July 23,2014


Hazards tied to medical records rush

The Boston Globe reports on the sometimes tragic results of the nation’s hasty implementation of EHRs, and the anti-regulatory message being broadcast by vendors.

Swiss Walgreens? $4 Billion Tax Cut Considered At Corner Of Happy, Healthy & Tax-Free

Walgreens considers moving its headquarters to Switzerland through the acquisition of Swiss-based Alliance Boots, a move that would save the company $800 million in taxes annually.

Characteristics Associated With Post-discharge Medication Errors

A small study examining post-discharge medication errors finds that 54 percent of cardiac patients reviewed had at least one error on their discharge medication list.

Hospital trust makes ‘biggest investment in IT for more than a generation’

In England, West Hertfordshire Hospitals NHS Trust signs a $44 million contract with CGI to update the IT infrastructure of its 600-bed hospital, Watford General, which came under scrutiny last year when its EHR was blamed for a scheduling issue that resulted in the death of two cancer patients.

Source: HISTalk
This appeared last week:Late discharge letters frustrate GPs16 July, 2014 Michael Woodhead The frustration GPs feel over late-arriving hospital discharge letters is justified, according to a new study that shows tardy communication impairs patient management.Researchers in WA have measured the additional burden created by delayed discharge letters, finding that GPs are unable to adequately manage a discharged patient's problems until they receive the all-important discharge information.The study showed that a timely but brief discharge letter was preferable to a longer letter that arrived after a discharged patient had attended their GP.And delayed discharge letters often meant that patients had to revisit their GP.More here:http://www.australiandoctor.com.au/news/latest-news/late-discharge-letters-frustrate-gpsHere is the abstract: BMJ Open 2014;4:e005475 doi:10.1136/bmjopen-2014-005475 A randomised trial deploying a simulation to investigate the impact of hospital discharge...

This is the initial part of the post - read more by clicking on the title of the article. David.
Categories: MedTech and Devices , All

July 22,2014

Last month, the FDA released draft guidance on social media and internet platforms with character space limitations and a separate draft guidance for correcting misinformation posted online. Some of us had been waiting for these guidelines for five years or...

You should follow me on Twitter: @healthblawg

David Harlow
Source: HealthBlawg
17 - 18 September 2014, Berlin, Germany.
Anyone who's ever tried to launch a start-up knows how hard it is. It takes all you've got to succeed. DocCheck Guano organises a 2-day hospital camp event for start-ups in the health sector that will get you in shape. Whether you're a greenhorn or an old campaigner - any kind of healthcare start-up will get a treatment at M.E.S.H Camp 2014 (Medical Entrepreneur Start-up Hospital Camp 2014).

I’ve long been a fan of open source technologies. My blogs are run and created almost entirely on open source software. In fact, I first wrote about open source EMR on this blog back in January of 2006. We’ve come a long way since then with Vista being the top open source EHR in the hospital world and OpenEMR leading the pack in the ambulatory world.

We’re starting to see more and more application of open source technology in other areas of healthcare IT beyond EMR as well. There are some really amazing advantages to a thriving open source community. I think the key there is to have a thriving open source community behind the project. It’s not enough to just say that your software is open source. If you don’t have a great community behind the project, then the open source piece doesn’t do too much for you.

With that said, I was really intrigued by this whitepaper from Achieve Health that talks about why they are applying the popular open source Drupal framework to healthcare. While I’ve mostly used WordPress for the things I’ve done, I’ve had a chance to use Drupal for a few projects and I’m really intrigued by the idea of applying the Drupal framework to healthcare.

This section of the whitepaper describes their vision really well:

Drupal is not a replacement for legacy IT systems from EMRs, Billing, Practice Management etc., but rather an extension to these systems. Through sophisticated integrations Drupal can enhance the functionality of each system concurrently. While there is no one panacea for the trials ahead, Drupal is highly capable of rising to meet many of the existing and future challenges the industry has to offer.

In the whitepaper they mention open source success stories like Pfizer, Florida Hospitals, Amerigroup Health Services, and Alliance Imaging. I think we’ll continue to hear of more and more open source success stories in healthcare for the reasons outlined in the whitepaper Harnessing Open Source Technology to Drive Outcomes in Healthcare. It takes a bit of a different mentality to go the open source route, but those who do are usually very satisfied. I think healthcare IT could really benefit from this shift in mentality.

An article in Becker’s Hospital Review caught my attention this morning, not specifically because of the topic but rather because of what it portends for the careers of physicians and health IT workers. The article, 10 Concerns and Trends Facing Hospitals...(read more)
Source: HealthBlog

Top News


A Boston Globe article says that HITECH has pushed EHRs into clinical settings, but “staunch resistance to any regulation by the politically influential health records industry” has sidestepped the reporting and tracking of medical errors they cause. It cites a malpractice study that found that the most common adverse event to which EHRs contributed – of which 46 caused patient death – was often due to providers that straddle both paper and electronic records. The study also cited problems of incorrect data entry, inappropriate use of EHR copy and paste instead of entering fresh daily notes, and computer downtime.

Reader Comments


From Anonymous Tipster: “Re: Siemens acquisition. I heard from a highly placed Cerner executive that the deal will be done for $1.2 billion. It will probably shake up Cerner’s stock price, but leave it with better financial capabilities and a bigger customer base.” Unverified, but the rumor that Cerner will acquire the Siemens healthcare IT business seems to have legs and the non-anonymous folks who are telling me have well-placed sources.

From Recognize This: “Re: Nuance. I heard a rumor about major layoffs and closed job requisitions.” Unverified.


From Desai Arnaz: “Re: HITPC. I looked at the HITPC schedule and every MU Committee meeting is cancelled the rest of the year. They have met faithfully every two weeks for the past several years. What is going on?” I think the old Meaningful Use Workgroup has been replaced by Advanced Health Models and Meaningful Use under Paul Tang, and since that group was just formed, they probably haven’t put their meetings on the calendar yet. But my already-slim interest in ONC’s doings is lessening by the day, so maybe someone more attuned to HITPC’s workings can jump in with an explanation.

HIStalk Announcements and Requests

The LinkedIn Police Department has decided that my Carl Spackler photo and my use of “Mr.” as a first name makes them unhappy, so I need suggestions for alternatives. I’m at least impressed that someone at LinkedIn recognized the Cinderella boy’s photo on my profile even though it means I have to replace it.

Acquisitions, Funding, Business, and Stock


HealthEquity, which offers an online health savings account management system, announces plans for a $100 million IPO. I’m intrigued by co-founder Steve Neeleman, MD, who played Division 1 college football, ran the airport services division of an airline, wrote a book on HSAs, and still practices as a surgeon. I’m not impressed by wealth or self-importance, but I like people who are interesting in multiple ways.


PM/EHR vendor Azalea Health will merge with competitor simplifyMD, although “merge” sounds like an acquisition by Azalea Health given that the new entity keeps its name and executive team. Azalea Health got its start with a $1,000 business plan prize from the local chamber of commerce. Its founders all graduated from Valdosta State University (GA). The company will now have 70 employees with main offices in Alpharetta and Valdosta, GA.


“Smart clothing” vendor Sensoria (formerly Heapsylon), whose tagline is “The Garment is the Computer, gets a $5 million first-round investment. The Redmond, WA company was founded by former Microsoft executives, as you might suspect given its location.


England-based HealthUnlocked, which calls itself “LinkedIn for Health” in connecting people with a given condition to each other and to providers, announces plans to expand globally and its release of a new mobile app. 


Canada-based Privacy Analytics, which offers data de-identification and masking products for healthcare organizations using data for secondary purposes, gets $3.5 million in seed funding.


Epion Health, which offers a patient check-in app, receives a $4.5 million first funding round. It announced last week its participation in athenahealth’s More Disruption Please program.


Forty big US companies, some of them drug manufacturers, have recently bought small foreign firms and declare their new headquarters to be at that company’s overseas location, a loophole (“tax inversion”) that allows companies to avoid paying US taxes on their foreign profits. The latest rumored possibility: Walgreens, which has an option to buy the remaining 55 percent part of a European drug wholesaler that it doesn’t already own.


GE Chairman and CEO Jeff Immelt says GE Healthcare is facing US market challenges as hospital admissions decline and the Affordable Care Act makes hospitals wary of buying new medical equipment.



Parkview Medical Center (CO) selects the Emma clinical communication system from PatientSafe Solutions.

Community Hospital Corporation (TX) chooses the HCS Interactant EHR for its long-term care hospitals.


Fauquier Health (VA) chooses TigerText secure messaging.


In England, the trust running Watford General Hospital signs a $44 million contract with CGI to update its IT infrastructure and services. The hospital blamed its outdated IT system earlier this year after an internal review found that at least two cancer patients died when the hospital failed to send them appointment letters. CGI had a software-related problem of its own – Healthcare.gov.



Population health management vendor Aegis Health names Chuck Steinmetz (Emdeon) as CIO.


Systems Made Simple elects its CMIO, Viet Nguyen, MD, to its board.

Announcements and Implementations

Coastal Healthcare Consulting announces a Meaningful Use mock audit service.

New York eHealth Collaborative announces the first seven healthcare startups selected to participate in the 2014 New York Digital Health Accelerator. They are AllazoHealth (predicting medication non-adherence; Clinigence (care gap identification); Covertix (protection of confidential information); iQuartic (analytics); Noom (weight loss app); Quality Reviews (hospital patient feedback and online ratings); and Sense Health (connecting with Medicaid patients).

Lifepoint Informatics introduces a patient portal for lab results and diagnostic imaging reports.


MemorialCare Health System’s Orange Coast Memorial Medical Center (CA) goes live on the Aventura Roaming Aware Desktop.

East Jordan Family Health Centers (MI) goes live on Forward Health Group’s PopulationManager.

Vocera releases Alarm Management and Alarm Analytics, patient safety solutions that address alarm fatigue. The company also releases the latest version of Vocera Care Experience, with enhancements to its Care Rounds, Care Calls, and Business Intelligence modules.


Ping Identity announces PingID, a smartphone-based user authentication system for what it calls the “post-password era.” Any application or person requesting authentication sends a push message to the phone of the user, who then simply swipes the message to verify their identity.

Government and Politics


NPR covers Mini-Sentinel, a $116 million FDA project that will churn through medical claims data provided by 18 insurers and health plans to look for adverse drug events.

Mary R. Grealy, president of the Healthcare Leadership Council, tells a House subcommittee that for-profit companies should be given access to federal health databases to help work on disease and population health problems.

Innovation and Research

A small study finds that half of post-discharge hospital cardiac patients were taking at least one medication not listed on the discharge medication list or vice versa, a problem more commonly found with patients with low health literacy.


An Illinois-based ambulance company is testing Google Glass units from Pristine, Inc. to allow paramedics to transmit live video to the ED for real-time consultation, saying the $1,500 units are a low-cost entry to telemedicine. The test will determine whether the consumer-grade technology and available bandwidth are reliable enough for treating critical patients.

Amazon announces a limited preview of Zocalo, a fully managed cloud-based storage and synchronization service for enterprises that will compete with Dropbox, Box, Microsoft OneDrive, and many others. Zocalo costs $5 per user per month for 200GB, offers administrative and signup tools, and integrates with Active Directory. It runs on and is managed from Amazon Web Services. That’s bad news for the hugely money-losing Box, which focuses on the non-consumer market and has targeted healthcare as a key vertical.


The New York Times profiles NovaSom, which just released a wireless, at-home sleep apnea test that costs $300 (a tenth of what hospitals charge) and eliminates the patient inconvenience of being wired up and put to bed under the watchful eyes of camera-monitoring sleep technicians.


A Minnesota TV station covers Ambient Clinical Analytics, which is commercializing Mayo-developed ICU dashboard technology.



Eight-hospital UNC Health Care (NC) says it expects to bounce back this year after financial losses it attributes largely to the cost of its Epic implementation. The system delayed its approval of its new budget until the Epic rollout was further along.


The Johns Hopkins Hospital (MD) will pay $190 million to settle a class action lawsuit brought by 8,000 patients stemming from the actions of a former employed gynecologist who used a secret camera worn around his neck to record his examinations. The doctor committed suicide in early 2013 days after he was fired.

A Texas doctor says her EHR is “only a little better than a fax machine” because nobody requires that EHRs communicate with each other even though the government rewards their use. The chair of the Texas Medical Association Practice Management Council says the government has failed to set standards and wants medical societies to get involved. “Had we when this all started said we need open databases … that any EMR can understand, then the EMR vendors would have to compete on workflow and features. If we could somehow organize to say this is the way databases need to work, so that we can have this data exchangeability, then we’ll have competition on the presentation layer and the workflow.”


The CEO of Henry Ford Health System (MI) says she’s disappointed that Moody’s downgraded the health system’s bonds because of poor operating results and its $356 million Epic system, admitting that it had “two or three tough years for us with increasing uncompensated care, Medicare cuts, and the Epic impact to us that caused productivity issues.” However, she adds that the use of Epic is producing $50 million per year in savings.

Patent troll Uniloc USA files lawsuits against Cerner, CPSI, e-MDs, Epic, GE Healthcare, Greenway, Medhost, and other vendors for violating its patent, which involves displaying clinical data in a spreadsheet-type format. One of the company’s idiotic lawsuits was against Rackspace, which it said violated its patent because Linux rounds a number before performing a calculation. The judge told Uniloc to hit the road before its case even came to trial.


New York-Presbyterian Hospital (NY) is renting space at the Blueprint Health accelerator, installing its own computers and servers at the accelerator’s SoHo offices to create an “innovation space.” It will work on projects that include a system that allows inpatients (presumably pediatric ones) to play games and message each other and another involving tablet-based bedside communications. The hospital says it is also open to commercializing technologies developed by Blueprint’s startups.

The American Osteopathic Association passes a resolution urging patients not to use symptom-checker apps and websites as an alternative to an office visit, saying that such self-diagnosis tools don’t take their medical history into account and often miss drug interactions.


The husband of a pregnant woman who started early contractions three hours from the nearest hospitals uses the First Opinion app to text a doctor, who walked the couple through delivering their healthy baby. The 24-hour-per-day service offers one free consultation each month or $12 for additional ones and guarantees a doctor’s response within nine minutes. The company announced $1.4 million in new funding in May 2014, raising its total to $2.6 million. The founder and CEO intended developed the app for pregnant women, but saw an opportunity in the 85 percent of family doctor visits that he says involve five-minute conversations that end with the doctor saying, “Come back if it gets worse.”

Weird News Andy titles this story as “Getting Screwed.” A former California hospital owner admits to bribing surgeons to implant counterfeit spinal surgery hardware, some of it made by local machine shops, into patients. The bribes included cash and flights staffed by accommodating prostitutes.

Sponsor Updates

  • Besler Consulting offers a free version of its Readmission Analytics tool for hospitals to manage their 2015 QualityNet Hospital-Specific Reports, covering number of days to readmission, a summary of discharge destinations, the presence of clinical contributors, and a breakdown of facilities to which patients are being readmitted.
  • Gartner positions Perceptive Software in the Leaders Quadrant for enterprise search solutions.
  • Black Book names Nuance the #1 vendor for end-to-end clinical documentation improvement.
  • Extension Healthcare will exhibit its next generation clinical alarm management and care team collaboration solution, Extension Engage, at the Siemens Innovations ’14 conference August 10-12.
  • TeraMedica announces that seven of the top 17 hospitals on the “US News & World Report Best Hospitals” list use its image archive and management system.


Mr. H, Lorre, Jennifer, Dr. Jayne, Dr. Gregg, Lt. Dan, Dr. Travis.

More news: HIStalk Practice, HIStalk Connect.

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Contact us online.



Source: HISTalk

I’m a big fan of the online world. I love the ease of online banking, the efficiency of Zappos shoe shopping, and the simplicity of reading The Drudge Report for all the latest news. Someday I may also be a huge enthusiast for online patient portals, but that’s not quite the case today.

During the workday I rarely think about mundane tasks such as scheduling physicals or calling the eye doctor to order new contacts. I am more likely to recall that my daughter needs a follow-up appointment with the ENT when I notice her taking off her hearing aid for the night. Or, I’ll remember it’s time for a mammogram while sharing a bottle of wine with girlfriends and someone mentions the joys of her most recent scan. That last one happens a lot, actually.

I’d like to think I am the quintessential candidate for online patient portals: busy single mom who works full-time and is tech-savvy. I have little patience for being placed on hold for 10 minutes while listening to an endlessly looping recording about the importance of my call. I’d much rather schedule a doctor’s appointment with a few clicks on my keyboard while sipping my first cup of coffee. I get annoyed when my only communication option is to wait until the office opens at 9:00 a.m., navigate the automated phone system, listen to on-hold messages, and finally exchange forced pleasantries with a multi-tasking receptionist.

Recently I had a very positive experience using my primary care physician’s patient portal. One of my specialists requested a copy of my PCP’s referral form in order to schedule a new appointment. I accessed the PCP’s patient portal and in about two minutes found the referral and requested a copy to be forwarded to the specialist. The next day the specialist’s office called to say they had the referral in hand.

Other recent patient portal attempts have been a bit less successful. Typically if I need to schedule any type of medical appointment, I first go to the practice’s website and determine if they have an online scheduling option. That’s what I did a couple of months ago to schedule an appointment for my daughter and the whole process worked beautifully: the system asked for my preferred days and times; the next day I had an email informing me to check to practice’s portal for a message; the message informed me of the appointment time, which I then confirmed.

Unfortunately, a couple of days later my daughter reminded me of a conflict. So, back to the portal I went to send a new message requesting a reschedule. After several days I realized no one had responded to my message. I sent a second message. Again, no response. I ended up having to call the office, navigate the automated phone system, listen to on-hold messages, and finally exchange forced pleasantries with a multi-tasking receptionist.

Another one of my physicians uses a patient portal but its functionality is limited. For example, I am able to request an appointment with preferred dates and times, but rather than having an automated response, someone calls me back to finalize the appointment time. It beats having to call the office and being placed on hold, but if I miss the call or am driving, it’s back to the old-fashioned telephone method.

I often hear providers complain about the Stage 2 Meaningful Use requirement that at least five percent of patients view or download their personal health information via an online portal. Many argue the threshold is too high because many patients lack Internet access or computer expertise, or simply prefer communicating with a live person. However, I’d contend that providers are not doing themselves any favors by implementing poorly designed portals with limited functionality. As a patient, I wonder why I should use a portal if it doesn’t eliminate having to call the practice. I worry that my messages are getting “lost” – either due to technical glitches or office workflow issues. I get frustrated with confusing navigation and functionality that can’t hold a candle to what my veterinarian offers.

In a world where we can spend 10 minutes online and pay a month’s worth of bills, buy a pair of shoes, and read the day’s headlines, why is the healthcare industry so far behind in its efforts to provide patients with a consistently efficient online experience?

Categories: News and Views , All

HealthEquity Sets $100 Mil IPO Terms

HealthEquity announces IPO plans that will raise $100 million through the sale of 9.1 million shares valued at between $10 and $12. The offering is being underwritten by JPMorgan and Wells Fargo Securities.

UNC Health Care bounces back from operating loss

UNC Health Care is forecasting a $53 million profit next year, up from last year’s $12.2 million loss which CFO John Lewis attributes to expenses related to its system-wide Epic implementation.

Big Data Peeps At Your Medical Records To Find Drug Problems

NPR covers the FDA’s $116 million mini-sentinel project, a data analytics initiative aimed at uncovering unknown side effects in post-market drugs and medical devices.

iEHR redefined: DOD’s top 3 tactics in VA turf war detente

Government HealthIT traces the remaining funding allocations for the defunct iEHR program, highlighting the various modernization and interoperability projects now being pursued instead


Source: HISTalk
PhilipsElekta (NSE:EKTAb) and Royal Philips (NYSE:PHG, AEX:PHIA) announced today that The Christie NHS Foundation Trust (Manchester, UK), a specialist cancer center, will join a consortium whose mission is to develop the clinical value of an integrated magnetic resonance imaging (MRI) guided radiation therapy system. Such a system would, in principle, improve the practice of radiotherapy via real-time visualization of cancer targets.
This appeared a few days ago:EHR Systems Falling Short in Improving Patient SafetyGreg Slabodkin JUL 18, 2014 9:21am ETHealth information technology, such as electronic health records, has the potential to dramatically improve patient safety. Nevertheless, a majority of healthcare organizations are not using EHRs to help track adverse events, and ones that are have their own health IT–related safety risks.“Most hospitals, even those with EHR systems, do not know their own rates of adverse events,” testified Ashish Jha, M.D., professor of health policy and management at the Harvard School of Public Health, on July 17 before the Senate Health, Education, Labor and Pensions Subcommittee on Primary Health and Aging. “They don’t know how often they harm patients. However, there are now tools available that automatically track these events and these tools are generally quite good. Yet, most EHR vendors have not put these tools into their EHR systems.”Jha argued that if automated patient...

This is the initial part of the post - read more by clicking on the title of the article. David.
Categories: MedTech and Devices , All

July 21,2014


A lot of people are talking about the recent JAMIA article that looked at whether Stage 2 Certified EHRs are ready for prime-time interoperability. It concluded that four key areas need to be addressed to improve CCDA quality. One area is “terminology vetting” for the multiple vocabularies used including SNOMED, LOINC, and RxNorm. Another area is reducing the amount of data that can be “optional” with a product still receiving certification.

I agree with both of those, as well as the paper’s assertion that document quality needs to be assessed in “real-world clinical environments.” However, it’s highly focused on the technical aspects of document exchange rather than the actual intellectual quality of the document being exchanged. I wrote about the quality (or lack thereof) of some physician notes a couple of weeks ago. Unfortunately, there are more elements besides the provider’s narrative and abbreviations that are problematic.

My health system is the ultimate best-of-breed nightmare, so I can attest to the fact that some vendors’ incorporation of the clinical problem list into the CCDA reads like one of those “choose your own adventure” novels. Is it an active problem, chronic problem, recurrent problem, or something that just happened once in the past? With some of our documents, I just cannot tell what it is trying to depict. I often feel like I have chosen a path to nowhere, just like the books.

There are fundamental differences between how physicians and other clinicians are trained to sort information. When I trained at a fairly “classical” medical school, we were taught that all of the patient’s problems were part of the Past Medical History, even those that were not truly past such as chronic hypertension, diabetes, obesity, etc. When I helped bring our organization into the EHR universe more than a decade ago, it took while for providers to get used to the idea of a chronic problem list being different from the PMH because many providers still wanted to include everything in the PMH.

Now we’re at the point where we have to educate them on the SNOMED-codified Problem List and how it differs from the ICD-10 Assessment List, even though there may be two codes that represent a single disease. I have finally gotten over it, but many of our physicians are still struggling with the concept despite having been trained two or three times.

Some of the CCDAs seem to comingle the two. It’s maddening. I’m tired of opening vendor support tickets to try to figure out if they’re functioning as designed or just messy. They must meet the letter of the law to receive certification, but that doesn’t necessarily mean they’re good for patient care or educating the patient on the conditions noted in his or her record.

Whether or not Eligible Providers are meeting the letter of the law or the spirit of the law with Meaningful Use is another hot topic. Lately, my running habit has been taking a toll on my feet, which prompted a trip to my favorite foot specialist. He’s a good friend of mine and part of a husband and wife team practice. They’re fiercely independent and have successfully deployed a Certified EHR over the past couple of years. We always chat about EHRs and where they stand.

I knew they were getting ready for attestation when the rooming technician came in with a wrist blood pressure cuff. In practice, I’ve found those kinds of cuffs to be notoriously unreliable, so I asked him if he wanted me to just self-report some numbers that would be accurate. He declined my offer and proceeded to document the 141/87 that the cuff read out. My blood pressure hasn’t ever been that high, but now it’s in my chart. When my colleague came in, I asked him what he thought about it. He wasn’t thrilled and said it sounded like some coaching was in order.

We talked a little bit about integrated vital signs monitors that would make things easier. He then he admitted that they’re thinking about throwing in the towel on MU. Their vendor has been doing a good job helping them dot the Is and cross the Ts, but the thought of an audit scares them. With all the points that must be perfect for an honest attestation, they are wondering if it’s worth the risk. Right now their patients are happy, their staff is happy, and their practice is running well enough from a business standpoint, so why upset the apple cart?

I don’t disagree with them. At times it doesn’t seem like it’s worth it. A lot of practices are just operating out of fear of future penalties or fear that commercial payers will adopt the CMS standards. Fear isn’t really a healthy way to run a business, however.

Since we’ve been friends for a long time, I offered to do a peer audit for them using my knowledge of MU to see how close to compliance they are. There are plenty of professional consulting firms that will do practice audits and they may want to ultimately do that, but are interested in seeing where they sit from a friendly point of view.

In the olden days (or in a truly free market economy) we could have traded some consulting for a free cortisone shot or something like that, but the insurers would take a dim view of that, I’m sure. Given my CMIO role, I also have to be careful about doing anything that could be interpreted as a donation from the health system so I don’t run afoul of any anti-kickback rules. When all is said and done, it will be interesting to see how many providers end up opting out of MU and what percentage of them are independent physicians.

Are any of your providers opting out of MU? Email me.

Email Dr. Jayne.

Source: HISTalk

Amy Abernethy, MD, PhD is SVP/chief medical officer of Flatiron Health of New York, NY.


You’re going from ivory tower research and patient care to work for a start-up run by a couple of twenty-something Internet millionaires who have no healthcare experience. What do you hope to accomplish at Flatiron Health that you couldn’t do at Duke?

For the last decade or so, I’ve been working under the basic premise that a fundamental challenge in better bridging research and clinical care was the lack of interoperable or real-time data. I’ve been working on this problem from every direction, usually with cancer care and research as my demonstration model. Sometimes my approach was to focus on how to create the data stream. Sometimes I focused on cyber infrastructure. A lot of other times, my focus was from the point of view of, “If you have the data, what would you do with it next?”

In this vein, I thought about the context of clinical use as well as other problems like storing the information for research, quality, etc. in the future. It has been clear over and over again that a key bottleneck to solving the problem has been in creating the right kind of data infrastructure that is large enough and represents a broad enough footprint of the whole population.

About a year ago, I started learning about what Flatiron was trying to do. It’s interesting the words that you described, “Internet millionaires who didn’t know anything about health IT or healthcare.” That’s exactly where I was when I first started talking to them. They would call me and I would give them a hard time on the phone, and then otherwise that was the end of the conversation. But every single time I said to them, “OK, here’s what I think you need to solve and here’s what I think you need to do next,” and then, a month or two later, they would call me back up and they had done it.

Over the course of about six to eight months, they advanced a series of what I thought were critical steps to solving this problem, at least within the cancer space. By March, the convergence of those steps got me to the point where I said to myself, ”If I’m going to truly work on this problem, solving it and taking it to the next level, then I need to not be watching from the ivory tower, but right in the middle of it. I need to help lead it forward.”


It sounds as though you’re buying into their premise that oncology needs to be disrupted.

I am absolutely buying into that premise. From the standpoint of being an oncologist, I have sincerely believed that it needed to be disrupted for a very long time. But I feel like I have been playing around with how to disrupt it and have been more nibbling on the edges rather than getting into the center of the story.

As this year has progressed and I’ve been talking more and more to Flatiron, working with important groups like the American Society of Clinical Oncology, laying out a roadmap for learning healthcare, etc. it became clear that solving this problem was part of the major disruption action.


Oncology is more patient-centered and longitudinal in treating patients for years. In your TEDMED talk, you talked about using data both from providers and from patients themselves more effectively. How do you see all of that feeding together and what’s the patient’s role in creating this data?

I’m going to take that question into two parts. On one side, I’m going to talk a little about why I think oncology is a unique space, then also talk about what I think the role of patients is.

From a standpoint of oncology being a unique space, in 2009 or so there was a paper in Health Affairs by a guy named Lynn Etheredge that set out the premise that if we’re going to solve the Medicare dilemma — in other words, making Medicare sustainable — we need to attack it from the point of view of oncology. My point is that I’m not the first person to say what I’m about to say, but it has started to crystalize and become clear over the last three to four years.

Oncology is unique because of some of what you said, which is there’s a longitudinality to it. We follow patients very intensely and have very close connections over time. It’s also a space where the science and the clinical care meet.

If you want to solve problems in learning healthcare where the science is as visible and as expected to be a part of the clinical space as the rest of clinical medicine, oncology is a good place to do that. Its a place where the conversation around a patient being involved in clinical trials is a given, not an extra conversation on the side. Then there’s an inherent urgency to cancer care and research; an inherent patient and family centeredness to it.

Then, frankly, it costs a lot of money. The expense of cancer care is going up both because it’s now becoming one of the dominant causes of death, if not the leading cause of death, worldwide. Interventions are getting more and more expensive.

We’ve got this confluence of reasons that make oncology a good use case, a demonstration model. It’s not the only place we’re ultimately going to need to solve this problem, but it’s a good place to start.

The other question that you had was something that I really believe in, which is that patients shouldn’t be a sideline in the story, but need to be central to the story. When we talk about learning health systems, it’s as if the unit of goal optimization is the health system itself. But shouldn’t it be that we’re optimizing healthcare because it’s better off for people and for patients? Instead of optimizing healthcare so that the hospital makes more money or the health system is financially sustainable, let’s focus on better care for patients, with improvement of the health system as a byproduct. That’s a much better model.

I always start off my thinking about how to tackle these problems with the patient at the center of the model. An interesting thing happens when you do that. One of the big issues in learning health systems is data linkage — the ability to take care of populations, the ability to follow people longitudinally over time. When you center the conversation on the patient first, it is much easier to think about how to solve some of those problems.

I have found that by disrupting even our way of thinking about learning health systems so that the patient is the central unit of what we’re thinking about as opposed to the health system being the central unit of what we’re thinking about, we approach solving a lot of problems much differently and smarter.

We’re also in an interesting place where the kind of data sets that we’re going to have in the future aren’t just going to be, for example, electronic health record data or administrative data. It’s going to be data generated by patients, by people, wherever they are.

I started off doing this work in patient-reported outcomes and thinking about how we ask about their symptoms, their quality of life, what is meaningful as it relates to health and healthcare. It turns out that technology enables us to imagine a world where you can ask a patient about symptoms sitting in the clinic waiting room or you can ask about symptoms when the person is sitting in their home in Asheville, North Carolina. You can follow people in between the visits, etc., gathering a much clearer picture of the longitudinal story and implications of different health interventions. 

The land of patient-generated data is getting more and more interesting. The ability to use biometrics and sensors and understand what our world looks minute to minute and day to day from an individual person viewpoint really changes the landscape of how we use big data to solve problems in healthcare. The ability to think of glucose data not just as a data point being generated by the hospital lab, but as glucometer-based data that’s coming from the home.

We’ve been collecting these kinds of data for a long time. The home glucometer is nothing new. Pain became the fifth vital sign in the 1990s. But we haven’t really systematically thought about how this is a part of our national data set in order to solve the problems of learning healthcare. When it comes to patient centricity, it shouldn’t just be a byline, but part of the way you think about designing and developing our systems.


When people think of oncology data lately, they’re probably thinking about applying genomic information to treatment decisions or sharing protocols from major cancer treatment centers. How do you see all that fitting together, particular on the genomics side?

The genomics side again is a really nice use case. I don’t think you or I believe that genomics is going to be the only scientific story in the future. There’s going to be a lot of other ones. But if we can start to get our head around how we merge what’s happening within the context of life sciences and basic sciences with clinical annotation of basic science data putting biological discoveries into context of what happens for individual patients, our science will be much better.

Those two pieces need to come together. In order for that to happen, we need to do a lot of things. One is we need the cyber infrastructure that allows that to happen. It’s the combination of bioinformatics as we’ve classically thought about it plus clinic informatics and applied informatics and the emerging combination of these, including dealing with everything from the storage, data quality, and data use issues. Also starting to think about how much information do you really need to store for this particular patient, how do we analyze it, what is the right research to conduct, and what should that look like.

Another example of what we’re going to need to deal with is trying to get our heads around if we did have a cyber infrastructure, how do we thoughtfully manage the security, confidentiality, and privacy issues? If we are bridging between questions in clinical research and healthcare quality, how do we deal with questions of permissions, consent, and human subjects protections? These pieces are starting to crystallize, but we have a long way to go.

The genomics use case also takes us into the clinical applications side. As we start to have more genomics-informed cancer care, for example, how do we help clinicians and patients make snap, very quick, well-informed decisions at point of care so that we’re surfacing in real time the right combination of this person’s genomic profile, coupled with what we know are the right drugs for that particular clinical scenario, and understanding that there are limitations to what’s possible depending on reimbursement scenarios? It needs to be the complete complement of data in order for clinical decision support systems to be truly useful and not annoying. As a very basic example, if we surface genomics plus drug information independent of reimbursement, we’re not doing anybody any good.

Ultimately, solving these problems for genomics and, along those lines, next-generation sequencing, within the context of cancer care, presents us with a great use case that’s going to be replicated multiple times.


Oncology is a lightning rod is from a societal perspective. Hospitals that suddenly start treating oncology patients as outpatients because they mark up their visit higher than oncologists in the office, for-profit cancer chains, oncologists paid to administer or incented to administer more expensive drugs, a lot of pharma influence, the pharmacoeconomics of expensive drugs versus what benefit the patient gets. All those are issues interfere with the pure science and medicine of how cancer is treated. Do you see that being something that Flatiron will help resolve?

This is the reason why data is the bridge. All of those problems have as a foundational or fundamental underpinning — the need for discrete, interoperable data that can be reused to address each of those things simultaneously. Whether or not you’re actually trying to get the science smarter or you’re trying to optimize reimbursements, you need essentially the same data points to do so.

One of the reasons that I made the jump from academia to industry is to try and figure this out. Resolving all of these problems means that first you’ve got to deal with the data bottleneck. But at the same time, you need to be doing R&D work, imagining a world when the data bottleneck is solved and answering the question of “and what do I do next.” You have to be ready to work through all of those different, as you said, lightning rod questions, which is going to take a lot of work and practice.

While ultimately the data are substrate and producing the data streams that can be analyzed to solve those different problems is a fundamental underpinning, after that you still need to advance the work in the analytics space, align culture, sand out processes including scientific methods in order to pull all of the pieces together, etc. I have this one talk that I always give on the convergence of personalized medicine, comparative effectiveness research, healthcare quality, healthcare optimization, and patient centricity. If you take all of those, the one common element is interoperable data.


Along those lines, along with the announcement of the Google Ventures investment in Flatiron was its acquisition of Altos Solutions and its oncology EMR. Was that done as a way to get quick access to a lot of oncology information without having to do individual integration with the varieties of EMR systems that are used by oncologists and hospitals?

There’s a couple of pieces of an answer here, so I’m going to take it separately. First of all, the way that Flatiron is doing its work is EHR independent. The idea is essentially to extract the data from the back end use a process of technology-enabled chart abstraction and other techniques to make it to a common data model. This dataset can then be integrated with other data feeds like the Social Security Death Index. It doesn’t matter if it’s Varian or iKnowMed or Epic Beacon from an oncology EHR standpoint.

The addition of Altos revved the engine, because at least now there’s one cloud-based oncology EHR that has essentially a single instance and doesn’t require a different setup for every single site. But is really essentially one additional extraction to an overall model. That’s the first point of efficiency.

It also catalyzes or adds a jump to the next level in terms of acceleration of footprint for the number of oncologists and therefore their patients represented in the national footprint for Flatiron. Those two things are important and near-term wins for why Flatiron bought Altos, but now you’re going to hear Amy’s part of the story.

If you take what I just said — and I love the way you said it was a lightning rod – oncology is a lightning rod for all these pieces coming together, not just solving the science and genomics, but it’s the comparative effectiveness research, figuring out how to optimize healthcare, etc. As I mentioned, data is the fundamental substrate, but then you have got to learn what to do with it next.

A lot of that also is clinical decision support for personalized medicine and other interfaces directly in the clinic at the right time with doctors and patients to make healthcare more efficient, patient centered, and of better quality. For example, better allocation of care along predefined evidence-based pathways and monitoring of whether the care provided actually aligns with the evidence. The availability of real-time education.

Altos as a cloud-based EHR will provide Flatiron with a beautiful, national scale living laboratory to try out all the different ways of using and reusing data in the context of what EHR can do for you. It’s a near-term win in terms of data sets and efficiency, but the real big win here is in terms of a national living laboratory where Flatiron and clinical partners can work together to use technology tools to make cancer care better. Now that’s a use case.


Other than that acquisition, $130 million is a pretty big investment for a startup. How will that money be used?

A key aspect of the focus of Flatiron for the next two years or so is going to be making sure that the corporate philosophy is well attended. This includes building the tools that are needed, making sure that clinical practices are well served in terms of having their data extracted and getting them meaningful processed data back that’s actionable at point of care, and the scale from the technology development side in order to support key data partners like the life sciences. We need to ensure that this happens efficiently and with the right kind of engineering focus. That’s going to be a big piece of it.

There’s also ongoing work on how we surface this information, optimal data visualization solutions, how to help clinicians and practice administrators understand the information as efficiently as possible, how do we optimally interface with patients. There’s already a current product, OncoAnalytics, that allows practices to see their data in a dashboard format. It’s really good and certainly much better than anything they’ve already got. But how do you really rev that engine up for data users of all types? That’s going to be a place of substantial investment as we think about how we can get more and more information to practices, life science partners, health systems, researchers, professional bodies, etc.

Why is that so important? We need to see all users of the data, doctors and patients and health systems and sponsors, as key constituents. To create a national data set, it needs to be sourced from many, many places and those different contributors need to see value as to why they want to keep participating and contributing. And it needs to be used. Data quality improves when data are used, not hoarded. Servicing those places is a critical focus.


Do you have any final thoughts?

One of the things that’s been interesting to me and for me is personally making this jump. I haven’t left academia entirely. I still have a 20 percent footprint at Duke, which I maintain so that I can keep working with clinicians and others on solving the problems that we will be able to solve when the data bottleneck is resolved, on mentoring, on other aspects of R&D.

While it’s clear to me that Flatiron is the right vehicle with the scale and talent needed solve this data bottleneck, it was also important to continue to develop the future talent that will be needed to support the next steps in the vision. That’s where my Duke job comes in. Academia offers a unique place for growing the next generation. We all must keep our eye on the big vision, hammer home hard on the key tasks that have to be sorted out, and prepare for the exciting future.

Source: HISTalk

Living in Las Vegas I likely have a skewed idea of what customer service means. In the tech world, we have Zappos headquarters in downtown Las Vegas. Most of you are likely familiar with Zappos unique approach to customer service. They really have taken customer service to the next level and created an entire company culture around the customer service they provide. The same could be said for the experience that the various casinos on the strip offer their customers. They do a really amazing job at most casinos providing an amazing customer service experience.

With this background, I find it really smart of Kareo to open an office in Las Vegas. Although, that’s not really the point of this post. Instead, I want to focus on the idea that most EHR vendors need expand their idea of customer service.

As I look at the world of EHR customer service I see so many organization lacking. Certainly we see examples of terrible EHR customer service that include calling into a call center in another country where the person doesn’t speak English and has no power to actually solve a user’s problems (Disclaimer: I don’t have a problem with call centers in other countries if they are well trained and can actually solve problems). Of course, the same thing can apply to a call center in the US who can’t solve the users’ actual problems. Both are terrible customer service and a problem in the industry. However, there’s a far more painful problem that I don’t think most EHR vendors consider a part of their customer service plan and 99% of EHR vendors have done terrible at this.

Adding new features and accommodating an EHR user’s feature request is just as much a part of the EHR customer service experience as the person who answers the phone. I can assure you that every EHR vendor out there would get rated an F the past few years when it comes to this form of EHR customer service. Why do I know this? I know this because every EHR vendor has been focused on meaningful use that they haven’t had the time to add any meaningful EHR user feature requests and features outside of meaningful use.

This isn’t EHR vendors’ fault. The end users have required it and EHR vendors have had to spend the time doing it. However, EHR customer service has suffered as a consequence. Don’t believe me. Look through all the EHR press releases that have been released over the past couple years. Find me the plethora of press releases that talk about the innovations that EHR vendors have created for their end users that aren’t related to meaningful use. I get the press releases and they’re MIA.

That’s not to say that EHR vendors have done nothing for end users. They’ve made some incremental progress on a few things, but meaningful use has zapped their development time. Stage 2 was even worse. I look forward to the new day where EHR vendors can focus on great customer service and EHR features and not just MU.


Free-standing emergency rooms seem to be emerging as a new category of healthcare facilities, at least in New York City. This according to a recent article about this trend (see: E.R., Not a Hospital, Is Set to Open at St. Vincent’s Site). Below is an excerpt from the article:

The shiplike building on Seventh Avenue that used to house part of St. Vincent's Hospital is reopening in the coming days as a stand-alone emergency room and medical care center....The new E.R. [called HealthPlex], however, is part of a trend that has as much to do with a hospital’s bottom line as it does with providing acute care. Free-standing emergency rooms...have sprouted up around the country in recent years, driven by competition to capture lucrative markets, like the neighborhoods around Greenwich Village. Operators of free-standing emergency rooms....say they fill an important void in areas without full hospitals. They can bring in significant revenue, since they are allowed to charge the same high fees that hospitals charge while having lower overhead. And, since half of admissions come from the emergency room, free-standing E.R.s can funnel patient business to their parent hospitals....The first free-standing emergency room in New York State opened in the Bronx last year, and three more have opened since....Operators of free-standing emergency rooms like the HealthPlex say they fill an important void in areas without full hospitals. But the HealthPlex also appears designed to be an advertisement for the larger North Shore system, and to attract the kind of wealthy West Village residents who avoided St. Vincent’s....Ambulances will not bring patients suffering major trauma, head or spinal cord injuries, heart attacks, acute strokes, psychiatric disturbance or pregnancy-related complications, among other maladies, to the HealthPlex. But...[a hospital representative] said that if someone with any of these conditions walked through the door, the doctors at the HealthPlex would do everything that would be done in a hospital-based emergency room to stabilize the person and then transfer the patient by ambulance to the nearest appropriate hospital....Dr. Howard Mell, a spokesman for the American College of Emergency Physicians, said that in about 1 percent of cases, minutes could make the difference between a good outcome and a bad one, and the extra time for the transfer might be detrimental. But, he said, there were also cases in which getting to an emergency room sooner — because a free-standing emergency room had opened in an area that lacked a hospital — could be lifesaving.

So, like many initiatives in healthcare, the quest for increased revenue seems to be one of the main drivers in the development of free-standing ERs. The hospital systems that own them are allowed to charge the same rates for services as they do in the case of an embedded hospital ER. However, free-standing ERs don't incur the cost of expensive inpatient units such as the critical care units. They thus benefit from higher profit higher margins while, at the same time, providing the opportunity for inpatient admissions to nearby local hospitals within their system. Residents of the neighborhood benefit from rapid attention if they have a acute medical issues but suffer from the disadvantage of needing to then be transported to an inpatient facility for further treatment. 

As I have pointed out in previous notes, we now have the following continuum for routine to emergent healthcare in larger cities: office visit to a PCP or visit a walk-in clinic for simple matters > urgent care clinics for minor injuries or illnesses > free-standing ERs for serious problems (these may require transport to a nearby hospital) > typical hospital ER visit with possible inpatient admission. There is also a gradient of cost across these facilities. This is important for patients with no health insurance or a high-deductible policy to understand. Urgent care facilities provide treatment at a fraction of ER costs (see: Rapid Growth of Urgent Care Clinics; Cost Competition for Hospital ERs). This complex health delivery system puts pressure on consumers who often need to perform self-triage in order to get themselves to the best facility for their problem.

PhilipsPhilips reports Q2 sales of EUR 5.3 billion and EBITA of EUR 415 million. Healthcare comparable sales showed a 4% decline year-on-year. The EBITA margin, excluding restructuring and acquisition-related charges, declined to 10.5%, a decrease of 3.8 percentage points year-on-year. Equipment order Q2 2014 Quarterly report and Semi-annual report intake in Europe and growth geographies showed a high-single-digit increase, while North America posted a double-digit decline.
Here are a few I have come across the last week or so.Note: Each link is followed by a title and a few paragraphs. For the full article click on the link above title of the article. Note also that full access to some links may require site registration or subscription payment.General CommentAnother quiet week with the big news that there is to be some consultation between many stakeholders and Deloittes on the future of the PCEHR. Will be very interesting to see where this points and how deep a dive the consultation actually takes and how searching the questions asked of stakeholders will be.Enjoy browsing the articles!-----http://ehealthspace.org/news/realising-benefits-emm-st-vincent-sRealising the benefits of eMM at St Vincent’s Posted Tue, 15/07/2014 - 16:22 by Josh Gliddon St Vincent’s Hospital, a 320-bed facility in inner Sydney, has had significant success with its electronic medications management system, based around CSC’s proprietary MedChart software.According to Kate...

This is the initial part of the post - read more by clicking on the title of the article. David.
Categories: MedTech and Devices , All
An e-mail came in from the Health Department a few days ago.The gist of the e-mail is as follows.“As previously advised, the Department will be undertaking a range of consultation activities to consider issues relating to the implementation of the Review recommendations. The Department has engaged Deloitte to support it in undertaking these consultations. Consultation activities will include face-to-face meetings and a survey. Deloitte is currently finalising dates and venues for the meetings and will be writing to you directly to advise the details. …..An online survey will also be made available to capture stakeholders' views.  This survey will be made available shortly and can be accessed until 1 September via http://www.ehealth.gov.au.  These details will be included in Deloitte's letter to you.   The Department will also continue to receive any feedback on implementation issues until 1 September at pcehrreview@health.gov.au.”----- End Extract.Deloitte have sent out...

This is the initial part of the post - read more by clicking on the title of the article. David.
Categories: MedTech and Devices , All

July 20,2014


“We live in a golden era of digital toys,” noted comedian Stephen Colbert on “The Colbert Report” last Monday.

Indeed, some of the digital health and fitness products out there are rather ridiculous, even the popular ones, and we’re hearing just that at some actual health IT events. At last month’s WTN Media Digital Healthcare Conference in Madison, Wis., Adam Pellegrini, vice president of digital health at Walgreens, poked fun at programs that reward people for allegedly exercising. “You could put a pedometer on your dog and get 10,000 steps while watching TV,” Pellegrini joked.

Colbert, who certainly was not present at that Madison meeting, got the same idea about the Fitbit activity tracker. “Last week, I wanted to run a marathon, so I strapped this bad boy to a paint shaker for about 20 minutes,” he said.

Colbert then addressed the Vessyl digital cup, which records data on the beverages each user consumes. “That level of information was previously available only on the can you just poured it out of,” he said. He then pointed out that Vessyl only tracks half of the hydration equation, the input, so he announced the pre-release of his own “product,” Toylyt.

Watch the clip below.



July 19,2014

Here are the results of the poll.How Damaging Is The Continuing Lack Of Government Response To The PCEHR Review To E-Health In Australia Overall?Very Damaging 58% (25) Slightly Damaging 16% (7) Not Damaging 16% (7) I Have No Idea 9% (4) Total votes: 43 It seems most think the dithering is not helping anyone's interests! Again, many thanks to all those that voted! David.

This is the initial part of the post - read more by clicking on the title of the article. David.
Categories: MedTech and Devices , All

July 18,2014

I must admit that I’ve been feeling a bit depressed this week about the human condition. A passenger jet gets blasted out of the sky ( mistake or not) by hostile forces. There are rising tensions in the Ukraine and a ground war is now underway in Gaza...(read more)
Source: HealthBlog

I recently had lunch with an EHR vendor that had an extremely small number of providers. I’ve known this EHR vendor for about 5 years, so this isn’t a new EHR vendor that’s trying to establish themselves in the industry. Instead they’ve focused on having a small, nimble team that’s focused on making the EHR work the right way for the doctors. It’s a novel approach I know, but pretty interesting that his business can survive with so few providers. Also worth noting is that the EHR is certified for meaningful use stage 2 as well.

Now think for a minute how the development process of an EHR vendor would be better if your EHR only had 25 doctors (For the record, the EHR vendor above has a few more than 25 doctors). Would it be much easier to satisfy just 25 physician users? Imagine the personalized service you could provide your users.

One of the real challenges I’ve seen with EHR vendors is that when they’re small, they are extremely responsive to their end users and the end users are very happy. As the EHR vendor grows, they lose that personal touch with the end users and many of those originally happy end users become dissatisfied with their EHR experience.

The problem with scaling an EHR user base is that you can’t make everyone happy. You have to make compromises that will be great in some people’s eyes and terrible in another person’s mind. What large EHR vendors do to try and solve this problem is they create configurable options that allow the end user to customize their system to meet their personal needs. Problem solved, right?

The problem with these configurations is two fold. First, you can’t make everything configurable. Once you go down the path of making everything configurable, it never ends. There’s always something else that could be made more configurable. So, the culture of configurability leads to unsatisfied users who can’t customize everything (even if what they want to customize shouldn’t matter).

Second, if everything is configurable, then it makes the implementation that much more complex. I’ve written before about the need for EHR vendors to have great “out of the box” user experience, but balancing that with allowing the user to configure everything that’s needed. This is a real challenge and most fail. Just look at the number of high priced EHR consulting companies out there. Many of them could better be defined as EHR configuration companies since the configuration needs are so large and complex.

Returning to where we started, when you’re an EHR vendor with 25 doctors you don’t have to build in all the flexibility and configurability. You’re small enough that as an EHR vendor you can do any needed customizations and configurations for the end user. Plus, with this kind of personalized service you can charge a little extra as well.

When you look at EHR development, there’s a spectrum of approaches starting with a fully in house, custom designed EHR through a fully outsourced EHR that can apply to any organization or specialty. In many ways a 25 doctor EHR has a lot of the same benefits of a fully custom EHR software, but spreads the costs of development across more doctors.

As a business, maybe a 25 doctor EHR company won’t dominate the world. Maybe they won’t have a huge exit to some other company or an IPO. However, that doesn’t mean it’s not a great small business if it’s doing something you love. Once you get World Domination out of your sites, it changes a lot of things about how you do business.

Digital technologies are altering the very fabric of the traditional healthcare delivery model. Consumers are actively embracing digital tools to take charge of their health. Consider this: no less than 86% of respondents in a survey reported that they wanted to take a more proactive role in their healthcare decisions, and 76% reported that they have the tools and information to do so.
Agfa HealthCareAgfa HealthCare has won a highly competitive bid for a vendor-neutral archive (VNA) and an enterprise imaging workflow solution, for two major academic hospitals in the Netherlands: the Vrije Universiteit Medisch Centrum (VUmc) and the Academisch Medisch Centrum (AMC). This agreement is the result of a tender for the "EVA" project, a collaboration between the two hospitals for implementing a new electronic health record (EHR).

July 17,2014

Health information exchange is one arrow in the quiver that may lead to promised improvement in the coordination, efficiency and effectiveness of health care services based on the sharing of data contained in individual patients' electronic health records. An article...

You should follow me on Twitter: @healthblawg

David Harlow
Source: HealthBlawg

Like many other enabling-technologies in healthcare, telemedicine has vast unrealized potential.

If we make location completely irrelevant and can deliver care virtually, we can address the supply and demand imbalance plaguing healthcare. The benefits to patients would be enormous: lower costs and improved access in ways that are unimaginable in the analog era.

However, one of the many roadblocks to adoption is the cost of the legacy technology powering clinical telemedicine use. In this post, I’ll outline why the telemedicine systems are so expensive, even in the era of Skype and other free video-conferencing systems.

The Telemedicine Industry Is Old…School

Telemedicine as an industry has existed for about 15 years, although uses of telemedicine certainly predate that by another 10-20 years. A decade and a half ago, the foundational technologies that enable video-conferencing simply weren’t broadly available. Specifically, early telemedicine companies had to:

1) Develop and maintain proprietary codecs
2) Design and assemble hardware (e.g. proprietary cameras) and device drivers
3) Deploy hardware at each client site and train end users on its management
4) Build an expensive outside sales force to carry these systems door-to-door to sell them
5) Endure long, grant funding-driven sales cycles

Though some of these challenges have been commoditized over the years, many of the legacy players still manage and maintain the above functions in-house. This drives up costs, which in turn must be passed onto customers. Since many customers initially paid for telemedicine systems with grant money (that telemedicine technology companies helped them write and receive), the market has historically lacked forces to drive down prices. Funny how that seems to be a recurring theme in healthcare!

But, there’s a better way

Today, many startups are building robust telemedicine platforms with dramatically lower cost overhead by taking advantage of a number of technologies and trends:

1) Technologies such as WebRTC commoditize the codec layer
2) The smartphones, tablets, and laptops already owned by hospitals (and individual providers) have high quality cameras built into them
3) Cloud providers like Amazon Web Services make it incredibly easy for young companies to build cloud-based technologies
4) Digital and inbound marketing enable smaller (and inside) sales forces to succeed at scale.
5) To reduce the cost of care, providers are increasingly seeking telemedicine systems now, without wading (and waiting) through the grant process of yesteryear.

In short, telemedicine companies today can build dramatically more cost-effective solutions because they don’t have to incur the costs that the legacy players do.

Why don’t the old players adapt?

The simple answer: switching business models is exceedingly difficult. Consider the following:

1) Laying off hardware and codec development teams is not easy, especially given how tightly integrated they are to the rest of the technology stack that has evolved over the past decade

2) Letting go of an outsides sales force to drive crafty, cost-effective inside sales is an enormous operational risk

3) Lobbying the government to provide telemedicine grants provides an effectively unlimited well to drink from

Changing business models is exceedingly difficult. Few companies can do it successfully. But telemedicine is no different than all other businesses that thought they were un-disruptable. Like all other technologies, telemedicine must adapt from legacy, desktop-centric, on-premise solutions to modern, cloud based, mobile and wearable-first solutions.


Any dancer or doctor knows full well what an incredibly expressive device your body is. 300 joints! 600 muscles! Hundreds of degrees of freedom!

The next time you make breakfast, pay attention to the exquisitely intricate choreography of opening cupboards and pouring the milk — notice how your limbs move in space, how effortlessly you use your weight and balance. The only reason your mind doesn’t explode every morning from the sheer awesomeness of your balletic achievement is that everyone else in the world can do this as well.

With an entire body at your command, do you seriously think the future of interaction should be a single finger? – Bret Victor

MultiSense ICTThe Future will be Virtual, Augmented, and Wearable

The USC Institute for Creative Technologies is a pioneer in Virtual Human (VH) technology. ICT’s work with virtual humans creates digital characters that look, sound, and behave like real people.

Understanding the human face is an especially complex process. The face contains 43 muscles, and it takes five muscles to display whether we are happy, sad, afraid, angry, disgusted or surprised.  But understanding and sensing emotions in real humans is key to making virtual characters more realistic.

VH technology is currently being used to help clinicians better interact with patients.

MultiSense and SimSensei in Healthcare 2014

ICT developed MultiSense as a way to quantify facial expressions, body posture, and speech patterns. Algorithms combine this data to create a complete picture of a user’s emotional state in real time, and with a profile that recognizes changes over time. MultiSense drives SimSensei – a next generation Virtual Human platform designed to improve healthcare decision-making and delivery.

Virtual Humans USC ICT

Learn more about MultiSense and SimSensei in healthcare.

Patients More Honest with Virtual Humans

Virtual Human technology is used in role-playing and training to help clinicians improve their interactions with patients. But new research by ICT has netted some surprising results.

New research finds patients are more likely to respond honestly to personal questions when talking to a Virtual Human.

Originally, ICT began training clinicians by having them interact with a Virtual Human patient. In the new research, the tables were turned – patients interacted with Virtual Human interviewees asking questions a physician might normally ask. The process started with general getting-to-know-you types of questions gradually leading to more personal and revealing questions like, “How close are you to your family?”

“Half of the participants were told that their conversation was entirely computer-driven and not being observed. The others were informed they were being watched by a person in another room who was also manipulating the machine to ask certain questions. In all cases, video images of their faces were recorded and later analyzed to gauge their level of emotional expression.” – Tom Jacobs, “I’ll Never Admit that to My Doctor

Surprisingly, Virtual Humans were able to extract better patient data. In discussing private matters with the computer-generated entities, patients disclosed more information. Why? According to Gale Lucas, who led the study for ICT, participants did not feel like they were being observed or judged. They also reported “significantly lower fear of self-disclosure.”

You can read more about the study in the journal Computers in Human Behavior.

Virtual Humans Will Help Predict Treatment

Across the pond, researchers in England are using Virtual Physiological Humans “to engineer a simulation of the body so true to life, any data could be potentially input to create a personalized health plan, and predictions for any future patient.”

According to Marco Viceconti, Director of the Insigneo Institute at the University of Sheffield,

“If I now feed to my simulations the data related to a particular individual, that simulation will make health predictions about the status of that individual. This is not personalized medicine, this is individualized medicine, we can finally say something about you not because you are about the same age and sex and disease as another thousand people, but because you are you with your condition and your history.”

Virtual Human Insight for Wearable Technologies

In a recent opinion piece for CIO,  Brian Eastwood writes that wearable tech’s dilemma is too much data, and not enough insight. He explains that even though he runs marathons and writes about healthcare IT, he still does not have a fitness tracker.

I started thinking about how Virtual Human technology could combine with wearable devices. Although speech recognition technology is already used with Google Glass, it is not at the level of sophistication of VH. Imagine your own Virtual Human personal trainer who would have an understanding of your emotions and behaviors, and your personal weaknesses and motivators. Interacting with your VH through speech-recognition technology would minimize the need to display lots of data on a small screen. Your VH-enabled wearable device could know just the right words and cues to promote healthy behaviors, and maximize your personal wellness.

There will be no distinction, post-Singularity, between human and machine and between physical and virtual reality. – Ray Kurzweil

Additional Viewing


Categories: News and Views , All

Uwe Reinhardt has published an op-ed piece in the NYT about the illogic about employee-sponsored health insurance plans in connection with the recent Supreme court decision (Burwell v. Hobby Lobby) (see: The Illogic of Employer-Sponsored Health Insurance). Below is an excerpt from it:

...[T]he premiums ostensibly paid by employers to buy health insurance coverage for their employees are actually part of the employee’s total pay package...and that the cost of that fringe benefit is recovered from employees through commensurate reductions in take-home pay. Evidently the majority of Supreme Court justices who just ruled in Burwell v. Hobby Lobby case do not buy the economists’ theory. These justices seem to believe that the owners of “closely held” business firms buy health insurance for their employees out of the kindness of their hearts and with the owners’ money. On that belief, they accord these owners the right to impose some of their personal preferences...on their employee’s health insurance. In the ruling, the owner of Hobby Lobby, a chain of craft stores, gained the right not to include certain contraceptive goods and services in the insurance bought for employees, because use of these services conflicts with the owner’s Christian beliefs. Although the justices argue that their ruling is narrowly confined to contraceptive services, one must wonder what other items other business owners in the future may seek to jettison from benefit packages on the basis of this or that professed religious belief. The ruling raises the question of why, uniquely in the industrialized world, Americans have for so long favored an arrangement in health insurance that endows their employers with the quasi-parental power to choose the options that employees may be granted in the market for health insurance....Furthermore, the arrangement induces employers to intervene in many other ways in their employees’ personal life – for example, in wellness programs that can range from the benign to annoyingly intrusive, depending upon the employers’ wishes.

The illogic of employee sponsored health insurance, explained by Reinhardt, is that the employer take some of the money normally paid to an employee as salary and uses it instead to buy health insurance for that employee. In so doing, the company gains certain opportunities and advantages that it would not normally have. These include the ability to limit the number of health insurance plans from which the employee can choose or the opportunity to not cover the cost of contraceptive goods and services because this is antithetical to the company owner's religious beliefs.

Why and how did employee-sponsored health insurance evolve in the first place? Some of the labor unions favored such a system because it constituted a bargained-for benefit that did not count as employee salary. Employees favored this approach because they received benefits that were not taxed. Legislators liked it because is provided broad health insurance for workers with less federal red tape and control than government-run health systems.

I personally have mixed feelings about what Reinhardt calls the "annoyingly intrusive" demands in wellness programs. I think that the obesity epidemic in the U.S. is one of our biggest public health crises. I don't believe that the majority of overweight Americans are willing or able to reduce their weight and improve their health. It's certainly big-brotherish but I do like employer programs that encourage weight loss. The employers like them because they saves them money and avoids unnecessary absenteeism.

July 16,2014


I’m back from an extended break, though hardly a vacation. I spent 11 days this month cycling from Chicago to Washington to raise awareness of multiple system atrophy, the rare neurodegenerative disease that killed my father in 2012. For my first post in more than two weeks, I’ll keep it simple but important, namely with an update on Health eVillages, the program I sit on the advisory board of, as well as some vaguely related news from Qualcomm.

First off, Health eVillages this week officially welcomed five new board members: Brad Fluegel, Spencer Warden, Mike Hamilton, Lorri L. Jean and Ulya Khan. Here’s the press release in full:


Health eVillages Welcomes Five Renowned Executives to Advisory Board
Will Provide Strategic Guidance to Bring Quality Healthcare to People in Underserved Areas

READING, MA – (July 16, 2014) -Health eVillages , a program founded by Donato Tramuto andPhysicians Interactive in partnership with the not-for-profit Robert F. Kennedy Center for Justice & Human Rights (RFK Center), has appointed five new members to its Advisory Board.

Health eVillages provides iPod®, iPad® and other handheld devices equipped with specialized reference and clinical decision support tools to improve primary and preventive healthcare in underserved areas around the world.

“We are proud to announce the addition of these five fantastic non-profit and corporate executives to our Advisory Board,” said Donato Tramuto, the Founder of Health eVillages. “As HealtheVillages continues to grow its presence across the globe, we are excited to be able to mine the breadth and depth of experience that Brad Fluegel, Spencer Warden, Mike Hamilton, Lorri L. Jean and Ulya Khan bring to the table. We look forward to using their guidance to help shape innovative, strategic approaches to bringing quality healthcare to people in some of the most underserved areas around the world.”

Since its inception in 2011, Health eVillages has made a significant impact in improving access to critical, live-saving medical information worldwide, launching programs in Africa, Central America, Pacific nations, the Caribbean and areas of Louisiana affected by the Gulf oil spill.

The most recent additions to the Health eVillages Advisory Board include:

Brad Fluegel is the Senior Vice President and Chief Strategy Officer at Walgreens Co. Prior to coming to Walgreens in 2012, Fluegel was an executive at several prominent healthcare companies, including Wellpoint, Aetna, Inc., United Health Group and Tillinghast-Towers Perrin. He also serves on the Board of Directors of Metropolitan Jewish Health System in New York City,Health Integrated, Inc., and Performant Financial Corp.

Spencer Warden is the Provider Engagement Lead at Dabo Health Inc., which provides a community healthcare platform to view and track improvement in key performance metrics and allows for collaboration across hospitals and healthcare systems. Spencer’s responsibilities at Dabo Health include business development, corporate strategy, and strategic partnerships in the Hospital and Payer marketplace. He previously worked for Eli Lilly as a Sales Representative in San Francisco’s Neuroscience sleeve.

Mike Hamilton , President of Engagement at Blood: Water Mission, has received numerous honors for his work with youth and children, especially for orphan crisis issues and healthcare needs in Africa. Hamilton came to Blood: Water after 26 years in intercollegiate athletics at Clemson University, Wake Forest University, and the University of Tennessee. He also served on the board for Show Hope and chaired the Knoxville Chamber Partnership and the local United Way Chapter in Knoxville.

Lorri L. Jean is a nationally recognized leader in the lesbian, gay, bisexual and transgender (“LGBT”) civil rights movement.  She serves as CEO of the L.A. Gay & Lesbian Center, the world’s largest LGBT organization.  Previously, Jean served as the Executive Director of the National Gay and Lesbian Task Force.  Jean was the first openly gay or lesbian person to receive a top secret security clearance from the Central Intelligence Agency, and with her appointment in 1989 as Deputy Regional Director of the Federal Emergency Management Agency (“FEMA”), she became the highest-ranking openly gay or lesbian person in the Federal government. OUT Magazine has twice named her one of the 50 most powerful gay people in the nation and Los Angeles Magazine named her one of the 100 most influential people in Los Angeles.

Ulya Khan, the Chief Operating Officer at Physicians Interactive, has more than 20 years of experience in technology, data and operations. Prior to joining Physicians Interactive, Khan held several leadership positions including Chief Operating Officer and Chief Of Staff at Thomson Reuters in London and New York City, where she was instrumental in building and exponentially growing several businesses and managing global teams across Asia, Europe and the Americas.

Additional members of the Health eVillages Advisory Board include:

Donato Tramuto, Founder, CEO and Vice Chairman of Physicians Interactive

Steve Andrzejewski, Chief Executive Officer of Spiritus Pharmaceuticals

John Boyer, President and General Manager of MAXIMUS Federal Services

Dr. Tim Bristol, Nurse Educator

Caleb DesRosiers, Healthcare Counsel at Foley Hoag LLP

Greg Divis, President and CEO of KV Pharmaceutical

Dr. Mary Jane England , Professor at Boston University School of Public Health

Mark Friess, CEO and Founder, WelVU, Inc.

Dr. Antoinette Hays, President, Regis College

Kerry Kennedy, President of the RFK Center for Justice and Human Rights

Devin Paullin, Executive Vice President of Corporate Business Development of Physicians Interactive

Derek Rago, Vice President of Marketing & Strategy, McKesson Patient Relationship Solutions

Glen Tullman, Managing Director, 7Wire Ventures

Neil Versel , Freelance Healthcare Journalist

About Health eVillages
Health eVillages, a program of the not-for-profit Robert F. Kennedy Center for Justice & Human Rights and Physicians Interactive, provides state-of-the-art mobile health technology including medical reference and clinical decision support resources to medical professionals in the most challenging clinical environments around the world. For more information about Health eVillages, please visit http://www.healthevillages.org/.

About Physicians Interactive
Headquartered in Reading, MA, PI aspires to use the power of worldwide networks of healthcare professionals and life sciences companies together in ways that will change the practice and business of medicine for the better. PI’s value proposition is to offer the life science industry a low-cost, virtual, multi-channel marketing approach that can be used to supplement currently promoted products, as well as non-promoted and orphaned products, that deliver benefits to physicians and patients. A key focus is providing services that fit into physicians’ and healthcare professionals’ daily workflow at the point-of-care when they make diagnosis, treatment and prescribing decisions. More information can be found at www.PhysiciansInteractive.com.

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Interested in seeing the kind of difference Health eVillages is making in remote parts of the world? Check out this short video about “moving the needle on global health.”

In somewhat related news, Qualcomm Wireless Reach and Trice Imaging reported last week how their mobile ultrasound technology saved significant amounts of money, time and, ultimately, lives in prenatal care, at three small, rural health clinics in Morocco. Click here to read the case study.


The following is a guest blog post by Jennifer Bergeron, Learning and Development Manager at The Breakaway Group (A Xerox Company). Check out all of the blog posts in the Breakaway Thinking series.
The closest I’ve come to experiencing a house call was watching Dr. Baker on “Little House on the Prairie” visit the good folks of Walnut Grove. Today, most people have no choice but to trek to their doctors’ offices and hospitals for health maintenance, diagnoses and check-ups. But new technologies are returning the personalized attention of the house call and will need to be adopted to retain the convenience and accessibility they offer.

I haven’t met anyone with a practice like Dr. Baker’s, though I recently read a news article that highlights the comeback of the house call. Some practitioners are banding together to provide round-the-clock care to patients who benefit from the fast response and lower cost: If a deductible or copay is higher than the price of the doctor’s visit, the patient may opt for the home visit.(1) The updated versions of the house call, however, are born of the technology used for telehealth, mobile health and health stations.

Telehealth allows a person to connect with a provider via the Internet. Patient and doctor can video conference, share informational media, and experience a face-to-face interaction without either party traveling from his or her home or office.(2) This allows patients better access to specialists who may have been too far away to visit and more frequent care at the right time to reduce the chances of serious complications or hospitalization. For patients who require frequent care over time, telehealth enables them to receive the medical attention they need while staying near their support network.(4) For providers, access to networks of specialists who can provide remote consultation helps them retain and ensure the highest level of care for patients rather than refer patients to another location.(3)

Both patients and providers also save time and money when there is no commute to an office or to a patient’s home. This is especially true of patients who live in rural areas and have to travel long distances for care. The quicker a patient can connect with the right specialist to treat or prevent serious illness, the lower the overall cost of care. (3)

Mobile health, or mHealth, takes technology one step further by allowing providers to track and monitor patient health on mobile devices such as tablets or phones. This includes monitoring devices that measure heart rate, blood pressure, oxygen levels, blood glucose and body weight. mHealth can be used in the office or taken on the road the way mobile clinics do. When healthcare is mobile, the ability to bring a doctor’s office to a neighborhood gives access to communities that otherwise wouldn’t seek or know how to find care. Currently, all 50 U.S. states have mobile clinics.(4)

Another trend in the making is the health kiosk. These look like private pods, about the size of four phone booths side by side. Think of it as telehealth combined with a mobile clinic. HealthSpot, a provider of health kiosks, describes them as “the access point to better healthcare.”(5) In addition to providing interaction with healthcare professionals via video conferencing, each station has an attendant and an automatic cleaning system. HealthSpot aims to give patients a private, personal, efficient experience.

Healthcare is on the move to better accommodate our lives, schedules, family structures and communities, which have vastly evolved from the “Little House on the Prairie” days and even from a decade ago. At the same time, our industry faces challenges in making the new technologies simple to use in order for them to be effective. With telehealth, for example, people typically need help setting up a home system and technical assistance. Meanwhile, providers face communicating and documenting in a new environment.

As we enter this new, modern, faster era of healthcare, both patients and providers will need to learn how to implement and adopt new systems, technologies and ways of interacting. Easing adoption is what we are prepared to do at The Breakaway Group. Once the learning-and-comfort curve is overcome, patients can experience the convenience of Dr. Baker’s updated home visit.

(1) Godoy, Maria, (December 19, 2005). A Doctor at the Door: House Calls Make Comeback.
(2) Health Resources and Services Administration Rural Health, (2012). Telehealth.
(3) Hands on telehealth, (2013). 15 Benefits of telehealth.
(4) Hill, C., Powers, B., Jain, S., Bennet, J., Vavasis, A., and Oriol, N. (March 20, 2014). Mobile Health Clinics in the Era of Reform.
(5) The HealthSpot Station.

Xerox is a sponsor of the Breakaway Thinking series of blog posts.

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