The #1 thing you need to know from the 2017 JP Morgan Healthcare Conference: Follow the money

Via Beckers Hospital Review »

If you want to understand the future of the $3 trillion U.S. healthcare industry, the lesson of the past is to ‘follow the money.’ And no one would argue that the place to do that is the infamous JP Morgan Healthcare Conference taking place this week in San Francisco.

While there are an estimated 4,000 people attending the conference, there’s roughly another 20,000 here for ‘off the grid’ meetings in every nook and cranny you can find. It is a surreal atmosphere in the form of the top executives from more than 450 private and public companies in biotech, pharmaceutical, medical device and technology, as well as healthcare providers, payers, private equity and venture capital firms and investment banks. Simply stated, this is where medicine’s flow happens.

With that said, roughly $1 trillion or one-third of annual U.S. healthcare spend flows through hospitals and healthcare delivery systems. So, if you want to understand what’s happening now and what will happen in the future, a good place to start is in the nonprofit healthcare provider track, where CEOs and CFOs of over 20 of our nation’s largest healthcare delivery systems presented their strategic plans in rapid fire 25-minute presentations.

Together these organizations represent over $100 billion or 10 percent of that $1 trillion spend. Incredible. The average organization presenting had over $6 billion in annual revenue, 15 hospitals, close to 30,000 employees and thousands of physicians on staff. Many of the name brands in healthcare including Downers Grove, Ill.-based Advocate Health Care, Irving, Texas-based CHRISTUS Health, Cleveland Clinic, Detroit-based Henry Ford Health System, Salt Lake City-based Intermountain Healthcare, Indianapolis-based IU Health, Oakland-based Kaiser Permanente, Cincinnati-based Mercy Health, New York-Presbyterian, Chicago-based Northwestern Medicine, Northwell Health in Great Neck, N.Y., and Robert Wood Johnson Barnabas Health based in West Orange, N.J., presented along with leading children’s hospitals such as Children’s Hospital of Philadelphia and innovative physician focused models such as Marshfield Clinic in Wisconsin and Geisinger Health System in Danville, Pa.

This provided an incredibly important snapshot of both the ground level view of what’s happening in the real world today as well as the bets being placed for the future. What follows is a high-level perspective of what was shared by these prominent provider organizations.

So, follow the money…and here’s the Top 10 Trends shaping how that money is flowing:

1. The Affordable Care Act
The ‘elephant in the room’ was the uncertainty relative to repealing and replacing the ACA. Surprisingly, the reaction wasn’t what you might have expected.

From an absolute dollars perspective, no one stands to lose more than the folks who were in this room. With that said, the ACA didn’t dominate the conversation. As stated by the executive team at Kaiser, “we’re not going to get out, we’re going to figure it out.”

The general consensus is that the ACA has flaws, yet there is also a shared belief that it has been a “great first step at getting more in the door” and that whatever is done moving forward must build on it, not destroy it. The CEOs and CFOs who presented shared an extraordinarily strong view that replacement has to happen at the same time as repeal.

From a financial impact perspective, several health systems believed the ACA has had a net neutral effect. One example is Henry Ford Health System, which cited “favorable reductions in charity and bad debts were substantially offset by Medicare cuts and increased Medicaid losses.” This sentiment, relative to the past and future financial impact, was consistent and the level of concern relative to a replacement of the ACA was lower than one might have expected.

The bigger issue was the overall uncertainty of what “replace” will mean. Many believe this uncertainty will be the new normal for some time and that they need to stay the course strategically. The translation of this is that the election is not causing major shifts in their approach. The direction communicated in every presentation was to keep going forward as the focus on value — high quality affordable care and health for a population — has to continue.

An interesting side note: JP Morgan Chase Chairman, President and CEO Jamie Dimon shared that the firm self-insures, spending $1.6 billion per year to cover 300,000 employees. So, add another billion dollar healthcare company to the list.

2. The Need to Manage Margins and Reduce Cost
“Affordable care” and reducing cost structure was a consistent mantra and strategic priority highlighted in nearly every presentation. Cost management has become a board-level strategy as providers continue to see downward pressure on the top line, a shift to ambulatory and a movement to risk-based, bundled contracts in high-volume and high-value specialties.

The focus is on driving out variation and many different strategies are in motion. Intermountain has been ahead of the curve for many years on cost management, coming in at $1,800 less per patient than the national average. They shared that national health costs would be “34 percent lower” if everyone else hit that same mark.

Many are making progress. Cleveland Clinic has achieved $775 million in savings over the last four years, including close to $2 million in their total joint program, partially achieved by discharging 66 percent of their patients directly to their home, delivering better clinical outcomes and a better patient experience. Advocate achieved $73 million in the Medicare Shared Savings Program, with $34 million coming back to the organization. Houston-based Memorial Hermann achieved $93 million in Medicare savings, sharing in $47 million, making it the most successful effort in the country.

There is also a shift towards investing in staffing performance improvement teams on an ongoing basis. Henry Ford Health System now has over 40 people on their performance improvement team, significantly more than most organizations. One would anticipate future investments in this area as the focus on margins is expected to continue, especially as the movement into bundled contracts in specialties such as orthopedic and cardiac care.

In order to enable this new approach from a technology perspective, organizations are investing in more advanced cost accounting systems to better understand both cost and margins. This supports a focus on clinical standardization and reducing variation, from a quality and cost perspective.

3. The Move to Revenue Diversification, Ventures and New Lines of Business
A term that is starting to gain some traction is “revenue diversification,” also known as finding new streams of revenue. Healthcare providers have recognized that their business model has to change and they can’t just sit around and wait for the next nuance to reimbursement and regulations. They need to go on offense, and there are many different ways they are starting to attack. The biggest focus appears to be on new ventures.

To be clear, revenue diversification represented the biggest shift in mindset year over year at the conference. This form of business “innovation” has become a board-level imperative, seemingly overnight. As an example, Intermountain already has a full pipeline of companies and stated plans to develop “one to two new companies per year.” Children’s Hospital of Philadelphia commercialized a driving simulator. Northwell has “70+ ventures” in motion. Mercy has set aside $50 million for direct investments in private equity and acquired their own revenue cycle company to serve their needs as well as become part of their investment portfolio. Many are moving deep into genomics. The list goes on.

The summary is that major health systems are recognizing they need to find other ways to drive value, deliver on their mission and create a more viable, sustainable enterprise.

4. Geographic Expansion and Increased Access to Care
Many health systems have expanded their geographic reach significantly in a short period of time. One example is Northwestern whose flagship Northwestern Memorial Hospital in Chicago accounted for 82 percent of revenue a few years ago, but now represents only 38% as the system has expanded into the suburbs. Northwestern executed a methodical acquisition strategy over the last four years and created an impressive balance, both financially and strategically, in a short period of time. RWJBarnabas Health, Hackensack, Meridian, Northwell and many others cited this same approach.

CHRISTUS Health is one health system that many are watching. The system has doubled in size in the last few years, not only through acquisitions in their home base of Texas, but also with an international expansion into three countries — Mexico, Chile and Columbia.

Additionally, many health systems are expanding their access to care through primary care relationships and extended outpatient services. While there is a general slowdown in acquiring physician practices, some are still moving in that direction. Others are focused on forming tight partnerships to coordinate care provided beyond the inpatient visit as they move into longitudinal population health.

5. The Growth of Value-Based Contracts
The expansion in access points across the continuum within a single healthcare delivery system has led to an increased willingness to take on risk and value-based payments in a large-scale population setting. Most of the presenting companies have some form of a health plan, but all have also taken on some form of risk-based contract. Advocate, a pioneer in accountable care, now has 865,000 covered lives accounting for a total spend of $4.6 billion in value-based agreements.

6. Consumer Engagement
The movement from treating patients to building relationships with consumers was a headline last year and this trend continues to mature. There is a major focus on the experience of care. For example, Northwestern is one of a number of providers where every employee has incentives related to satisfaction. Northwell has developed its own Customer Relationship Management system, and many others have made similar moves. Geisinger has now given over $500,000 in satisfaction rebates based on its money-back guarantee since November 2015, arguably the most effective marketing investment in healthcare today. Intermountain is now recording personal, non-health and healthcare related goals to help motivate recovery and compliance. Every health system came up with a pretty full list of investments in this area, and it is clear they are just getting started.

Branding is one part of systems’ consumer strategy that is gaining more investment. While health system rankings by U.S. News & World Report were cited by all who make the list — and this will remain a focus — the approach many are taking toward branding is getting much more sophisticated.

7. A New Focus on Mental and Behavioral Health as a Strategy
A welcomed and critical addition to the strategic plan of many health systems was mental and behavioral health, with attacking “social determinants” now making its way to the executive suite. Intermountain outlined an investment in integrated, team-based care practices — clocking out to $22 per member per year — decreased overall medical expenses by $116 per member per year compared to traditional practice management. One benefit of their team-based approach was a 23 percent reduction in emergency room visits.

With that said, this is clearly an area where many are struggling in the early innings of thinking through their strategy. Mental and behavioral health is ripe for collaboration, not just innovation in a silo. The good news is that the discussion and the work have started.

Outside of mental health, many health systems are taking a comprehensive approach to managing social determinants. One example is St. Louis-based Ascension, which has made major investments in applications and initiatives to move the dial in the community, including setting up food pharmacies.

8. Digital Tools and Data
This is the first time where the EHR was not cited as a strategy by itself, but as a baseline assumption. Virtually every organization was on either on Epic or Cerner — it was seen as table stakes. The big shift that has taken place is that the data is now available and accessible. That doesn’t mean it’s perfect, but it has opened the door on innovation relative to using that data to drive change, and many are now beginning to walk through it. There was a great deal of discussion on how to now use that data to improve outcomes and drive out cost with very specific strategies in motion to capitalize on it.

9. A New Investment in the Workforce of the Future
This was another surprising area of investment with at least four organizations opening new medical schools, you read that right. The move is primarily focused on primary care and family medicine, including Cleveland Clinic, Geisinger, Hackensack and Meridian. In that same light, other systems are investing in physician assistant and advanced practice nursing schools.

10. And the List Goes On…
Additional hot topics included the continued shift to ambulatory care, a focus on quality and outcomes, precision medicine, aligning incentives with physicians and virtual health (for example, Cleveland Clinic which has seen a 168 percent annual increase in virtual visits). There were also newer and interesting strategies that were less prominent, like shared medical appointments at Geisinger where 10 diabetes patients are seen at a time in a supportive group setting.

The bottom line: There is a noticeable shift in strategy for major healthcare providers as many begin to move from defense to offense as they look to the future. How an organization spends their money is their strategy, and it is starting to flow into some new, exciting and important directions.

ONC finalizes 2017 Interoperability Standards Advisory

The ONC’s web-based 2017 Interoperability Standards Advisory will be updated throughout the year.

21st Century Cures Act passes Senate; Barack Obama expected to sign wide-ranging healthcare bill into law

Via FierceHealthcare »

The Senate approved the 21st Century Cures Act Wednesday afternoon in a majority vote. President Barack Obama could sign it into law as early as tomorrow.

The final vote was 94 to 5.

The act covers a broad range of medical reforms and innovations, including fixes to the Food and Drug Administration’s process for approving drugs, funding for the “Cancer Moonshot” and precision medicine initiatives, and expanded access to mental health services.

RELATED: 3 ways hospitals must prepare for 21st Century Cures Act

It also aims to support health information technology goals, including electronic health record (EHR) interoperability and data privacy and security.

Language in the bill could force technology vendors to make their systems talk to one another, prohibiting information blocking and other practices that interfere with data-sharing that would benefit patients. In addition to EHR interoperability, it also addresses product standards and certification.

The act will help dig doctors out of the “ditch” that EHRs have put them in, Sen. Lamar Alexander (R-Tenn.), chair of the Senate Health, Education, Labor and Pensions Committee, said from the floor just before the vote.

FDA fears 

Detractors, including Sens. Elizabeth Warren (D-Mass.) and Bernie Sanders (I-Vt.), say the act gives too much away to pharma companies and weakens FDA oversight.

Sanders, who voted against the act, noted in Senate floor debate yesterday that even President-elect Donald Trump was shocked to learn how much more Americans pay for prescriptions than people in other countries and that the federal government is restricted by law from negotiating drug prices. He urged fellow senators to vote against the bill.

Pharma’s bounty

A Los Angeles Times headline calls the act a “huge handout to the drug industry disguised as a pro-research bounty.”

If universal praise for a measure “makes your B.S. detectors twitch, you’re on the right track,” writes columnist Michael Hiltzik. “The 21st Century Cures Act is a huge deregulatory giveaway to the pharmaceutical and medical device industry, papered over by new funding for those research initiatives. The punchline is that the regulatory rollback is real, but the funding may not be—it’s subject over the next decade to annual appropriations by Congress that might never come.”

A PBS NewsHour piece, meanwhile, lists the “winners and losers” under 21st Century Cures. Not surprisingly, big pharma and medical device manufacturers make the “winners” list. Real-world evidence for approval of new indications for FDA-approved drugs lands in the win column, along with patient advocacy groups.

Losers include randomized clinical trials: “Currently the gold standard for testing drugs and devices for safety, the adoption of real-world evidence standards may indicate that randomized clinical trials will become less important for drug and device approval,” the article notes.

Biden’s ‘Moonshot’

On Monday, the Senate voted to rename the part of the bill that will provide $1.8 billion over 7 years to fight cancer after Joe Biden’s son, Beau Biden, who died of cancer in 2015. The vice president, presiding over the session, teared up as he responded to the formal motion: “Without objection.” He later told reporters he didn’t know of the plan.

“This is one of the last times I’ll preside over an actual vote count,” Biden said on a video shot before the session and posted to Twitter. “This is the beginning of a fundamental change … the urgency with which we treat the need to cure cancer and to turn some cancers into chronic diseases.”

A broad scope

The House voted 392 to 26 in favor of the landmark legislation last week. Rep. Erik Paulsen (R-Minn.) said the legislation is an “innovation game-changer … a once-in-a-generational transformational opportunity to change the way we treat disease. It expedites the discovery, the development, and the delivery of new treatments and cures and ensures that America will be a leader in the global fight for medical innovation.”

The wide-ranging measure (PDF) includes these and other healthcare provisions:

  • It provides $4.8 billion to the National Institutes of Health, which includes $1.8 billion to fund the “Cancer Moonshot” to accelerate cancer research; $1.4 billion for the Precision Medicine Initiative to drive research into the genetic, lifestyle and environmental variations of disease; and $1.6 billion for the BRAIN Initiative to improve understanding of diseases like Alzheimer’s and speed diagnosis and treatment.
  • It gives $500 million to the FDA to streamline the clinical trial process and hire new staff.
  • It provides $1 billion in grants to states to prevent opioid abuse.
  • The bill also aims to improve mental health programs, including integrating mental health services into primary care settings and expanding access to mental health treatment and services.

How the Cures law will force interoperability to move forward

Via Health Data Management »

The new 21st Century Cures Act is about to change healthcare IT, and most of the industry never saw it coming.

Passed easily on Wednesday by the House of Representatives, the bill is expected to sail through the Senate next week. It is supported by President Obama, who undoubtedly will sign it.

Much of the bill focuses on significant FDA regulatory changes, support of mental and substance abuse-related healthcare, and funding for programs such as Vice President Biden’s Precision Medicine Initiative, the Brain Research Through Advancing Innovative Neurotechnologies Initiative, cancer research and regenerative stem cell-based medicine. It also includes mandates to improve healthcare IT—most notably, in relation to nationwide interoperability and information blocking. Suddenly, those “Interoperability Pledges” that EHR vendors signed earlier this year will not be toothless expressions of good will.

Certain sections of the 996-page Cures bill are focused on “improving quality of care for patients” in the area of information technology, with interoperability the front and center concern. HHS will receive $15 million in funding to change ONC’s certification process to help push interoperability and fight information blocking by EHR vendors.

Specifically, HHS will change the conditions of Meaningful Use certification of healthcare IT to include interoperability. To be certified, vendors will not have taken “any action that constitutes information blocking” or “take any action that may inhibit the appropriate exchange, access, and use of electronic health information.” They may not prevent HIT interoperability and must develop application programming interfaces (APIs) or other technologies to enable the application to be “accessed, exchanged and used without special effort.” The vendors also must have successfully tested the “real world use of the technology for interoperability.”

The act also places strong emphasis on providing patients’ access to their electronic health information in a single longitudinal format that is “easy to understand, secure and updated automatically.” It recommends that ONC include this in Health IT certification, as well as providing the ability for patients to electronically communicate their health information to providers. HHS will convene with industry stakeholders to develop regulations that provide specific definitions and criteria. Vendors found to be blocking information are subject to penalties of as much as $1 million per violation.

The act also provides for greater support of networks exchange to advance an interoperable health information technology infrastructure, “for the purpose of ensuring full network-to-network exchange of health information.” The focus will be on establishing public-private partnerships to build consensus and develop a “trusted exchange framework, including a common agreement among health information networks nationally.”

Also See: Is information blocking finally on its last leg?

While no private or public health information network will be required to adopt the trusted exchange framework, federal agencies may require adoption within their networks. Health information exchanges are prohibited from information blocking, as are providers, and are subject to penalties of as much as $1 million.

Within three years of the Cure Act’s enactment, HHS must establish a “provider digital contact information index” for access by healthcare professionals and facilities.

The act also establishes a Health Information Technology Advisory Committee that will unify and replace the existing HIT Policy Committee and the HIT Standards Committee, to provide recommendations and report to ONC. Priority target areas for HHS and the HIT Advisory Committee, working with private and public healthcare stakeholders, will be:

  • “Achieving a health information technology infrastructure, nationally and locally, that allows for the electronic access, exchange, and use of health information, including through technology that provides accurate patient information for the correct patient, including exchanging such information.”
  • The promotion and protection of privacy and security of health information in health information technology, especially in the area of accounting of disclosures and protections of sensitive information. The act includes “the segmentation and protection from disclosure of specific and sensitive individually identifiable health information with the goal of minimizing the reluctance of patients to seek care.” This emphasis on segmentation of information is significant in the mental health / substance abuse world, where the existing inability of IT systems to separate out data that has not been authorized for disclosure inhibits data exchange and analysis.
  • The facilitation of secure access to health information by individuals, family members, caregivers and guardian including when related to age or other disability, cognitive impairment, or dementia.

The committee is authorized to determine other targets, and indeed, the act appears to be recommending specific emphases. It suggests considering targets related to population health, improving child healthcare, and use of telemedicine and “self-service” technologies, and patient matching, among others.

If you were at HIMSS’ 2016 Conference, you couldn’t miss the 20-feet long banners and overall chatter about “The Interoperability Pledge.” Software vendors were challenged by ONC to pledge voluntarily that they would facilitate communication of health information between providers, patients and other healthcare stakeholders. ONC appeared to be preparing for a combined industry/government initiative to get us over the long-time hump of non-interoperability between our many varied EHR systems. Indeed, vendors representing 90 percent of EHRs used by hospitals nationwide signed up.

And then? Nothing. Little has changed. Pledges were voluntary.

But now, with the new 21st Century Cures Act, compliance is going to be the name of the game, once again—and this time, for HIT vendors. It’s about to be time for them to step up and follow through.

Keys to Interoperability May be in Consumers’ Hands

Via HealthLeaders Media »

Making patients the stewards of their own health data could result in better access, despite a business environment where health systems do not make sharing a patient’s data with each other a top priority.

The barest outlines of the Trump Administration’s healthcare policy were not yet clear on the morning after Donald Trump’s upset presidential victory, but the CIO of a New York City health system was already looking forward to resolving issues unresolved by the election.

“If we were all on a common shared data platform and could easily access one another’s patient data, I think we would do a much better job of keeping people healthy,” said Daniel Barchi, senior vice president and chief information officer of New York Presbyterian Hospital in New York.

Speaking at the inaugural Techonomy Health conference last week in Half Moon Bay, CA, Barchi expressed hopes that the industry can agree to make patients the stewards of their own data moving forward.

In this way, he believes, patients can be at the center of sharing data in a business environment where health systems still do not make sharing a patient’s data with each other a top priority.

“The standard [in the 2009 American Recovery and Reinvestment Act] was so low,” he said.

“I can send a couple of packets of data. You can send me a couple of packets of data and check the box. That’s it. It’s not really interoperable in any way. And the EMR vendor was really not incented in any way. They were just helping everybody get live on all these new systems.”

No Incentive to Share Data

As a result, healthcare CIOs find themselves having built “really great complex systems within our own health systems, but aren’t incented to share data in any way, and so we’re doing it through a lot of back-door work,” Barchi said.

He equated continuity of care (CCD) documents to “electronic faxes, a couple-of-page PDF version of somebody’s care. Sure you can shoot it back and forth electronically, but you’re not going to interact with it.”

Barchi said he forward to accelerating innovation on the care coordination front.

“There’s an expectation in the technology industry that we have absolute huge airplane hangars full of people at desks making phone calls and checking up on people at home,” he said.

“Even in a $7 billion health system, I might be able to introduce you to our 17 care coordinators individually by name, so we’re not at the level where large health systems have these workforces that are incented to keep people healthy.”

Rooting Out Inefficiencies

Speaking at the same event, another speaker said technology is showing promise to squeeze inefficiencies out of back-office work.

“The provider is the main deliverer of healthcare,” said Jim Dougherty, who serves as CEO and co-founder at Madaket Health, a cloud-based service startup, which automates provider enrollment in payer plans.

“We’ve said we’re going to focus on making their lives better,” said Dougherty, a former member of the board of directors of Beth Israel Deaconess Medical Center in Boston.

Such enrollment still relies too often on laborious fax-based workflows. Via Madaket, a process that used to take a provider and payer 45 days “now takes two days, which benefits everybody,” he said.

Such cloud-based technology platforms can also be extended to accelerate other workflows.

“We at New York Presbyterian have this issue,” Barchi said, commenting on Madaket’s technology. “Mass General has this issue. Mayo has this issue. We all have this credentialing and payer issue with vendors. This is the kind of solution that will get in and solve a problem that occupies anywhere from 10 to 30 full-time employees on this kind of issue.”

One concern is whether to implement such point solutions in a piecemeal fashion, or to looking “to change the way that we’re running the healthcare system.”

Barchi said part of the answer will come from the next generation of electronic medical records.

“There are always upgrades that are happening to get better and better at sharing data,” Barchi said.

Evolving technologies pose challenge for medical device security

Via Vanderbilt University News »

It is the ultimate invasion of privacy: An unscrupulous hacker gains access to a network of interconnected medical devices and then, with a few quick keystrokes, remotely delivers a fatal electric shock to some unsuspecting victim’s pacemaker. This may sound like the plot of a spy novel, but such a scenario, at least from a technological standpoint, is not out of the realm of possibility.

As today’s health care industry relies increasingly on devices and systems that collect and share data between one another, cybersecurity breaches have become a troubling new reality. In fact, just last month, two device manufacturers—St. Jude Medical and Johnson & Johnson—issued separate warnings that their respective cardiac implants and insulin pumps were vulnerable to hackers.

While other industries, like the financial sector, have made cybersecurity a priority for 20 years or more, health care has been relatively late to the game and is now behind the curve in addressing such threats, according to M. Eric Johnson, dean of Vanderbilt Owen Graduate School of Management and Bruce D. Henderson Professor of Management.

“Health care is behind for several reasons,” he said. “It’s a very fragmented industry—you have countless clinical operations, and many of them are quite small and don’t invest in information security. And then at the other end of the spectrum, there are these hospitals that are, in effect, high-tech islands. They have these amazing surgical robots and other technology, but only in the last five years has there been a push to build a more integrated IT backbone with security.”

Johnson, who studies information technology’s impact on the extended enterprise, has co-written a new article examining the chronology of medical device security. Published in the October 2016 issue of Communications of the ACM“A Brief Chronology of Medical Device Security” is the result of an interdisciplinary project, known as Trustworthy Health and Wellness(THaW), which is funded by the National Science Foundation. A.J. Burns, assistant professor of computer science at the University of Texas–Tyler, and Peter Honeyman, research professor of computer science and engineering at the University of Michigan–Ann Arbor, collaborated on the article.

In the article Johnson and his co-authors identify four major inflection points that span the evolution of medical devices and their security: (1) “Complex Systems and Accidental Failures” (1980s–present), (2) “Implantable Medical Devices” (2000–present), (3) “Unauthorized Parties and Medical Devices” (2006–present), and (4) “Cybersecurity of Medical Devices” (2012–present). The authors also lay out a timeline of important legislation aimed at regulating and/or enhancing security and privacy in the health sector. In the end, they arrive at several conclusions:

  • The future of medical device security will be defined by the steps that the health sector takes today.
  • Security trade-offs characterize the design and deployment of medical devices.
  • Discussions of cybersecurity and medical devices often are distorted by misinformation and frightening language.

With regard to the latter, the authors wrote, “We must resist the temptation to sensationalize the issues related to cybersecurity in the health sector, and instead apply sober, rational, systematic approaches to understanding and mitigating security risks.”

What then should be the appropriate course of action for health care professionals and their patients? Is there one risk they should be concerned about above all others? Johnson and his co-authors offer a clear answer in that regard.

“It is safe to say that patients’ reluctance to accept medically indicated devices due to concerns about security poses a greater threat to their health than any threat stemming from medical device security,” they wrote.

In other words, the biggest danger to patients’ health is not the security threats themselves but rather the irrational decisions that might result from these perceived threats. While users of medical devices may be vulnerable to hackers in theory, there is not enough of a risk, according to the authors, to discourage use of the devices altogether. A hijacked pacemaker makes for an interesting plot twist in a novel, but it is not very likely to happen in real life.

“Unless you’re the president of some country,” Johnson said, “or someone with a lot of enemies, I wouldn’t worry about being personally targeted.”

Here’s a Crucial Technological Fix to Rising Health-Care Costs

Via Wall Street Journal »

Dr. Peter Pronovost (@PeterPronovost) is a practicing anesthesiologist, critical-care physician, professor, Johns Hopkins Medicine senior vice president and director of the Armstrong Institute for Patient Safety and Quality. He blogs fromVoices for Safer Care.

If we want to rein in the costs of the U.S. health-care system – now equal to nearly 18% of the nation’s gross domestic product – we cannot ignore the fragmented technologies used to help heal and save lives.

At first glance, the devices, monitors, electronic health records and machines found in today’s hospitals might inspire awe. Look beyond the slick displays with blinking lights, however, and the picture is less reassuring. Rather than working as an integrated whole, these technologies rarely “speak” to one another, reducing productivity and increasing costs. As a result, time that clinicians might spend at the bedside or discussing patient cases with colleagues is used to fill in the gaps between uncoordinated technologies.

For example, nurses scribble down a physician’s instructions for a drug infusion from one computer screen, do math to find the right dose, and then walk to the medication pump and enter the order. Every high-risk medication requires a second nurse to double-check that the pump is programmed accurately — a task that drains staff time. On a 12-bed intensive care unit, these double-checks add up to two full-time nursing positions, we found at Johns Hopkins. Yet if the electronic orders communicated with the pump, this extra work would not be needed, and the risk of entering the wrong dose would diminish.

Clinicians who want to gauge a patient’s progress and risk of complications need to make hundreds of clicks on computer screens, check devices and eyeball the settings on the patient’s bed. In one of our ICUs, the work of ensuring that patients received steps to prevent seven common harms – such as blood clots and infections – takes nearly 20 minutes. Integrate systems and that time can be cut by two-thirds, we found in a pilot project.

Hospital beds typically come with alarms that alert staff when a patient starts to get out of the bed on his or her own. Yet sometimes staff forget to turn the alarm back on — for instance, after the patient returns to the bed following an X-ray. An integrated system would quickly flag patients who are deemed a high fall risk but whose bed alarms aren’t activated. Instead, in many hospitals, staff still must walk from room to room to visually check that bed alarms are on for patients who need them.

Other fields have used systems integration approaches to become high-performing, less costly and ultra-safe. In aviation, for example, controls, instruments and mechanical systems communicate with each other, enhancing pilots’ situational awareness. Pilots don’t spend time poring over topographical maps to make sure they don’t fly the plane into a mountain; the plane gets that data and warns them if they are approaching a cliff. Yet health care has not embraced similar approaches.

Such a change is overdue. There are certainly other solutions to improve health-care productivity and decrease costs. Complications and substandard care make hospital stays longer or lead to readmissions. Staff spend too many hours on required documentation. Hospitals devote enormous administrative resources to working with hundreds of different insurers. Drug prices are constantly rising. Yet we cannot ignore the dysfunctional systems at the heart of how we care.

If we improve productivity by integrating technologies and extracting their data, we can do more than reduce costs. We can transform the patient experience: fewer complications, more “quality time” with their care team, and more opportunities to engage in their care.

EHR interoperability’s uncertain future

Via Medical Economics »

For urgent care physician John Kulin, DO, interoperability of electronic health records (EHRs) has long been a dream—one that remains unfulfilled.

In his Manahawkin, New Jersey, practice, he and his staff of 17 physicians have access to complete medical records for fewer than 5% of all patients despite significant investments in interoperability software. With 60,000 patient visits annually, he gets the patient information he needs electronically from only 3,000. For the rest, the practice relies on paper records. 

“Interoperability is a huge problem,” he says. “Yet, it’s one of the holy grails of actually engaging patients more and using our EHRs to make patient care better so that we’re not operating in different silos. But so far, it’s not happening well at all.”

The federal Office of the National Coordinator for health information technology (HIT) defines interoperability as the ability of information systems to exchange patients’ electronic health information and use information from other EHR systems without any special effort from the user.

For many patients, Kulin has a semblance of interoperability because he benefits from data on prescription medications and lab test results sent directly to his EHR . 

“When we get lab results back through our lab interface, it all comes right into the chart, so now we can compare and graph that data against prior lab work,” Kulin says. “That’s one of the few systems where we have prior data from other providers. That gives us a much better understanding of what’s going on with patients and enhances care.”

Kulin shares patient records via Direct secure messaging (Direct), a protocol for exchanging clinical messages and attachments such as patient records. In the second quarter of this year, physicians and other providers sent 24 million Direct exchange transactions via this secure email system, which complies with federal privacy standards under the Health Insurance Portability and Accountability Act (HIPAA). 

But when it comes to getting patient information from area hospitals and other physicians or imaging test results, Kulin is mostly operating blind. “From an urgent care perspective, I want access to every one of our patients’ medical records, particularly from primary care physicians,” he says.

When he does get medical records from hospitals or physicians, they come mostly via fax. “That’s problematic because it’s a hard copy that we need to read and put into a PDF that goes into the chart,” he explains. 

Interoperability still out of reach

Certainly paper is inconvenient, but for Kulin it’s also a sign that true interoperability is still years away, a factor that drives up costs needlessly. Without access to records, for example, he can’t compare a current EKG with an earlier one, making it impossible to know what’s normal for a patient, he adds.

Not knowing what’s normal means Kulin or someone on his staff may need to send a patient to the nearest emergency department. “Without that information, we’re just operating in a vacuum, and that’s something we never want to do,” he says.

Earlier this year, physicians were optimistic when the Senate Health Education Labor and Pensions (HELP) Committee unanimously passed S. 2511, the Improving Health Information Technology Act, to reform the rules governing federal standards for health information technology and EHR systems. Finally, Congress seemed to be addressing the problems that resulted after it passed the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009.

But despite the unanimous committee vote and support from members of both houses and both parties, the bill has not come up for a vote. Action on S. 2511 may have slowed because physicians and the Centers for Medicare & Medicaid Services (CMS) are preparing to implement new payment systems next year under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Physicians and HIT vendors have expressed concerns to Congress that the U.S. Department of Health and Human Services (HHS) may be changing too many of the requirements they impose on how  physicians practice all at once. 

So how long will it be before we achieve true interoperability? HIT experts tell Medical Economics that HHS will need to provide more incentives to HIT vendors to make their systems truly interoperable and that HHS has the power to do so now.

In its October, 2015 report, “Connecting Health and Care for the Nation. A Shared Nationwide Interoperability Roadmap,” ONC predicted it would be 2021 to 2024 before the nation’s health system achieves interoperability, which it defines as one that would “enable a learning health system, with the person at the center of a system that can continuously improve care, public health, and science through real-time data access.”

Our experts agree, predicting that true interoperability will be in place by the ONC’s target date. “We definitely want a system where information moves around seamlessly,” says Robert M. Wachter, MD, author of “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age”and a practicing hospitalist.

It would be best, he adds, if EHR vendors would allow physicians to move patient data easily from one system to another. But that seems unlikely given the restraints physicians face under HIPAA, the fear of system breaches that can—and do expose patients’ records to hackers, and the fact that vendors have little incentive to promote interoperability.

“There’s not a great market advantage for vendors to share. In fact, you could say there’s a market disadvantage to sharing information,” explains Wachter, a professor and interim chair of the Department of Medicine at the University of California, San Francisco. Some EHR vendors for hospitals and health systems don’t share patient information with physicians who are out of network, for example.

To address this problem, the federal government should use its clout as the nation’s largest purchaser of healthcare to get HIT vendors to enable patient data to flow more freely among systems, Wachter says. If necessary, he adds, the government should threaten that “interoperability will be forced on you if you don’t do it yourself.”

A combination of actions such as those called for in S. 2511 and government steps  to require HIT vendors to achieve interoperability will force those organizations standing in the way of interoperability to begin to do so, he explains. 

The double-sided coin of sharing data

But for now, even though all HIT vendors are not working toward true interoperability, Wachter says, “I don’t see any villains here.” He cites the problem of information blocking, which occurs when one EHR system does not allow providers working with another system or working for a different healthcare organization to access patient data. Information blocking is generally not malicious, says Wachter. 

Instead, most IT vendors working for physician groups, hospitals, and health systems serve the needs of their customers—healthcare providers–rather than the needs of the larger healthcare system. In these situations, committing scarce IT resources to sharing with other systems falls to a lower place on the priority list, Wachter says. Moreover, sharing patient data across multiple systems increases the risk that patients’ records could be hacked or stolen, he adds.

What’s more, if patient information leaks out due to a breach, leading to a $1 million fine, then a provider organization might be conflicted about data sharing, he says. “On the one hand, the provider might say, ‘Yes, we want to share information,’ but, on the other, they’re really saying, ‘No, we can’t do this because we don’t feel completely safe with that kind of risk,” he explains. 

The way Farzad Mostashari, MD, former National Coordinator for Health IT, sees it, physicians and other providers bear some of the responsibility for allowing hospitals and health systems to block information and should demand more, he says. 

Not only should physicians demand more from hospitals and health systems, they need to ask more from their EHR vendors, says Mostashari, the founder of Aledade, a company that helps primary care physicians form and operate accountable care organizations. Those vendors are required to meet specific certification requirements, and, previously, these systems were tested against the ONC’s certification standards and showed they could meet those requirements, he adds. But when Aledade evaluated 33 EHR systems to determine if they could meet those certification requirements, most of them failed, he says.

“Only 38% of those EHRs could actually give us an electronic download of the patient’s summary records in standard form,” he says. But when most don’t perform in the field, then neither legislation nor new regulations will solve the problem. “What we need is enforcement of the laws and the regulations we already have on the books,” he says. 

To ensure that their physician clients get the data they need from hospitals, Aledade pays EHR developers and interface vendors to improve the flow of patient information. “That’s a tax on physicians that we pay in order to ensure the success of population health,” he says. 

“Patient data shouldn’t be held hostage,” he adds. “If a physician has a certified EHR and that EHR can’t get the data physicians need, then physicians should complain to the certification body and to the ONC.” 

What’s the solution?

Still, it would be unfair to level all of the blame on providers and IT vendors, because regulators also bear some responsibility for the failure of HIT systems to achieve what physicians want, Wachter adds. “To a large degree we have not created a regulatory environment that promoted the development of an infrastructure for sharing,” he says. 

Congress anticipated that interoperability would reduce redundant services and lower costs, but that hasn’t happened. Realizing the benefits of interoperability will require Congress and regulators at HHS to urge vendors and health systems to allow a more unrestricted flow of patient data. “But exhortation is only the first step,” Wachter says, adding that HHS needs to flex its market power as a buyer and threaten to require interoperability.  

For John D. Halamka, MD, chief information officer of the Beth Israel Deaconess Medical Center in Boston, Massachusetts, interoperability requires technology standards and policies and a business case for sharing data, he says. 

S. 2511 would address some of these issues, such as commissioning the Government Accountability Office to investigate the possibility of a national healthcare identifier, critical for exchanging data, explains Halamka, the former chair of the US Healthcare Information Technology Standards Panel. Also, interoperability requires governance and data use agreements, he adds. “We need to understand who we can trust, the electronic address for sending them data, and how they’ll use the data,” he says.

The problem with new interoperability standards, he adds, is that they can impede progress. S. 2511 addresses the need for better standards by calling for the creation of a federal policy and standards committee, he says. In the past, members of Congress drafted policies and then staff members wrote the standards needed to implement those policies. But the act requires one group to produce policy and technology standards in parallel, he says.

Halamka agrees with Wachter that HIT vendors have an important role to play in solving the problems physicians face. Vendors already are taking steps to enhance interoperability, he adds, citing two examples that will ease the data-collection burden physicians face and the lack of true interoperability. 

First is the Argonaut Project, which aims to advance industry adoption of interoperability standards to foster the sharing of patient data in EHRs and HIT systems, he says. The project is a joint venture of EHR vendors such as athenahealth, Cerner, and Epic; health systems such as the Beth Israel Deaconess and the Mayo Clinic; and consultants such as Accenture. 

Second is a system to measure interoperability that KLAS is developing. An HIT research organization, KLAS rates EHR systems in such areas as usability and plans to report publicly on physicians’ experience using the interoperability functions of every EHR vendor, Halamka says.

Wachter cites another promising development: IT companies that were not previously involved with healthcare, such as Apple and Google, have seen the potential that follows when the federal government makes a $30 billion investment in HIT and Meaningful Use. “That amount of money woke up Silicon Valley,” he says. 

Consumer IT companies see a significant opportunity given that the United States spends $3 trillion on healthcare annually. While those companies are not solving physicians’ problems with interoperability or Meaningful Use, it is nonetheless significant that they are involved, even if it’s only to develop wearable technologies designed to get patients more involved in managing their health, he says. Apple and other companies making and selling gadgets to collect health data will start by serving consumers and then branch out to serve healthcare providers, he adds.

As consumers take on a larger role in managing their own health, Halamka says, they will demand improvements in HIT systems. “Every provider should have an EHR system and every patient should have access to that record,” he adds. And once EHRs can exchange data, if a consumer finds that his or her provider has one that cannot do so, that consumer should change providers, he says. 

In Health Affairs Blog, DeSalvo, Washington Share Ambitions for an Interoperable Future

Via Healthcare Informatics »

A new Health Affairs blog by Drs. DeSalvo and Washington shares thoughts on what will be needed to create an interoperable future

The immediate past National Coordinator for Health IT and the recently appointed National Coordinator for Health IT on Sep. 29 co-authored a blog online in Health Affairs touting the gains made in the adoption of electronic health records (EHRs) made in the years since the passage and implementation of the HITECH (Health Information Technology for Economic and Clinical Health) Act in 2009, and laying out their vision of a more digitally interoperable healthcare system. Writing on Sunday in the Health Affairs Blog,Karen DeSalvo, M.D. and Vindell Washington, M.D., the immediate past and current National Coordinators, highlighted the near-universalization of EHR adoption among U.S. hospitals and physician practices, while sharing thoughts on what elements will be needed to push forward the interoperability of healthcare information going forward.

Drs. DeSalvo and Vindell wrote that, “Over the past seven years, the United States has seen a historic health IT transformation, moving from a primarily paper-based health system to one where virtually everyone has a digital footprint of their care because of the dramatic uptake of electronic health records (EHRs). Recent data have helped quantify just how rapidly technology has transformed clinical settings. Today,” they noted, “nearly all hospitals (96 percent) and nearly eight in 10 (78 percent) physicians use certified EHRs. This transformation is the result of 2009’s Health Information Technology for Economic and Clinical Health (HITECH) Act, when fewer than one in 10 hospitals and 17 percent of physicians used EHRs. This rapid uptake of technology reflects the unyielding effort by clinicians and health systems across the board who helped usher in this new era of medicine. The result of this effort is a vast amount of electronic health data now exists which simply did not seven years ago.”

What’s more, DeSalvo and Vindell wrote in Health Affairs, “This transformation represents more than simply digitizing paper health records. It also puts us at a global competitive advantage and is leading to real-world impacts in the clinical setting. Systematic reviews of academic literature found that 84 percent of studies showed that certified EHRs had a positive or mixed positive effect on quality, safety, and efficiency of care. Other recent studies found that EHRs can reduce adverse events among cardiovascular, surgery, and pneumonia patients and that switching EHRs did not result in adverse safety events.”

As the federal officials noted, “These results reflect the vision we laid out in two key documents last year when we collaborated with more than 35 federal partners to develop the Federal Health IT Strategic Plan 2015-2020, and joined forces with the private sector to develop A Shared Nationwide Interoperability Roadmap, which outlines milestones, calls to action, and commitments that public and private stakeholders should focus on achieving, particularly in the near-term, to continue making progress.”

Moving forward, DeSalvo and Vindell wrote, it is the goal of federal officials at the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), and Office of the National Coordinator for Health IT (ONC) to create a “learning, person-centered health system,” one that helps the healthcare system to shift from the initial-adoption phase of the past few years to a more advanced phase involving “improving patient experiences and health outcomes” through EHR and other clinical information systems.

To do this, they write, ONC will focus on partnering with public and private partners to accelerate true interoperability of health information, via the following means: “the use of common, federally recognized, national standards; changing the culture around access to information—including combating data blocking; and, building the business case for interoperability.” They add that, “To achieve these goals, the Administration is leveraging impactful tools: delivery system reforms that drive a business case for interoperability; new guidance on the Health Insurance Portability and Accountability Act (HIPAA) to make providers and individuals aware of patients’ rights to access and transmit their data; and requiring publishing application programming interfaces (APIs) to enhance the connectivity between EHRs and provider and consumer applications.”

Interoperability, the cherished dream

Via Politico »

EXCHANGE OF VIEWS ON INTEROPERABILITY: CIOs who met at a Capitol Hill event Tuesday rejected comments by Allscripts CEO Paul Black suggesting that interoperability was just around the corner and that information blocking “has broadly been solved.” CHIME CEO Russ Branzell got the discussion going by asking panelists if they agreed.

“Not even close,” said Intermountain CIO Marc Probst, a former ONC adviser and never one to mince words. While some strides have been made by ONC and the private sector, “We have a long way to go to be truly, semantically interoperable, where data can be passed and not just PDF documents or automated faxes.”

Albert Oriol, CIO of Rady Children’s Hospital in San Diego, said his health system exchanged 500,000 records with others last quarter. Another 150,000 couldn’t be shared because they couldn’t correctly match records with the right patient, he said.

ONC head Vindell Washington also suggested that a culture of data sharing is a ways off. Providers and patients need to be able to expect information to be at their fingertips, he said — a far off goal. Health care providers need to incentivize information sharing, and standards need to be developed, he said.

Many of the doctors we’ve spoken to in recent weeks have given up on interoperability — at least in the lofty sense that HHS officials speak of it. They assume that the only way they can share data easily with another doctor is to belong to the same health care system — or at the very least share the same EHR. Some technologists agree, and think that EHRs are not the tools that will bring us free-flowing health information exchange.

Calling Apple….

Tweet of the Day: Brian Ahier @ahier Health insurers (finally) making use of #AppleWatch Looking forward to new #mHealth #apps for #wellness

Welcome to Wednesday eHealth, where we are too old to Twitch but still young enough to Zocdoc. Please send your reporting tips to, or tweet the most compelling and distracting rumors to @David_Pittman, @ arthurallen202, @DariusTahir @ POLITICOPro, @Morning_eHealth.

#AskVindell TWITTER CHAT: While Washington didn’t answer Branzell’s question about interoperability being “solved” during Tuesday’s event, he did say during a Twitter chat that “Information still does not flow as seamlessly as it needs to. That’s why we all need to work together to combat #datablocking.” Read a roundup of some of the key tweets in this post.

DIGITAL INSURANCE MOVEMENTS: Two pieces of business news point in a promising direction for health IT. First, HealthTap, which provides text, voice and video connections to doctors, announced Tuesday that health insurers are now covering its virtual consults. According to a news release, carriers such as United Healthcare, Cigna, Aetna and Humana will no longer require phoned permission to cover the visits; HealthTap will check patient eligibility in real-time, and the company also will submit electronic insurance claims on behalf of doctors to payors.

…. Aetna, meanwhile, announced that it will make Apple Watch available to some of its large employers and individual customers during open enrollment this fall, and will subsidize much of the cost, while allowing monthly payroll deductions to cover the rest. Aetna will provide Apple Watch for free to nearly 50,000 of its own employees as part of the company’s wellness program. Aetna is hoping that apps will help its customers improve their health and save it money. Apple Watch can help patients with medication adherence, wellness orientation, and decision support, according to a news release.

PDMP EXPANSION IN CALIFORNIA: Gov. Jerry Brown on Thursday signed into law a bill that requires all prescribers to check the state’s PDMP before prescribing opioids or other controlled substances. About 20 other states have laws requiring some degree of PDMP monitoring for physicians. Shatterproof CEO Gary Mendell, who lost his son Brian to addiction in 2011, led the fight for the bill in Sacramento.

PULL UP TO THE BUMPER, BABY: Ride-sharing provider Uber will start to work with hospitals in Massachusetts, Pennsylvania and Delaware to provide rides to medical appointments. Uber announced Tuesday it would partner with Circulation for the non-emergency medical transports. Because hospitals and health plans demand certain credentialing to get paid for lifts to doctors’ offices and hospitals, Uber needs a way to meet those higher standards, and Circulation provides it. Medicaid agencies spend $3 billion on non-emergency medical transportation, Uber says — and a third of the payments are inappropriate.

EVIDENCE TELEMEDICINE SAVES MONEY: Partners Healthcare has been using telemedicine to treat heart failure patients for some time and has data to show it has saved the sprawling Boston health system money — including for Medicare patients. At the CHIME event we mentioned above, CIO Cara Babachicos cited company data showing that remote monitoring of recently discharged heart patients has cut what Partners spends on Medicare patients by nearly 2 percent. It also reduced 30-day readmissions by 75 percent and 120-day readmissions in half. Congress has been working for years to boost Medicare reimbursement for telemedicine, but the Congressional Budget Office has said more remote doctoring will only increase federal spending on health.

EVERYBODY’S SHOOTING FOR THE MOON: The Patent and Trademark Office, which on Thursday announced the winners of its Cancer Moonshot Challenge, aims to leverage intellectual property data to illuminate new directions in research on cancer. First place was won by Dolcera, which makes rather “engaging visualizations” that offer insights on cancer research priorities. Second place went to Booz Allen Hamilton and Omnity, which built visual networks based on linguistic similarity among cancer patents and NIH-funded research. These findings, per the USPTO, will empower research funders of all stripes to point their money in the most promising directions. Get your details here.

KIBBLES ‘N BITS: The National Quality Forum’s Measure Applications Partnership brought on Chip Kahn, CEO of the Federation of American Hospitals, and Columbia psychiatrist Harold Pincus to co-chair a committee recommending the best measures to be used in federal programs that pay doctors. … Congress still hasn’t ponied up money to fight Zika, but University of Arizona researchers (who’ve been working with the CDC) launched a crowd-sourcing mobile app, called Kidenga, Tuesday to help detect outbreaks. … A VA inspector-general investigation showed that providers in the New Mexico VA Health Care System did not always respond to EHR alerts regarding irregular colonoscopies in a timely way — and as a result nine patients eventually diagnosed with colorectal cancer got their results late enough to potentially affect their clinical outcomes in 2013 and 2014.

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