VA moves closer to doing Cerner EHR deal, real Choice for veterans (updated)

The Cerner EHR deal with the VA edges closer to closing. Another VA contractor, MITRE, reviewed the agreement and recommended 50 changes that, according to POLITICO Morning eHealth’s source, address many of the interoperability-related usability features “that irritate EHR users” such as reconciling data coming from outside sources (Home Telehealth, perhaps?–Ed.). VA officially updated the status with Congressional Veterans Affairs staff on Tuesday. The deal could be inked as early as next week, but never bet on this when the Secretary seems doubtful of the agreement date. In any case, it will be a decade before VA is fully transitioned from VistA. Speaking of the Secretary, Dr. Shulkin’s crisis of last week seems to have passed with a White House vote of confidence. He can ‘cashier’ his critics and according to him, everyone’s on board with a clear direction. We’ll see. 

Updated. Well, it’s 2 March and still no word on closing the Cerner contract. Meanwhile, the VA ‘revolt’ continues, with either true or false reports of demands for Dr. Shulkin’s resignation. It’s exhausting, and meanwhile who pays? Staff and veterans. See POLITICO from 1 March here.

Modern Healthcare reported that important reforms in the VA Choice legislation are closer to reality with the Senate Veterans Affairs committee. They are proposing changes, supported by the White House, that would open up VA Choice eligibility to nearly all veterans by “making VA facilities responsible for meeting access standards set by the VA secretary. If a facility can’t, the patient can seek out a community provider if both patient and a VA provider or an authorized provider in the community working closely with VA deem that a better option than a VA facility.” This is a step beyond the earlier proposed access standards which would have given the VA Secretary discretion to relax restrictions to community care provision. Currently the VA Choice program is used by only 1 million veterans who have to prove that they are facing wait times of 30 days or more, or 40-mile travel time to a VA clinic. While the tone in the article is slightly disparaging, firm standards and opening the VA to limited market pressures to this Editor is a good thing–and getting effective care faster to veterans, many of whom live in exurban or rural areas, is beyond all considerations, absolutely necessary. How this affects veterans monitored by telehealth programs–and interoperability of their records–are open questions.

The King’s Fund: ‘Sharing health and care records’ Leeds 13 Dec

Wed 13 December, 9.00am-4.30pm
Horizon Leeds, Kendall Street, Leeds 

The King’s Fund is hosting a December conference in Leeds on the digital sharing of health and care records. Delivering the key benefits of coordinated care requires three things: the appropriate technology, the right governance structure and a culture of adoption. Attendees will learn more at this full-day event about:

  • The direction of national programmes on interoperability and data sharing across and between local areas
  • Case studies from around England where teams have developed ways to share health and care records locally
  • The challenges involved in implementing data sharing across and between local areas and learn how others have overcome them

Keynote speakers include Will Smart (CIO, NHS England), Prof. Maureen Baker (Chair, Professional Record Standards Body), Andy Kinnear (Director of Digital Transformation, NHS South, Central and West Commissioning Support Unit and Chair, BCS Health), Nicola Quinn (Project Manager, Health Informatics Unit, Royal College of Physicians), and Jan Hoogewerf (Programme Manager, Health Informatics Unit, Royal College of Physicians).

For complete information, agenda, and to register, click on the sidebar advert or here. TTA is pleased to be a long-time supporter of The King’s Fund and a supporter of this event. Hat tip to Claire Taylor of The King’s Fund–if you are interested in supporting this conference, contact her here.

Want to know effectiveness of telehealth, interoperability? NQF reports take their measure.

There’s been an increase in doubt about the efficacy of telemedicine (virtual visits) and telehealth (vital signs monitoring) as a result of the publication of two recent long-term studies, one conducted by the University of Wisconsin and the other by CCHSC for Telemonitoring NI [TTA 13 Sep]. These follow studies that were directionally positive, and in a few cases like the VA studies conducted by Adam Darkins, very much so, but mostly flawed or incomplete (low N, short term, differing metrics). What’s missing is a framework for assessing the results of both. In an exceptionally well-timed announcement, the National Quality Forum (NQF) announced their development of a framework for assessing the quality and impact of telehealth services. 

In a wonder of clarity, the NQF defines telehealth’s scope as telemedicine (live patient-provider video), store-and-forward (e.g. radiology), remote patient monitoring (telehealth), and mobile health (smartphone apps). Measurement covers four categories: patients’ access to care, financial impact to patients and their care team, patient and clinician experience, and effectiveness of clinical and operational systems. Within these categories, NQF identified six areas as having the highest priority for measurement: travel, timeliness of care, actionable information, added value of telehealth to provide evidence-based practices, patient empowerment, and care coordination. Finally, the developing committee identified 16 measures that can be used to measure telehealth quality.

The NQF also issued a similar framework for interoperability, a bête noire that has led many a clinician and developer to the consumption of adult beverages. Again there are four categories: the exchange of electronic health information, its usability, its application, and its impact—on patient safety, costs, productivity, care coordination, processes and outcomes, and patients’ and caregivers’ experience and engagement. And it kept the committee very busy indeed with, from the release, “53 ideas for measures that would be useful in the short term (0-3 years), in the mid-term (3-5 years) and in the long-term (5+ years). It also identified 36 existing measures that serve as representative examples of these measure ideas (sic) and how they could be affected by interoperability.”

Both reports were commissioned and funded a year ago by the US Health & Human Services Department (HHS). We will see if these frameworks are extensively used by researchers.

NQF release, Creating a Framework-Telehealth (download link), Creating a Framework-Interoperability (download link), Mobihealthnews 

Why do hackers love bitcoin? Blockchain. And why are healthcare, IoT liking blockchain?

Hackers love bitcoin for their ransomware payment because it’s virtual money, impossible to trace and encrypted to the n-th degree. Technically, bitcoin is not a transfer of payment–it IS money of the unregulated sort. The ransomee has to pay into a bitcoin exchange and then deliver the payment to the hacker. However, what sounds straightforward is actually fraught with risks, such as the bitcoin exchanges themselves as targets of hacking and the fluctuations of bitcoin value meaning that a ransom may not actually be paid in full. ID Experts‘ article gives the basics of bitcoin, what to expect and when paying a ransom is the prudent thing to do.

click to enlargeTurn what is behind bitcoin around though, and it becomes intriguing to HIT and IoT. Blockchain is “a distributed, secure transaction ledger that uses open-source technology to maintain data. Records are shared and distributed over many computers of entities that do not know each other; records can be time-stamped and signed using a private key to prevent tampering.” Each record block has an identifying hash that links each block into a virtual chain. (Wikipedia has a more complete description.) For bitcoin, it ensures security, anonymity and transferability without a central bank. For healthcare, distributed data and security is the exact opposite of the highly centralized, locked down approach of standard HIT to enable interoperability and security (left above). The Federal ONC-HIT (Office of the National Coordinator for Health Information Technology) under HHS is soliciting up to 15 proposals for “Blockchain and Its Emerging Role in Healthcare and Health-related Research.” through July 29. Cash prizes range from $1,500 to $5,000. The final eight will present at the awards presentation September 26-27. Potential uses are:

  • Medical banking between dis-intermediated parties
  • Distributed EHRs
  • Inventory management
  • Forming a research “commons” and a remunerative model for data sharing
  • Identity verification for insurance purposes
  • An open “bazaar” for services that accommodates transparency in pricing

Health Data Management, Information Management, Federal Register announcement

Our wrapup of news and tart takes on HIMSS 16 (updated redux)

Lions Lie Down With Lambs, and Other Miracles!

HIMSS 16’s main ‘breaking news’ centered on HIT interoperability. The lead was US Department of Health and Human Services (HHS) Secretary Sylvia Burwell’s announcement on how Lions Will Lie Down With Lambs, Or Else. 17 EHRs that cover 90 percent of electronic health records used by U.S. hospitals–including the bitterest of rivals, Epic (the EHR everyone likes to hate) and Cerner, 16 providers including the nation’s five largest private healthcare systems, and more than a dozen leading professional associations and stakeholder groups (including HIMSS) pledged to implement three core commitments that allegedly will improve the flow of health information to consumers and healthcare providers. They are consumer access, no information blocking and standards. When? Where? How? Strictly TBD. HHS release, MedCityNews, Modern Healthcare, which dubbed it ‘another year, another promise’.

Innovate or Die. For companies and providers, it’s not about compliance anymore but about improving patient outcomes due to value-based care and incentives. Providers will increasingly be responsible for patient care throughout the community to make their numbers. Having made this sound point, Dr John Halamka then proposes they will need a ‘care traffic control’ system through data aggregation, with a laundry list of ‘enablers’, directories and connectors surrounding the EHR. How this all will work together, and who will buy in already challenged practices and ACOs, plus how those 17 notoriously territorial EHRs will work with said ‘enablers’ — or complicators — is a mystery to this Editor. Pass the Advil, please. MedCityNews

Read on for more Top 10s, roundups, DOD and VA EHR news, the Super Bowl-winning quarterback tackles the closing keynote, and 10 ways you can become a HIMSS speaker! (more…)

Cerner win at Defense a crossroads for interoperability (US)

Modern Healthcare’s analysis of the Cerner/Leidos/Accenture win of the Department of Defense (DoD) EHR contract focuses on its effect on interoperability. In their view, it’s positive in three points for active military, retirees and their dependents.

* EHR interoperability with the civilian sector is needed because 60-70 percent of the 9.6 million Military Health System beneficiaries—active duty military personnel, retirees and their families—is delivered by providers in the US private sector through Tricare, the military health insurance program.

* A major criticism by Congress and veterans’ groups of both DoD and VA is the lack of interoperability between these systems as well as civilian. Many military members change their status several times during service, and can cycle within a few years as active, Reserve, National Guard and inactive reserve. Records famously get lost, sometimes disastrously.

* It’s a boost to state health information exchanges (HIE) in states with large military bases and also for the CommonWell Health Alliance, an industry group which is establishing EHR interoperability standards.

Less optimistic are some industry observers who see the DoD contract as sidelining resources demanded by Cerner’s civilian hospital clients, and whether realistically they can develop a system to exchange data with every EHR, including dental, and e-prescribing system in the US (and probably foreign as well). Modern Healthcare

US Department of Defense picks Cerner/Leidos/Accenture for $4.3 bn EHR

Breaking News Updated  The winner of the massive, potentially ten year contract for the Defense Healthcare Management System Modernization program is defense computer contractor Leidos, which brought in Cerner and Accenture Federal Systems.The DOD announcement mentions only lead contractor Leidos, interestingly under the US Navy Space and Naval Warfare Systems Command, San Diego, California. The announcement was released just after 5pm EDT today.

This combination beat the Epic/IBM and the Allscripts/Computer Sciences/HP bids. According to the DOD announcement, “This contract has a two-year initial ordering period, with two 3-year option periods, and a potential two-year award term, which, if awarded, would bring the total ordering period to 10 years. Work will be performed at locations throughout the United States and overseas. If all options are exercised, work is expected to be completed by September 2025. Fiscal 2015 Defense Health Program Research, Development, Test and Evaluation funds in the amount of $35,000,000 will be obligated at the time of award.” Modern Healthcare attended the embargoed press conference this morning and adds in its article that only one-third is fixed cost, with the remainder as ‘cost plus’, which could conceivably run the contract to the $4.33 bn ceiling over the 10 years. The system will be used in 55 military hospitals and 600 clinics, with an initial operational test as early as 2016 (Washington Post) and full rollout by 2023.  Interoperability with private EHR systems was a key requirement (Healthcare IT News).Over the 18 year life cycle, the contract value could be up to $9 bn, according to the WaPo.

The race to replace DOD’s AHLTA accelerated with the final failure to launch a plan to create a joint DOD-VA EHR in March 2013 [TTA 27 July 13], though hopes revived in Congress occasionally during the past two years [TTA 31 Mar].

It is also widely interpreted as a blow to Epic, which has been defensive of late about its willingness to play in the HIT Interoperability sandbox with other EHRs; certainly it cannot make Big Blue, which would undoubtedly have found some way to sell Watson into this, happy.

POLITICO’s Morning eHealth had many tart observations today, mostly pertaining to the belief of some observers that Cerner will be strapped in meeting this Federal commitment and would find it increasingly difficult to innovate in the private sector.

Example–From Micky Tripathi, CEO of the Massachusetts eHealth Collaborative: “My biggest worry isn’t that Cerner won’t deliver, it’s that DOD will suck the lifeblood out of the company by running its management ragged with endless overhead and dulling the innovative edge of its development teams. There is a tremendous amount of innovation going on in health IT right now. We need a well-performing Cerner in the private sector to keep pushing the innovation frontier. It’s not a coincidence that defense contractors don’t compete well in the private sector, and companies who do both shield their commercial business from their defense business to protect the former from the latter.”

HIMSS’ last full day highlights company partnerships

click to enlargeIt’s almost time to Say Goodbye to Sinatra’s ‘My Kind of Town’, but there’s still news: Samsung+Partners Healthcare, IMS Health, AliveCor, Interoperability≠Humana, Panasonic+Cisco

  • Samsung and Partners HealthCare announced a direct-to-mobile partnership to develop chronic care management mobile software that monitors vital signs such as blood pressure, blood glucose and weight, as well as delivers mobile patient engagement, medication adherence and wellness self-management. Clinical trial is scheduled for June. Partners has always been a pioneer in the mHealth area, but playing with Samsung, Partners is flying at a slightly higher level than with Wellocracy and certainly the late Healthrageous. Partners release, Mobihealthnews (more…)

HIMSS Monday highlights

HIMSS is the largest US healthcare conference in the world, and Neil Versel, who has just joined the staff of MedCityNews, reported that registrations in this year’s event in Chicago were in excess of 40,000. He has a 37 minute interview with HIMSS Executive Vice President Carla Smith where they touch on CMS, Meaningful Use, EHR interoperability, data security, patient engagement and the empowered patient such as E-Patient Dave deBronkart (who will also be at The King’s Fund Digital Health conference in June). HIMSS is also showcasing on the show floor mobile health, interoperability, cybersecurity, disaster preparedness, intelligent health and the connected patient….Another sign that the Wild West days of digital health are over is the increasing oversight of the Federal Trade Commission (FTC) on non-HIPAA regulated health data collected by fitness and wellness devices. This is in addition to health apps making unsupported claims (see today’s and previous articles on melanoma detection apps) and the PaymentsMD patient billing software that was collecting a little extra patient data. This is both extra- and in addition to FDA. Mobihealthnews….. The Venture+Forum on Sunday discussed doctor burnout particularly in acute care and to ease this, focusing on the Holy Grail of proactive rather than reactive care and results rather than ‘shiny new objects’ (what this Editor has called Whiz-Bang Tech) “Doctors want clinical decision execution. Don’t give me any more tools.” Healthcare IT News….A survey by Accenture released today on doctors and EHR usage headlines good news–79 percent US doctors feel more proficient in their EHR usage than in their 2012 survey. The bad news is that other numbers are plummeting: fewer believe that EMR has improved treatment decisions (46 percent in 2015 vs. 62 percent in 2012), reduced medical errors (64 vs. 72 percent) and improved health outcomes for patients (46 vs. 58 percent). Familiarity breeds contempt? Buried way down in the release is that US physicians offering telehealth monitoring to patients has tripled since the last survey, from just 8 percent in 2012 to 24 percent now. Accenture surveyed over 2,600 physicians in six countries….HIMSS goes to Thursday, so more to come!

30 ways mHealth is impacting healthcare–and EHRs need to be

If EHRs were perfect, there wouldn’t be so many companies developing communication workarounds. And why does a HIT consultant play Blame The Doctor?

Practice Unite, an early-stage company fresh out of Newark (cross the Hudson, head south) that knits together patient and clinician communications in highly customized app platforms for healthcare organizations [TTA 11 Mar], has put together a thought-provoking and fully attributed list of 30 ways mHealth is impacting healthcare: the value for patients and clinicians, the need for mHealth apps as part of collaborative care platforms and communication, plus the investment trail towards digital health. Hat tip to @PracticeUnite via Twitter.

One notable point is the difficulty current systems have in integrating data and the increased administrative load (+10 percent more) physicians experience with EHRs versus paper patient records. Confirming this are two items in Thursday’s POLITICO Morning eHealth: one, the privately-driven workaround for universal health data interoperability that the CommonWell Health Alliance is seeking as a non-profit trade alliance. and two, what happened when the GE Centricity EHR used by MedStar Health group’s DC and Baltimore-area outpatient clinics crashed after a weekend upgrade and stayed down through Tuesday night. Weekend data was lost. One doctor’s reaction:

“They kept saying it would be back up in an hour, but when I left work Tuesday night it was still down.” This doctor told us that the outage was “disruptive and liberating at the same time. I wrote prescriptions on a pad for two days instead of clicking 13 times to send an e-script. And I got to talk to my patients much more than I usually do. But of course we didn’t have access to any notes or medication history, and that was problematic.” 

Now this observation is neither petty nor isolated. Last Fall we noted a JAMA study of internal medicine physicians finding that for both experienced physicians and trainees, there was a loss of time across the board in taking notes, reviewing patient data and at least one data management function was s-l-o-w-e-r. [TTA 12 Sept 14] Houston, we have a problem.

Yet there are still the ‘nothing to see here, move along’ types sailing down A River in Egypt. Others blame the victims, as in the doctors, for their cloddish unwillingness to Get With The HIT Program. (more…)

Pondering the squandering redux: $28 billion gone out the HITECH window

In 2009, the US Congress enacted the HITECH Act, as part of a much broader recovery measure (ARRA or ‘the stimulus’), authorizing the Department of Health and Human Services (HHS) to spend up to $35 billion to expand health IT and create a network of interoperable EHRs. Key to this goal of interoperability and seamless sharing of patient information among healthcare providers was achieving stages of ‘meaningful use’ (MU) with these EHRs in practice, to achieve the oft-cited ‘Triple Aim‘ of improved population health, better individual care, delivered at lower per capita cost. Financial incentives through Medicaid and Medicare EHR programs were delivered through multiple stages of MU benchmarks for hospitals and practices in implementing EHRs, information exchange, e-prescribing, converting patient records, security, patient communication and access (PHRs).

Five years on, $28 billion of that $35 billion has been spent–and real progress towards interoperability remains off in the distance. This Editor has previously noted the boomlet in workarounds for patient records like Syapse and OpenNotes. Yet even the progress made with state data exchanges (e.g. New York’s SHIN-NY) has come at a high cost–an estimated $500 million, yet only 25 percent are financially stable, according to a RAND December 2014 study. (more…)

EHRs can’t exchange patient records? $$ in workarounds.

Some of the Excedrin/Panadol Headaches (#11, #14, #23 and #54) in healthcare are around the very ‘miracle technology’ that was supposed to make it all seamless, non-duplicative, time/cost-effective and coast-to-coast–EHRs. The exchange of patient records between hospitals, within health systems between sites and with medical practices plus vice versa–works haltingly if at all. It works best within well-established, highly integrated delivery systems –the VA, DOD, Mayo Clinic, Kaiser, Geisinger, Intermountain Healthcare. But once you’re away from it–good luck. Where are the problems? The closed standards of the major hospital EHRs–Epic, Cerner, Allscripts, McKesson and brethren; the extreme customization most health systems demand (nay, a major Epic selling point!); structured versus unstructured data and how handled; a lack of a secure interoperability standard are but a few. Where is the gold? Getting patient health records exchanged, accessible and transportable, among systems that were essentially designed not to speak with each other. (more…)

The sun is in his heaven and all’s well with the world?

It’s tempting to think that nothing much has changed in the world of telehealth & telecare recently. For example the quality of healthcare PR looks to be unchanged, if the recent announcement by Telehealth Sensors is anything to go by. They claim to have developed  an incontinence sensor that is “a revolutionary advancement in the home healthcare and post-acute care monitoring market.” Careful reading suggests this “revolutionary advancement” is based on the property of water, apparently only recently recognised by Telehealth Sensors,  that it conducts electricity (especially if its impure) – so advanced in fact that such sensors with a rather longer lifetime than the 30 days claimed by Telehealth Sensors, have (more…)

VA, DoD aren’t collaborating on EHR: GAO

Your ‘Dog Bites Man’ item for the weekend (no, it’s not in reverse!) is that the Government Accountability Office (GAO) has determined that Veterans Affairs (VA) and the Department of Defense (DoD) have not yet proved that their current two-system path, having rejected a single EHR, actually will be workable. In February 2013, both agencies abandoned a joint system after $1 billion in spend, and $4 billion in fixes/upgrades to their separate VistA and AHLTA systems. [TTA 15 Dec] By the two agencies going their separate ways, the GAO is mystified on what is going on with interoperability. The answer: not much. And as mentioned in our 15 December article, there was a 31 January deadline for an interoperability plan (or single system) to be implemented by 2016, mandated by the 2014 National Defense Authorization Act (NDAA). Obviously, this deadline has come and gone. FierceEMR article, GAO recommendation (full text PDF)

One way to overcome the interoperability problem and too much in the EHR? Get rid of those pesky backlogged patient records! The Daily Caller uncovered a VA whistleblower’s complaint to the VA’s Inspector General and their office of special counsel, plus Congress, that VA officials in Los Angeles intentionally canceled backlogged patient exam requests going back more than one year–and that the delay on exams went back 6-9 months. The deletions started in 2009. There is a wrongful dismissal (of said whistleblower) suit and other joy. Article, audio (02:21) Updates 3-4 March:  according to Under Secretary for Health Robert Petzel, the Daily Caller report was ‘scurrilous’. He stated that about 300 records were closed but not deleted after administrative review, generally for old imaging requests, and there was no effort to delete records to boost performance.  According to FierceHealthIT, the backlog is about 400,000. Also Military Times. According to EHR Intelligence, both DoD and the VA agree with the GAO recommendations; GAO will update its findings once the agencies have taken action. Also iHealthBeat.

An essential link to mHealth devices and apps?

Guest columnist Lois Drapin thinks so. She shares her insights on Validic, an emerging company in data integration for payers, providers, preventive wellness companies and pharma;how it evolved from its original concept in consumer health engagement, along with a few pointers its founders have for fellow entrepreneurs.

One of the keystone aspects of “ecosystems” is interoperability and this also applies to the data pipeline that flows from health apps and devices to the appropriate segment of the healthcare delivery system, and eventually, to the users—patients, consumers and/or medical professionals such as physicians and nurses or other clinicians. By now, we all know that the capture and analytics for both “big” and “small” health data are business imperatives for healthcare in the US. With data of this nature, we can embrace our understanding of behavioral change at the individual and population levels. The anticipated outcomes of behavioral change may power operational and cost efficiencies in the healthcare industry.

But data will no longer come from just inside the healthcare delivery system. In addition to the changing technology enablement within the health system, as we all know, data will flow from many things—in fact, The Internet of Things (IoT). This means that data that relates to our lifestyle, wellness and health will pour from the many types of wearable devices not now connected to the heath delivery system. In addition to our computers, tablets, phablets and smartphones, are the many sensors paired with tech innovations such as the wearables— from wristbands, smartwatches, clothing (from shoes to headbands), glasses, contacts, and pendants — to things such as refrigerators, clocks, mattresses, scales, coffee pots, cars, and even, toilets…all of which are predicted to become an important market in the coming years.

Validic, based in Durham, NC, has put itself smack in the middle of that market (more…)