development.
From TooMuch Coffee: “Re: WA state healthcare insurance exchange. You mention that 15k applications are stuck in limbo. I agree that’s not great, but they have signed up around 500k successfully. The site basically works, unlike OR and HI sites.” I’ve written about Oregon’s struggling exchange, so here’s the story on Hawaii’s: it received $204 million in federal funding, went live two weeks late due to software problems, has enrolled fewer than 5,000 people (at a cost of about $46,000 each), and has already been declared unsustainable without ACA rule changes since few potential customers and insurers are interested and it’s supposed to be self-funding its $15 million annual operating budget with 2 percent of the take. Meanwhile, the US Government Accountability Office says it will audit Oregon’s exchange, which cost $304 million and hasn’t enrolled a single person without manual help.
From Concerned: “Re: UHN in Toronto. Can anyone confirm that they are replacing QuadraMed EHR with Cerner?”
From Nobody Knows: “Re: value-based risk contracts. Is there a resources that details which payers and providers are engaging in them vs. those doing fee-for-service? I’ve tried AIS, HIMSS Analytics, and Billian’s and so far, no dice. Even a high-level report would be nice.”
HIStalk Announcements and Requests
This week on HIStalk Practice: You won’t want to miss the summary of my chat with eClinicalWorks CEO Girish Navani, who shares his thoughts on the MU program, population health, and health information exchange, plus provides an estimate of the company’s valuation if it were to go public. Despite the growing number of employed physicians, work still needs to be done to integrate physicians and develop performance-based reward programs. The pay gap between primary care providers and specialists narrowed in 2013. I recap some vendor announcements from last week and muse on various HIMSS sights and sounds, including the future of Practice Fusion; Allscripts and its new tag line; what’s driving Aprima’s recent growth; and, the hot topic of ICD-10. Thanks for reading.
This week on HIStalk Connect: Samsung unveils the Galaxy S5, which integrates with both its two new smart watches and its new activity tracker. Basis, the maker of the B1 activity tracker, is acquired by Intel for a rumored $100 million. The FDA is looking for a vendor to develop social media analytics tools.
Welcome to new HIStalk Platinum Sponsor CompuGroup Medical. You see the count of big global customer numbers in their graphic above and the owner-led and publicly traded company is expanding its US sales. Offerings include CGM Clinical (integrated PM/EHR), CGM DAQbilling (PM), CGM webEHR (EHR), CGM webPRACTICE (PM), and CGM Enterprise (PM/EHR for community health centers); LIS, outreach, and reference lab solutions; the eSERVICES Patient Portal, EMEDIX Reimbursement Solutions, and the SAM disease management platform. The new CEO of CGM US is Norbert Fischl, who has an interesting background as leader of the company’s Northern European region, managing director of a software company, McKinsey consultant, and an Internet entrepreneur. Thanks to CompuGroup Medical for supporting HIStalk.
Here’s another update on one of our DonorsChoose projects that was paid for by the top-of-the-page ads. The 35 freshman girls in the Illinois high school taught by Teach for America teacher Ms. Schwartz are using the notebooks and colored pencils we provided to create College Bound Journals. They will fill them with goals, thoughts about their futures, and information they gather about college campuses and majors. You can see in the photo sent by the teacher that they’ve already started.
More remote mug sightings.
Anne-Marie wasn’t able to get way from the family medicine practice she manages to attend the HIMSS conference, so she made her own mug. She says it’s not nearly as cool as the original, but I disagree.
It’s time for the once-yearly HIStalk Reader Survey. It’s quick and I use the results to plan the entire next year of HIStalk, so I would really appreciate your taking five minutes or less to give me some guidance. I’ll sweeten the pot by randomly drawing three responses to receive $50 Amazon gift cards. Thanks in advance – most of the good ideas I’ve put in place came from responses to this survey.
March 19 (Wednesday), 1:00 p.m. ET. The Top Trends That Matter in 2014. Sponsored by Health Catalyst. Presenters: Bobbi Brown, VP and Paul Horstmeier, SVP, Health Catalyst. Fresh back from HIMSS14, learn about 26 trends that all healthcare executives ought to be tracking. Understand the impact of these trends, be able to summarize them to an executive audience, and learn how they will increase the need for healthcare data analytics.
Acquisitions, Funding, Business, and Stock
MedAssets reports Q4 results: revenue up 4.1 percent, adjusted EPS $0.28 vs. $0.25, beating estimates on both.
Clinical prediction software vendor Health Outcomes Services completes a $5 million financing round. CEO Jim Wilson has worked for McAuto, EDS, and Cerner and was president of Craneware before joining HOS.
ArborMetrix appoints former CMS administrator and FDA commissioner Mark McClellan, MD, PhD (Brookings Institution) to its board.
Idea Couture hires James Aita (Medicomp) as head of healthcare solutions.
Bart Foster, founder and CEO of self-service medical kiosk maker SoloHealth, is replaced by Chairman Larry Gerdes (both above.) The company’s CFO has also resigned and an undisclosed number of employees have been laid off. Gerdes sold transcription vendor Transcend Services to Nuance for $300 million in 2012. One of SoloHealth’s investors is healthcare IT long-timer Walt Huff, the “H” in HBOC, where Gerdes was an executive from 1977 to 1991.
Tamyra Hyatt (McKesson) joins Azalea Health as VP of marketing.
Announcements and Implementations
The New York eHealth Collaborative and the Partnership Fund for NY call for applications for participation in the second class of the NY Digital Health Accelerator, where 10 early- and growth-stage companies will each receive mentoring and $100,000 of investment capital.
North Dakota officials announce the official rollout of the state’s HIN, which will connect all of North Dakota’s hospitals by the end of the year.
The US Army deploys a software upgrade to its battlefield Medical Communications for Combat Casualty Care EMR, also known as the MC4 system, that includes an upgraded operating system, enhanced security, and patient safety improvements related to allergies and medication history.
Government and Politics
HHS includes $75 million in its 2015 budget for ONC, a $14 million increase over last year.
ONC updates its Health IT Dashboard to include a Rand Corporation-prepared review of literature on the impacts of HIT, with a focus on MU functionalities.
Analysis of full-year 2013 MU attestation data by Wells Fargo Securities finds that 92 percent of hospitals stuck with the same vendor for at least two years. Meditech, Allscripts, and Siemens topped the list of hospitals that stayed the vendor course, Cerner and CPSI were average, and Healthland, McKesson, and HMS lagged. It also finds that small hospitals seem to be dropping out in big numbers by the third year, perhaps because they’ve paid their EHR costs in the first two years and don’t want to deal further with MU complexity.
Innovation and Research
Hospitalization rates declined at nursing homes that used after-hours telemedicine services, according to a Commonweath Fund-sponsored study. Researchers estimate that the use of telemedicine services could net Medicare a $120,000 savings annually per nursing home.
Azoi announces Wello, a $199 case that turns an iPhone into a monitor for blood pressure, ECG, heart rate, blood oxygen, temperature, and lung functions.
Epic, Orion, and Siemens earn the highest customer satisfaction scores in a KLAS survey on HIE solutions. Overall provider satisfaction with HIE solutions has dropped an average of eight percent since last year.
Becker’s Hospital CFO looks back at hospitals whose bond ratings have been downgraded by Moody’s Investors Services because of EHR-related budget problems: (1) Health East Care System (MN), which is spending $145 million on Epic; (2) Community Medical Center (MT), which is having cash flow problems after installing Cerner and NextGen; (3) Saint Luke’s Health System (MO), implementing Epic for $200 million; (4) Scott & White Healthcare (TX), seeing increasing costs with Epic; (5) Washington Hospital Healthcare (CA), having increased costs and a negative margin after implementing Epic; (6) Robinson Memorial Hospital (OH), with losses partially attributed to its Allscripts Sunrise implementation.
Bloomberg News calls Mount Sinai Hospital (NY) “a heart surgery factory with obscene levels of pay,” claiming the hospital coaches patients to feign heart attack symptoms in the ED to get their stents covered by insurance, earns referrals from doctors with financial ties to the hospital, and pays its head of interventional cardiology $4.8 million per year. The head of another New York interventional cardiology program summarizes, “You essentially have physicians combing the streets of Staten Island, Queens, Brooklyn, and Bronx looking for patients they can screen on a treadmill to feed into the cath lab, where the big reimbursement comes.”
In Canada, Pierre Le Gardeur Hospital cancels all elective procedures after experiencing an unspecified computer system problem.
Weird News Andy has his ear to the UK ground in noticing this story, in which the British public reacts to news that a marketing company used a 47 million-record hospital data extract to target Facebook and Twitter ad campaigns. Another company was found to have loaded the entire database to Google’s servers to create interactive maps. The Hospital Episodes Statistics database had been made available by the government to researchers and approved private companies. The government has a PR nightmare on its hands because de-identification is hard to describe to laypeople who react to “my hospital records are on the Internet.”
EPtalk by Dr. Jayne
One of my fondest memories from medical school is working the ER during Mardi Gras. I sewed up more than one reveler who didn’t really need anesthesia because they were already feeling no pain. I chuckled when one of my former classmates sent me this story about the germs residing on Mardi Gras beads. Who would have thought that beads that have been thrown around in the midst of public drunkenness might have germs? I wonder if there’s an ICD-10 code for that? Maybe there’s one for choking on the baby in the King Cake as well.
One thing I found lacking at HIMSS was the presence of wearable devices (other than on attendees). I didn’t see much vendor promotion or anything cool enough that I’d consider it (although watching people try to interact with Google Glass was pretty funny). I don’t have any experience with Fitbit, but after reading this article I heard about on Twitter, I might consider one just to have this app. The Sleep Tracker Hack, which emerged from the recent Netflix Hack Day, helps a viewer find her place after sleeping through streaming media. I just might know someone who has fallen asleep in the middle of re-watching “Grey’s Anatomy” for the last several weeks. Unfortunately the hack was part of an internal hackathon, so it may never see the light of day.
I believe in patient engagement and making health-related technology accessible to patients, but there’s such a thing as going too far. I was reading a piece about the Bellabeat Connected System that turns a smart phone into a fetal heart monitor. It also mentioned the Huggies “TweetPee” that sends a tweet when the baby wets its diaper. Seriously? Unless your infant has a urologic problem, I’m not sure tracking urination on social media will do much more than drive followers crazy.
One of my favorite HIMSS connections reached out earlier this week to ask if I would be willing to help mentor a physician who would like to join the CMIO ranks. When I first started out, I had no one to look to for advice, so I was happy to oblige. One of his questions was what I think is the most important CMIO function. I’m not sure I can pin down a single one, but one of the most important in my book is being able to be the peacemaker among IT, the operations folks, and the physicians. Certainly there are other constituencies, but those are the three that tend to be the most contentious.
I’m still surprised that nearly a third of health systems still don’t have a CMIO. The organization where my mentee works falls into that category, but at least they understand that they need to work towards filling that role even if they aren’t ready to admit they need an honest to goodness CMIO. Whether we’re called Medical Directors or Directors of Informatics or Physician Champions, we can still help organizations move forward.
His hospital is currently struggling with physician engagement and clinical oversight, so it makes sense that a physician would be uniquely positioned to assist. He’s not highly techy, but I think that’s OK – if we can master anatomy and pathophysiology, we can learn enough about networks and software to be meaningful participants. The key is knowing who our experts are and being willing and able to leverage them appropriately.
He’s worried that his hospital isn’t really ready to formalize physician leadership in the IT space. There have been comments made about fears that the CMIO “will come in and boss IT around because he’s a physician” or that he will preferentially take the physicians’ side in arguments. I’m encouraging him that even though his role is emerging, he should ensure that it’s well defined and that leadership is prepared to support him. Without those elements, the risk of frustration will be fairly high for all involved.
At this point, I think he’s wise to negotiate for a formal position, but I’d recommend going for something part time that lets him dip his toes in the waters of clinical informatics without locking in at an organization that might not be as ready to move forward as he thinks they might be. That will buy him some time to work on professional development and to build the skills he’ll ultimately need if he wants to make a career of this. I’ll keep you posted as I hear from him. I’m looking forward to remembering what it was like to be young and idealistic before the CMIO life started beating me down.
One of the most interesting things I wrote about thanks to the HIMSS conference was what I called the real cause of hospital readmissions. I’m still interested in working with more hospitals to verify the data that’s presented in that blog post, but I’ll be surprised if it doesn’t play out as an important finding when it comes to reducing hospital readmissions.
In the post, I probably was a little aggressive in my statements about how the hospital can reduce readmissions through their own actions versus depending on home health, primary care doctors, or post-acute care providers. The good news is that my great readers always hold me accountable when I step too far over the line. In this case, Richard D. Tomlinson, RN, BSME, CMUP and Founder & CEO of Nuclei Health Consultancy, offered up a deeper perspective on the complexities associated with solving the hospital readmission problem.
I would like to take a moment to provide some perspective relative to your blog post today.
Hospital readmissions are, of course, clinically complex at times. In actuality, the risk for readmission can be influenced/increased due to lack of or missed opportunity for interventions prior to patient discharge. Effective quality measures, and robust analytics, with effective data feedback and clinical governance, can be deployed as components to an overall readmission reduction strategy; more on that later.
When we discuss readmissions we must consider the fact every case is unique; the circumstances, follow up care, coordination with 3rd party caregivers/providers (e.g. home health), level of transitional intervention, cultural influences, income levels, environment, stress levels. These factors are difficult to quantify, yet I do believe there is a way to translate these factors into reasonable algorithms.
I mentioned readmission as a strategy. Hospital readmission with most health systems I have worked with do not view it in strategic terms, and they must in my opinion in order to be effective (it could be argued Very often, initiatives are tactile in their core and therefore do not have a genesis of the strategic perspective when planning/implementing. As such, critical components such as clinical governance and workflow changes within the readmioften fall by the wayside or are missed completely. Add to that BI tools in the market today are not addressing predictive analysis for readmission risk as a dynamic in the overall care plan. A future-state, effective, model in my opinion would incorporate all the aforementioned factors, and in real-time track these factors and provide the care team with dynamic risk for readmission. That, combined with robust strategic tools and models in place, would have in my view significant outcomes.
Readmission engineering must be redesigned and retooled before any ROI level discussion can take place. Thank you for your fine Site and information exchange. All the Best, RDT.
I agree completely that the hospital readmission problem is not a simple problem. However, I still think a lot of people are looking in the wrong place. I look forward to digging into this problem a lot more. Reducing hospital readmissions is great for everyone involved.
A colleague of mine, Dr. Alan Weder, has recently begun to offer his services as a medical navigator to patients and their families for an hourly fee. He is a retired University of Michigan Medical School faculty member. In a previous note, I discussed how so-called "navigators" have begun to crop up as staff members in physician offices (see: Yet Another Type of Healthcare Professional Who Focuses on Patient Support). Dr. Weder is also offering to serve as a navigator but one who is independent of any caregivers and working solely on behalf of the patient. I personally think that such advice can be very useful but, obviously, the quality is highly dependent on the skill set of the physician-navigator. There are also for-profit physician navigator companies advertising on the web but I can't vouch for their quality (see, for example: Your Medical Navigator). In a previous note, I commented about how difficult it was to say "no' to physician recommendations; this is relevant to the emergence of medical navigators (see: Teaching Consumers to Say "No" to Physicians' Recommendations). Here is an quote from it:
It will be extremely difficult for most consumers to say "no" to their physicians. The knowledge and experience in diagnosing and treating disease lies with the physicians we consult for problems. Such a scenario rarely lead to "no". However, try substituting the word "maybe" for "no" in response to a physician's recommendations. This "maybe" approach allows the patient to seek more information to determine whether the recommendation is appropriate. Don't attempt this in the pressure-cooker environment of a doctor's office.
Seeking the services of an independent physician navigator provides another source of information for a patient and family. Here are a number of interesting points I learned during my discussions with Dr. Weder:
The views and opinions expressed in this blog are mine personally and are not necessarily representative of current or former employers.
Executive Success – The Secret Unplugged, Part 2
This is the second guest post from my wife Julie. The first one is here. She writes what she feels and it is unfiltered, straight from her perspective. She would not have it any other way! I am thankful to have married a very strong woman.
“No, no! Take your finger off that send button, Edward Marx.”
Yes, I had to stop him before he sang his own praises on this blog. For heaven’s sake, he just finished pouring out his heart in a four-part series on Identity based on humility, and now he was about to shoot himself in the foot.
I confess. It’s tough living with a “celebrity,” especially when his prominence is bigger in his head than it is in the mortal world.
Don’t get me wrong, I’m extremely proud of him for winning the “John E. Gall CIO of the Year” award. After all, how many execs choose to trample their way out of the policy box their organizations try to keep them in? How many execs have disrupted their workplace practices and standards and influenced their peers and followers to change their own organizations?
Ed has a voice that speaks volumes to improving healthcare on the technology side. He draws out leadership talent in people everywhere he goes. He absolutely deserved to win the award.
Ed was equally proud of winning the HIStalkapalooza IT Leader of the Year award.
But I can always hear the tremble in his voice that asks, “Why are these people following ME? What if I lead them in the wrong direction?”
Ultimately, time will tell on the direction part. But my response to the first question would be “vision.” Am I right? We like to go somewhere important and add significance to our sphere of influence.
Now that the 2013 award ceremony is over, my hope is that you show your admiration and appreciation by applying all the spoken and unspoken lessons you’ve learned from the 2013 CIO of the Year and revolutionize your own domain. Don’t live vicariously through Ed’s achievements and settle for complacency in your own world. Seriously, one man can only accomplish so much, but an army of like-minded leaders can advance the IT kingdom beyond its present borders and into a model worth imitating.
Yes, you do have what it takes. For some of you, the secret is to bust the box. And that would be an applause heard around the world.
Julie’s personal highlights from the HIMSS conference:
Ed Marx is a CIO currently working for a large integrated health system. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this post. You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook and you can follow him via Twitter — user name marxists.
Last Spring, after attending an Institute of Medicine meeting on Childhood Obesity, I wrote about fronts and Heroes in the Health Attention War. Arguing that if we were going to do anything about long-term patient engagement around health and influencing healthy decisions, we had to start with habits and getting attention at an early age. Attention is the first step towards long-term behavior change.
At that time, I was happy to see the The Ad Council, who has been so successful in campaigns around littering and drunk driving, was working to get attention around childhood obesity to some specific communities. Advertising, after all, is all about directing attention, the necessary first step towards new behavior change. Meanwhile, some school districts were using the ideas behind behavioral economics to influence healthy food choices in schools, which continue to show success.
Today, I’m happy to report that something – or many things – have been working. Via the Robert Wood Johnson Foundation (RWJF) a JAMA Report “shows that that obesity prevalence among 2 to 5 year olds has dropped by approximately 40 percent in eight years.” This is truly outstanding progress. This is the most important age group to address as habits formed here can remain very hard to break later in life.
RWJF goes on to say “After decades of seemingly endless bad news about obesity, our collective efforts over the last several years show that we as a nation are finally moving in the right direction. Of course we can’t stop now.”
Also encouraging, they mention a report yesterday by “Let’s Move” declaring , “Nine out of ten schools across the country are certified to meet healthier lunch standards, and all schools with 40 percent of students qualifying for free or reduced-price lunch will soon be able to provide healthier, free meals to all of their students.”
Let’s continue to build on this progress, getting attention and enabling smarter choices around the problem that eventually became our nation’s health care crisis.
Dr. Christine Cassel, chief executive of the National Quality Forum, quits her board positions with Kaiser Permanente and Premier Inc. after ProPublica reported that she was being paid a cumulative $400,000 for her advisory role with the companies.
The DHA has requested $1.6 billion to support operations and maintenance of its health information management systems in 2015, seven percent more than its 2014 budget.
Becker’s Hospital Review evaluates President Barak Obama’s 2015 budget proposal, highlighting Medicare payment reforms, critical access hospital reimbursement changes, and increased funding for Medicaid/Medicare fraud detection programs.
More than seven million health records in the United States were affected by data breaches in 2013, an increase of 137% over the previous year, according to the annual breach report..
Dr. Jayne asked important questions in her Curbside Consult about big data, EHR conversions, the “sheer magnitude of bad data out there,” and how best to insure the integrity of health data.
The best way to address the issue of bad data is to follow the old adage,“Begin with the end in mind.” Implementing an enterprise-wide EHR is a massive, complex undertaking. It involves considering the needs of many stakeholders when defining the build requirements. For example, workflow must support ease of use and not interfere in patient care delivery and related work processes. Furthermore, many implementation decisions focus on driving clinician adoption to ensure that both quality and efficiency objectives are met (not to mention regulatory requirements related to Meaningful Use.)
With all the multi-threaded work streams and decision processes involved in planning and executing an EHR implementation, the re-usability of captured data frequently falls out of scope. That leads to the bad data problem.
Re-usability means using data captured in any source system (EHR, ADT materials management, patient accounting, registration, operating room, emergency department, etc.) for reporting, measurement, and analytics. Re-using the data captured in these source systems accelerates the value realized from implementing such systems and supports a virtuous cycle of performance improvement across an enterprise.
It all relates to, “You can’t manage what you don’t measure.” That is, you can’t measure something if you don’t have the right data. This leads back to the decisions made in implementing EHRs and other systems. You need to start with what data is required to measure and analyze what’s important to the organization and ensure that data can be consistently, reliably, and accurately captured at the point of origin (e.g., at registration or in the care process).
It’s not realistic, however, to expect that every bit of data about a patient should be captured in a discrete form for re-use. What’s required is a balance between supporting ease of use in the appropriate workflows and the availability of data for reusability.
An effective way to strike this balance is to create a list of data elements the organization agrees is necessary for analytics. Some detective work is required: tracing the journey of that data back to the source system and ensuring that each data element is captured as expected in the intended workflow. This requires collaboration across a multi-disciplinary team — one involving experts in quality reporting, data analysis, and clinical (or operational) workflow.
The inventory of data elements can be used to identify where each data element can be captured in the source system (e.g., EHR, ADT, etc.). This is the “data chain of trust.” Team discussion and compromise are required to design workflows that both support ease of use and capture data reliably and consistently.
With a documented inventory of data elements married to how that data will be captured in the source systems, data can start flowing into an analytics environment. Applying sound data governance principles and implementing a data profiling discipline will ensure data consistency and reliability.
Organizations don’t have to begin with a large set of discrete data, but they must recognize that any level of measurement, reporting, and analytics requires consistent, reliable, accurate data starting at the point of capture in the source systems. They should begin with the data most important to each organization and ensure that data can flow from origin to analytics in a chain of trust that is known and transparent.
From there, health systems can incrementally increase the available data as they come to understand why it’s important to capture data discretely and accurately and as more stakeholders benefit from access to that data. With the increasing value realized comes the understanding that, “It’s all about the data.”
Randy Thomas is associate partner of health analytics with Encore Health Resources.
In my January update on Meaningful Use Stage 2 readiness, I painted a dismal picture of a large IDN’s journey towards attestation, and expressed concern for patient safety resulting from the rush to implement and adopt what equates to, at best, beta-release health IT. Given the resounding cries for help from the healthcare provider community, including this February 2014 letter to HHS Secretary Kathleen Sebelius, I know my experience isn’t unique. So, when rumors ran rampant at HIMSS 2014 that CMS and the ONC would make a Meaningful Use announcement, I was hopeful that relief may be in sight.
Like AHA , I was disappointed in CMS Administrator Marilyn Tavenner’s announcement. The new Stage 2 hardship exemptions will now include an explicit criteria for “difficulty implementing 2014-certified EHR technology” – a claim which will be evaluated on a case-by-case basis, and may result in a delay of the penalty phase of the Stage 2 mandate. But it does nothing to extend the incentive phase of Stage 2 – without which, many healthcare providers would not have budgeted for participation in the program, at all, including the IDN profiled in this series. So how does this help providers like mine?
Quick update on my IDN’s progress towards Stage 2 attestation, with $MM in target incentive dollars at stake. We must meet ALL measures; there is no opportunity to defer one. The Transition of Care (both populating it appropriately, and transmitting it via Direct) is the primary point of concern.
The hospital EHR is ready to generate and transmit both Inpatient Summary and Transition of Care C-CDAs. The workflow to populate the ToC required data elements adds more than 4 minutes to the depart process, which will cause operational impacts. None of the ambulatory providers in the IDN have Direct, yet; there is no one available to receive an electronic ToC. Skilled resources to implement Direct with the EHR upgrades are not available until 6-12 weeks after each upgrade is complete.
None of the 3 remaining in-scope ambulatory EHRs have successfully completed their 2014 software upgrades. 2 of the 3 haven’t started their upgrades. 1 has not provided a DATE for the upgrade.
None of the ambulatory EHRs comes with a Clinical Summary C-CDA configured out-of-the-box. 1 creates a provider-facing Transition of Care C-CDA, but does not produce the patient-facing Clinical Summary. (How did this product become CEHRT for 2014 measures?) Once the C-CDA is configured, each EHR requires its own systems integrator to develop the interface to send the clinical document to an external system.
Consultant costs continue to mount, as each new wrinkle arises. And with each wrinkle, the ability to meet the incentive program deadlines, safely, diminishes.
Playing devil’s advocate, I’d say the IDN should have negotiated its vendor contracts to include penalty clauses sufficient to cover the losses of a missed incentive program deadline – or, worst case scenario, to cover the cost of a rip-and-replace should the EHR vendor not acquire certification, or have certification revoked. The terms and conditions should have covered every nuance of the functionality required for Stage 2 measures.
But wait, CMS is still clarifying its Stage 2 measures via FAQs. Can’t expect a vendor to build software to specifications that weren’t explicitly defined, or to sign a contract that requires adherence to unknown criteria.
So, what COULD CMS and the ONC do about it? How about finalizing your requirements BEFORE issuing measures and certification criteria? Since that ship’s already sailed, change the CEHRT certification process.
1. Require vendors to submit heuristics on both initial implementation and upgrades, indicating the typical timeline from kick-off to go-live, number of internal and external resources (i.e., third-party systems integrators), and cost.
2. Require vendors to submit customer-base profile detailing known customers planning to implement and/or upgrade within calendar year. AND require implementation/upgrade planning to incorporate 3 months of QA time post-implementation/upgrade, prior to go-live with real patients.
3. Require vendors to submit human resource strategy, and hiring and training program explicitly defined to support the customer-base profile submitted, with the typical timeframes and project resource/cost profiles submitted.
4. Require vendor products to be self-contained to achieve certification – meaning, no additional third-party purchase (software or professional services) would be necessary in order to implement and/or upgrade to the certified version and have all CMS-required functionality.
5. Require vendor products to prove the CEHRT-baseline functionality is available as configurable OOTB, not only available via customization. SHOW ME THE C-CDA, with all required data elements populated via workflow in the UI, not via some developer on the back-end in a carefully-orchestrated test patient demo script.
6. Require vendor products adhere to an SLA for max number of clicks required to execute the task. It is not Meaningful Use if it’s prohibitively challenging to access and use in a clinical setting.
Finally, CMS could redefine the incentive program parameters to include scenarios like mine. Despite the heroic efforts being made across the enterprise, this IDN is not likely to make it, with the fault squarely on the CEHRT vendors’ inability to deliver fully-functional products in a timely manner with skilled resources available to support the installation, configuration, and deployment. Morale will significantly decline, next year’s budget will be short the $MM that was slated for further health IT improvements, and the likelihood that it will continue with Stage 3 becomes negligible. Vendor lawsuits may ensue, and the incentive dollar targets may be recouped, but the cost incurred by the organization, its clinicians, and its patients is irrecoverable.
Consider applying the hardship exemption deadline extension to the incentive program participants.
I have posted a number of notes about incidentalomas which are benign lesions in the lungs, as only one example, which may be better undetected (see, for example: How to Avoid the Risks of a CT Incidentaloma; More (and Interesting) Discussion about Incidentalomas). Once even a hint of a lung lesion appears in a radiology report, there is a need for the treating physicians to try to diagnose and sometimes resect it. This can lead to complications for the patient. Incidentaloma are only one example of mischief due to diagnostic procedures that may be too sensitive. Another possible example of this phenomenon may be the recent surge of thyroid cancer cases. This idea was discussed in a recent article (see: Surge in Thyroid Cancer Cases May Be Due to This). Below is an excerpt from it:
A surge in the number of thyroid cancer cases in recent decades suggests the disease is being overdiagnosed and overtreated, a new study contends. Although the number of thyroid cancer diagnoses has almost tripled since 1975, most are the more common and less aggressive form of the disease known as papillary thyroid cancer, the study authors said. "The incidence of thyroid cancer is at epidemic proportions, but it doesn't look like an epidemic of disease, it looks like an epidemic of diagnosis," said lead researcher Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. According to Welch, more people are having their neck imaged to look for blockage of the arteries or for other reasons, and nodules on the thyroid are then found."This means that a lot of people are having their thyroids removed for a cancer that was never going to bother them," he said. Welch believes that thyroid cancer should be treated much like prostate cancer, another slow-growing cancer, where patients have an option for watchful waiting that may never result in aggressive treatment...."Once a thyroid abnormality is found, it is hard to ignore it in the current medical environment, and patients often end up on an unstoppable juggernaut, leading to invasive procedures such as thyroid biopsy and ultimately to surgery"....
I made reference to the ideas of Dr. Welch regarding over-diagnosis in a previous note (see: Sensitivity of CT Scans for the Coronary Arteries May Lead to Unnecessary Surgery). Here's a link to another note about the confusion that may exist between a false positive and over-diagnosis in the case of cancer of the breast (see: Confusion Caused by Conflating "False Positive" and "Overdiagnosis" in Breast Cancer). Some cases of overdiagnosis are related to the medico-legal imperative whereby physicians fear medicolegal liability for not working up (and often treating) a diagnosed lesion that is probably benign.
Part of this problem can also be attributed to overutilization of diagnostic studies by physicians. Although it is theoretically possible that healthcare reform and cost-cutting may help to solve the overutilization of diagnostic services, I personally doubt it (see: Cost-Cutting as the Key Element in Healthcare Reform). Our young physicians are trained to aggressively order diagnostic tests and imaging procedures. This won't change quickly even if there is a concerted effort to effect such change. What is more likely is that the federal government and insurance companies will drive down the cost of such studies and overdiagnosis will continue unabated.
John Lynn, prolific blogger and health IT media magnate, and I are teaming up to produce and deliver the world’s first marketing conference focused on helping innovators cut through the noise when trying to market their healthcare and medical tech products to physicians, hospitals, and similar customers. Called The Healthcare IT Marketing Conference, it will cover very important subjects by some of the world’s best experts on those topics.
Learn how to align the Payers, Beneficiaries, and Users (PBU) of your Health IT or MedTech product
There are three distinct groups you’re marketing and selling your products to:
I call this the “PBU alignment” problem. In a complex environment like healthcare, the three groups are often not the same — if you can find a market in which the payers, the beneficiaries, and the users are all the same then your sales job is easy. However, that’s commonly not the case. Let’s take a look at the typical example of a complex product like an electronic medical records (EMR) software package in the era of ARRA, HITECH, and meaningful use (MU). The “payer” may ultimately be government reimbursements through Medicare, the “beneficiaries” are the healthcare insurance firms and the government agencies that need the MU data, and the “users” are the doctors and staff at physicians offices and hospitals. Why has it taken decades for EMRs to be sold to just a tiny fraction of the total industry? Because the PBU alignment hasn’t been reached — until the users, beneficiaries, and payers of the products all understand the value and are willing to work together to achieve a goal it will be tough.
Join us at the conference to talk with experts on the PBU lesson and advice for your product. Figure out the PBU alignment problem and see how you’ll sell to each of the groups and make the right arguments — you do it right and you’ll make money. If you forget the complexities of the PBU and you’ll be languishing, too.
Learn the difference between Marketing, Advertising, PR, and Branding
Everyone tells small companies that they need to “do marketing” but that’s really hard to do so I started with a quick visual to explain what it means. It comes from Marty Neumeier on pages 24 and 25 of ZAG by way of the Brand Autopsy Blog (which I highly recommend reading) and illustrates the differences between Marketing, Advertising, PR, and Branding. It’s a wonderful visual and clearly shows that small companies should focus on marketing and free PR, shoot for branding and probably eschew advertising until they have enough money. Our expert speakers know the difference and can teach you how to make sure you’re not taking the wrong steps.
Learn about major healthcare industry fallacies
Selling to the healthcare community is very hard and there are many myths that our conference will dispel:
Learn how to conduct appropriate market research
Lots of (even innovative) companies don’t do basic market research so we will cover:
Learn about the different kinds of of Business Models to consider
Go home with many tips and tricks:
As a former system administrator that worked in a number of data centers, it’s been really interesting for me to watch the evolution of healthcare data centers and the concept of healthcare cloud solutions. I think we’re seeing a definite switch by many hospital CIOs towards the cloud and away from the hassle and expense of trying to run their own data centers. Plus, this is facilitated greatly by the increased reliability, speed, and quality of the bandwidth that’s available today. Sure, the largest institutions will still have their own data centers, but even those organizations are working with an outside data center as well.
I had a chance to sit down for a video interview with Jason Mendenhall, Executive Vice President, Cloud at Switch Supernap to discuss the changing healthcare data center and cloud environment. We cover a lot of ground in the interview including when someone should use cloud infrastructure and when they shouldn’t. We talk about the security and reliability of a locally hosted data center versus an outside data center. We also talk a little about why Las Vegas is a great place for them to have their data center.
If you’re a healthcare organization who needs a data center (Translation: All of you) or if you’re a healthcare IT company that needs to host your application (Translation: All of you), then you’ll learn a lot from this interview with Jason Mendenhall:
As a side note, the Switch Supernap’s Innevation Center is the location for the Health IT Marketing and PR Conference I’m organizing April 7-8, 2014 in Las Vegas. If you’re attending the conference, we can also set you up for a tour of the Switch Supernap while you’re in Vegas. The tour is a bit like visiting a tech person’s Disneyland. They’ve created something really amazing when it comes to data centers. I know since a secure text message company I advise, docBeat, is hosted there with one of their cloud partners Itrica.
“Healthcare is influenced by where people live, learn, work and play, which has a huge influence on an individual’s overall health.” ~ Karen DeSalvo, MD, MPH, MSc
This year’s HIMSS Annual Conference and Exhibition saw Karen DeSalvo, the new National Coordinator for Health Information Technology, take the stage and it was clear we are entering a new era under her leadership. She recognizes that we are at a pivot point in the history of health IT and sees the need for everyone to take a breath and possibly find some better ways to reach some of our goals.
Speaking at a press event on Tuesday, one on one with me on Wednesday (video is below), during a Town Hall as well as a CCHIT led forum, then during her keynote on Thursday with CMS Administrator Marilyn Tavenner, and finally another press availability at the end of the conference, she laid out a broad vision of the current landscape and where we are heading as an industry.
On Tuesday DeSalvo explained some of her goals. One would be that every provider is using an EHR and health IT to capture, share and meaningfully use health information.
“That requires that there’s some floor that we set, that is raised, whether you’re a rural, small hospital, provider, payer, whatever you are,” she said. She also iterated a policy goal of using meaningful use as a driver to advance the healthcare marketplace. “It’s one thing to have an EHR,” she said. “We need to meaningfully use it, and push technology so that it is driving interoperability across the continuum and that it is improving outcomes.”
She also spoke of the critical importance of interoperability. “The reason I get excited about interoperability is because for it to work, for the doctor to show up in the ER and to know what medicine you’re allergic to, if you’re unconscious and need some help, there’s a lot of back work to see that everything comes together just at the right moment to save your life. That’s pretty exciting to me,” she said.
On Wednesday she joined former National Coordinators for a very interesting discussion on the birth and growth of the ONC. The only one missing was Dr. David Blumenthal, who headed the ONC during the passage of the HITECH Act and was instrumental in its creation.
“I’m sorry David Blumenthal isn’t here because he was advising (the Obama administration) but he was also advising Kerry when he ran against Bush,” said David Brailer, the first National Coordinator. “We spent the entire night trying to get two teams to back off of each other. We both agreed the next morning we made health IT bipartisan.”
The bipartisan nature of health IT was also important to Rob Kolodner during his tenure at ONC. “We didn’t want anyone to grab and control the core infrastructure. It was important to bring it in the room so that the solution didn’t favor one interest or the other.”
But Washington, DC, is often gridlocked, and even bipartisan efforts are difficult to get into law. It was only during a financial crisis and the trillion dollar stimulus that could really provide the funding to substantially move the needle on health IT adoption.
“It took an economic crash to create the opening for something that the groundwork had been laid for,” former National Coordinator Farzad Mostashari said. “The idea that we would get this opportunity was so unbelievable, literally unbelievable, and when the HITECH Act passed, it was a broad movement.”
Dr. DeSalvo, with only weeks in her current role, said, “I don’t have a low point yet.” She expressed optimism about her work saying that after her first HIT Policy meeting, “I got very excited about that because this is a community of vendors, purchases, providers, policy folks, who really want to get it right.”
The ONC has been focusing heavily on patient ID matching recently, including launching a collaborative initiative last fall.
During her keynote Thursday she emphasized interoperability and health data exchange saying, “We can do national healthcare exchange in three years.”
She also stressed the importance of meeting the challenge of patient matching to be sure that the right information about the right patient is being shared safely and securely. “This issue of patient matching and making sure that we get that right is very important,” she said. But she was very optimistic that we can get this done. “I know that this is possible. I have seen exchange in every part of our country.”
With regards to flexibility in stage 2 meaningful use and the challenges of many providers to meet the requirements in 2014, CMS Administrator Marilyn Tavenner announced that CMS will be “flexible” in granting providers “hardship exemptions on a case-by-case basis.”
“We have decided to permit flexibility in how hardship exemptions are granted in the 2014 reporting year,” Tavenner said.
Last December they announced they were extending Stage 2 of the HITECH Act EHR incentive program one year but that did not give any relief with providers who are struggling to meet the requirements in 2014, while simultaneously dealing with the ICD-10 conversion and a plethora of government mandates. Possible exemptions will be outlined in a forthcoming FAQ and will likely include vendors not being ready with their stage 2 technology.
The exemptions to deadlines will be granted for providers in situations where, “despite their best efforts, for reasons beyond their control, they can’t meet meaningful use Stage 2.” I predict there will be a LOT of providers that will need to take advantage of these hardship exemptions in order to avoid penalties.
Standing firm on the upcoming ICD-10 deadline, Tavenner said, “Now is not the time for us to start moving forward. Let’s face it, we’ve delayed this several times, and it’s time to move on.”
The switch from ICD-9 to ICD-10 means that the industry will have to change from about 14,000 codes to about 69,000 codes. I think the deadline for implementing the ICD-10 diagnostic coding set of October 1, 2014. is fairly well carved in stone. Since it had already been delayed one year, now it will not be delayed again.
At the press conference following the keynote, Dr. DeSalvo reiterated the hardship exemptions. Recognizing the call by a coalition of provider organizations to delay the timeline of the meaningful use incentive program and to offer providers more flexibility, she offered hope that these exemptions might stave off failure.
During my discussion with Dr. DeSalvo at HIMSS, she did a very good job of extemporaneously laying out the current landscape of health IT and a glimpse of the future. One of the things that I found compelling was the notion that we could eventually begin to pull in all those data that are outside of the traditional healthcare system that make up what are termed the “social determinants of health.”
She talked about the quantified self movement, patient-generated health information, and a move away from capturing data in the standard EHR to include all of these other data—including providers, patients, payers, and the entire healthcare ecosystem in the digital architecture. She paints an interesting picture of a future tech-enabled transformed health system.
Last week I had two book chapters published.
First, a new social media book published by HIMSS titled Applying Social Media Technologies in Healthcare Environments edited by Christina Thielst, an early adopter of blogging in Health IT. My chapter is on “Social Media Hubs: Strategy and Implementation.” The book addresses a wide range of issues including legal and public health.
The second chapter is an update to Health Informatics: Practical Guide for Healthcare and Information Technology Professionals now in its 6th edition. My chapter is on eResearch, reviewing how information technology can support all aspects of the research workflow. The book is expanded adding several new chapters and is now endorsed by AMIA and available to AMIA members at a discount. Bob Hoyt, the editor from the University of West Florida, has created a companion website as a resource to informatics faculty and students called www.informaticseducation.org.
Both books are available in paper and as ebooks.
Another book chapter is nearing publishing. Will have an announcement about that soon.Share this: • Facebook • Twitter • Delicious • Digg • Tumblr • StumbleUpon • Pinterest • Add to favorites • Email • RSS
The HIMSS conference is so big, with so many different kinds of attendees and exhibitors that it’s almost impossible to have one big theme for any given year. Yet the question of theme for any given HIMSS is something we all talk about. The themes one perceives are at least partially defined by our own interests and area of focus. Consequently, the #HIMSS14 themes for me were:
Two of the market segments that I track with big shifts in value proposition were medical device data systems (MDDS) and messaging middleware. We’ll talk about specific shifts in a moment, but I think it worthwhile to consider why this change in value propositions has occurred. One obvious factor among MDDS vendors is acquisitions. Capsule Tech (registration required), Accent on Integration and iSirona have all been acquired. Acquisitions are major events when everything about a company is reevaluated in an effort to wring greater value from the acquired company. The other factor I think is the growing adoption of MDDS for clinical documentation into EMRs may have caused sales growth to temper a bit, causing vendors to look beyond clinical documentation and explore for ways to add value and differentiate. Let’s look at some examples.
Capsule Tech has released a new version of their Neuron device and transformed it into a vital signs monitor (pictured right). I’ve explored the virtualization of medical devices before in past conference presentations. This is where the core functionality of the traditional medical device is reduced to its essence and combined with an off the shelf computing platform. Imagine an ultrasound transducer, spirometer or EKG leads with a USB connector. Such products are delivered with software that runs on a laptop or desk top computer, tablet or smartphone. Simply install the software and plug in the sensors via the USB connector, and you have a fully functional medical device. (A more technical description of this may be found in this paper, from the Intel Technical Journal, published in 2006.)
Capsule has taken the general purpose computing functions that make up most of a conventional embedded system device and implemented them in the Neuron. Next they’ve taken sensors with miniaturized electronics that acquire and process the sensor data and convert it to a standard USB interface. Plug a temperature probe, SpO2 sensor, non invasive blood pressure module and similar sensors into the Neuron, and you have the new SmartLinx vital signs monitor, part of Capsule’s medical device information system. This new approach allows sensor vendors and Capsule both to add value at the expense of conventional vital signs monitor manufacturers.
In addition to SmartLinx, Capsule showed a new terminal server called Axon with power over Ethernet and Wi-Fi connectivity, and what they called “clinical analytics.” Capsule’s clinical analytics, really a clinical decision support system, is presently targeted at identifying patients with a deteriorating clinical condition and diagnosing patients with sepsis.
Accent on Integration (AoI) was acquired by Iatric Systems. AoI has extended their value proposition beyond MDDS and clinical documentation to include infusion pump interoperability whereby their software will be used to program infusion pumps based on orders from CPOE and pharmacy systems. This is one of the first pump interoperability solutions to come from a third party (i.e., not from a pump or EMR vendor). Iatrics is using Meditech’s proclivity to avoid systems integration to enter the pump interoperability market.
Nant Health is a health care IT and medical device company created by serial entrepreneur Dr. Patrick Soon-Shiong. The company’s atypical product portfolio ranges from mHealth to revenue cycle management. Since iSirona was acquired by Nandt Health, the company has received FDA clearance and brought to market an alarm notification solution for acute care. This pulls iSirona squarely into the messaging middleware space.
The company also showed HBox, a new terminal server and connectivity hub with a similar design and capabilities of Qualcomm’s 2net. The HBox includes wireless connectivity via Wi-Fi and a proprietary radio in the Sensium wireless sensor package from Toumaz (what they call a “sticking plaster” in the UK). It appears that Nant Health will be selling the Sensium into the acute care market as a means to identify patients with a deteriorating clinical condition. The HBox will be used as a gateway communicating with the Sensium device and connecting it to the enterprise network, and later HBox will be used to provide connectivity in patient homes.
Besides the changes at the MDDS acquisitions above, similar moves up the value chain away from conventional MDDS solutions are wide spread.
In the recent past the MDDS market was dominated by the acquisition of medical device data to populate flow sheets in EMRs – an important but basic enabling technology for higher value activities like alarm notification, clinical decision support systems and other tasks more directly related to patient care and outcomes. After just a few years – lightening speed for the health care market – the MDDS market is undergoing major changes.
Geoffrey Moore’s, Crossing the Chasm, is my favorite market adoption model because it fits health care technology markets so well. At this year’s HIMSS, I was struck by a parallel. Much like the bowling alley strategies described by Moore, what is called the messaging middleware market is driven by a variety of spot solutions. With Moore’s model, once sufficient bowling alley strategies have succeeded, the market enters the tornado where a brief period of rapid adoption occurs where buyers shift from the early adopters to the much larger early majority of the market. These spot markets for messaging middleware all revolve around facilitating communications and automating workflow. Examples of spot solutions include:
These spot solutions match a series of pain points for health care delivery organizations. Various messaging middleware vendors target one or more of these pain points with spot solutions. Since HIMSS14, I’m up to 25 companies that I track in messaging middleware. The product architecture and capabilities of these different company’s solutions are very similar, if not virtually identical. Yet few of these companies see more than a hand full of competitors in their sales efforts. This is because different companies are targeting different sets of pain points with spot solutions. These spot solutions can exist in customer sites as separate systems or they may be integrated to provide different capabilities to the same sets of users.
At some point the market is going to start to swing from spot solutions to enterprise solutions. Much like the transition experienced by Emergin years ago, buyers are going to wake up and recognize they’re buying multiple spot solutions that are technically very similar for their various pain points. The question will arise, “Why can’t we meet these various needs with one solution rather than having to buy one for each problem?” At this point, messaging middleware companies will start to recast themselves as enterprise solutions able to address a wider variety of pain points.
As manufacturers continue to draw outside the lines of conventional market segments, the challenges increase for buyers to select solutions that will serve them for more than the short term. Hospital buyers must complete rigorous requirements assessments to enable a meaningful assessment of competing solutions. And manufacturers will have to stay close to the pain points of buyers if they want to drive sales.
The best I could tell population health is something enabled by health information exchanges, or something. It seems vaguely like what the NSA does with our phone calls, smart phone apps, locations, email, webcams, Twitter, Skype, Facebook, Google, etc. Is there real value in all this? The NSA seems to think so. But I wonder if a panopticon of electronic health care data will be any more specific, sensitive or cost effective than conventional double blind clinical trials. Robust clinical trials are not cheap, but then extending the surveillance state to health care won’t be cheap either.
This blog post is part of the #HIMSS14 Blog Carnival #4, Looking Back at HIMSS14. Be sure to check out the carnival to see what other HIMSS14 Social Media Ambassadors though about this year’s event.
Finally, I’d like to thank the folks at HIMSS for letting me attend this year’s event as a Social Media Ambassador. I hope people got something from my tweets during the conference, and this wrap-up blog post.
I posted a note about the da Vinci surgical robot in 2009 in which I linked to an article suggesting that some of the surgeons using the devices were inadequately trained (see: Training and Credentialing Standards Proposed for Surgeons Offering Robotic Surgery). Here's a link to a more recent article about how the use of the device has drawn increased attention by the FDA (see: Surgical robot da Vinci scrutinized by FDA after deaths, other surgical nightmares; Study: Problems with Surgical Robots Going Unreported to the FDA). The manufacturer of this device, Intuitive Surgical, seems to be frequently navigating at the edge of the spectrum. Here's a very recent article about another misstep by the company involving some University of Illinois physician faculty (see: U. of I. doctors under scrutiny for surgical robot ad). Below is an excerpt from it:
When the makers of the da Vinci surgical robot asked University of Illinois doctors to appear in a national advertising campaign, their Chicago hospital saw an opportunity to promote its expertise with the device. But the plan backfired. Instead of gaining national publicity for being leaders in robotic surgery, the doctors and the University of Illinois Hospital and Health Sciences System are under scrutiny for endorsing a commercial product, a possible violation of U. of I. policy....[It has also been discovered that] some doctors pictured in the ad did not initially disclose their financial ties to the company that makes the robot, Intuitive Surgical..., as required by the university's policies on conflicts of interest. Intuitive selected the doctors to observe and monitor use of the device at other hospitals, work for which they were paid. The doctors disclosed that information only after the ad was published ....One surgeon received about $16,000 in the most recent one-year reporting period. For patients, the doctors' participation in the ad and the lack of transparency raise questions about whether their physicians can offer objective advice when discussing robotic surgery as compared with other options....The full-page ad, which ran in The New York Times Magazine on Jan. 19, shows a dozen U. of I. employees, dressed in white lab coats, with the caption: "We believe in da Vinci Surgery because our patients benefit." The names of the hospital and the doctors appear in smaller type above the employees. Intuitive Surgical paid for the advertisement, and U. of I. doctors and the hospital were not compensated for participating, according to the university. A disclaimer in the ad states that the company had paid some doctors for educational services. U. of I. officials have asked Intuitive Surgical to discontinue the advertisement, and two weeks ago the university launched an investigation into the "circumstances of participation" in the ad.
What could these U.I. surgeons have been thinking when they posed for this picture? I suppose that there is the possibility that they were duped and did not actually know that it would be used in a full-page advertisement in the New York Times. Even in the face of much tighter enforcement of physician relations with vendors in terms of "consulting" fees, I suppose there will be some of them who have failed to get the message. Perhaps the so-called Sunshine Act, a component of the ACA, will get their attention (see: Glaxo Stops Paying Doctors for Helping to Promote Their Drugs). Below is more information about the Sunshine Act courtesy of the AMA (see: Toolkit for Physician Financial Transparency Reports --Sunshine Act). The AMA also offers a toolkit that can be accessed via this link so that physicians can make sure that they are prepared when it’s time to review their 2013 financial data before it’s published.
The Physician Payments Sunshine Act (Sunshine Act) requires manufacturers of drugs, medical devices and biologicals that participate in U.S. federal health care programs to report certain payments and items of value given to physicians and teaching hospitals. Manufacturers are required to collect and track payment, transfer and ownership information beginning Aug. 1, 2013. Manufacturers will submit the reports to the Centers for Medicare & Medicaid Services (CMS) on an annual basis. In addition, manufacturers and group purchasing organizations (GPOs) must report certain ownership interests held by physicians and their immediate family members. The majority of the information contained in the reports will be available on a public, searchable website. Physicians have the right to review their reports and challenge reports that are false, inaccurate or misleading.