Further insights on and thoughts about the Oracle acquisition of Cerner

HISTalk, with its focus on health IT and generally short mentions without opinion on the news, in today’s issue includes some thoughts on the Oracle-Cerner deal, including a rare “Announcements and Requests” inviting reader thoughts on the acquisition’s effect on several issues. Also rare: a lengthy anonymous comment from a healthcare CIO.

A few highlights–your Editor recommends you go to the article for more:

  • Oracle’s free cash is far less than the purchase price at $23 billion. They will need additional financing to complete the Cerner acquisition.
  • Announcements and Requests: will customers on the fence between Epic and Cerner run towards the less uncertain choice? Will the Cerner VA and DOD business be affected? How does this affect Cerner’s implementations of cloud services, currently AWS versus Oracle’s Gen2, as well as healthcare’s usage of  InterSystems Cache versus Oracle’s relational databases? And will Oracle’s Voice Digital Assistant as the user interface to Cerner Millenium really fly?
  • From Change of Control: How key to the deal was CEO David Feinberg MD, who only joined in October? No matter what, he’s now a very wealthy man.
  • From On-Demand: Oracle is buying its way into healthcare. Cerner lost a lot of ground in executive changes and a less than effective CEO. (Editor’s note: This dates back to 2017–the illness and untimely death of Neal Patterson, the co-founder and CEO, at age 67 and president Zane Burke’s departure the following year after 20 years for the CEO spot at Livongo, which undoubtedly made him a wealthy man!)
  • From Anonymous Health System CIO’s Initial Thoughts: Their biggest problems are 1) people and process.”Cerner has struggled to maintain competent staff that understand healthcare and individual customer workflows. Throughout our implementations, we had major challenges with project management, availability of experienced staff, and the ability to help us make informed decisions.”  2) “If Oracle is going to help reduce the cost of healthcare, they also need to help find savings for their customers.” 

All these should be of concern to Cerner as they–and their people–try to maintain momentum until the acquisition closes. Customer uncertainty, staff competence, and Oracle’s lack of background in how healthcare operates (including a history of pulling some ‘fast ones’ around cloud licensing, as well as understanding clinician preferences such as Dragon as a voice assistant) are undoubtedly giving some investors–and hospital systems–pause. Hat tip to HISTalk. Our earlier coverage here.

One final comment from Editor Donna: Never underestimate the power of a CEO’s ego–especially one who is routinely compared to God, at least in TechWorld–in wanting One Last Coup to burnish his escutcheon, before that Long Sail Into The Sunset on his yacht Musashi.

News & deal roundup: Oak Street adds telespecialty RubiconMD, ATA plumps for wider telehealth access, yet claims fall to 4%, West Suffolk NHS adds Zivver mail/file security, Northwell’s $100M for AI–and miss industry shows yet?

Primary care network Oak Street Health acquired virtual specialty telehealth provider RubiconMD for $130 million. Oak Street is a 19-state network of physicians in care centers who specialize in Medicare patients. RubiconMD has 230 specialists who provide doctor-to-doctor teleconsults (eConsults) in 120 specialties, with an emphasis on cardiology, nephrology, and pulmonology, which is a strong fit for Oak Street. RubiconMD also has separate offerings for specialty care panels and behavioral health. The $130 million includes up to $60 million in cash or cash/stock, subject to achievement of defined performance milestones. Management transitions were not disclosed. Release, FierceHealthcare

The American Telemedicine Association wants to preserve wider telehealth access into 2022–even if the public health emergency (PHE) for Covid has to be extended. Although the Medicare Physician Fee Schedule proposed by CMS for 2022 includes areas of wider telehealth access and reimbursement (temporary access under Schedule 3 added in 2021) into 2023 regardless of the PHE, Congressional action is required to permanently expand telehealth beyond the existing programs mostly for rural areas. If necessary, ATA is advocating that Health & Human Services (HHS) extend the PHE through 2022 so that telehealth access and reimbursement are preserved. ATA releaseFierceHealthcare

While this Editor can understand ATA’s frustration and the sincerity of its aims, it distorts the emergency meaning of a PHE that is just about nonexistent except for mandates. And telehealth claims, even with current access, have sunk down to a tick above 4%, 60% of which are mental health codes (FAIR Health July national data). Too many providers, too little demand? 

The West Suffolk NHS Foundation Trust (WSFT) has selected Zivver UK to secure its mail and file transfer systems, as it migrates from NHS Mail to Microsoft 365. It includes encrypted email to patients as a core requirement meeting NHS digital standards, and ease of use for both sender and recipient in MS Outlook. 4,800 staff at WSFT, which covers 280,000 people who live in West Suffolk. Release. Hat tip to HISTalk for this and the next two stories.

Northwell Health backs AI health startups via joint venture with Aegis Ventures with $100 million stake. The JV between the two New York-based companies “will ideate, launch, and scale AI-driven companies to address healthcare’s most challenging quality, equity, and cost problems” with stakeholders across Northwell’s extremely large system. According to the release, “Northwell has a track record of success in AI research, including the development of a landmark algorithm that predicts patients’ overnight stability to reduce the need to wake them for vital sign checks.” Nice to know that a health system appreciates patient sleep. 

And finally–miss the grip and grin of a F2F industry trade show and presentations? Your Editor, who was once a habitué of meetings from Boston to Florida, does. Really! Virtual conferences, once fun, are now tedious. So enjoy this walk through of HLTH21 by Ben Rooks, the Investor Man, at the Boston Seaport (a great venue, though not precisely central), right down to the barbers, puppy rescue, disco ball, and juice shots. Courtesy of HISTalk

Breaking News: HIMSS20 canceled; Naidex update; what is the outlook for other major conferences? (updated)

UPDATED 5 and 12 March

At 12.25 pm today, according to an email visible on HISTalk, HIMSS has canceled HIMSS20. This cancellation is the first in the 58-year history of the conference.

Quick facts are on HISTalk at the link above, on the HIMSS announcement, and on their FAQs.

The advisory panel recognized that industry understanding of the potential reach of the virus has changed significantly in the last 24 hours, which has made it impossible to accurately assess risk. Additionally, there are concerns about disproportionate risk to the healthcare system given the unique medical profile of Global Conference attendees and the consequences of potentially displacing healthcare workers during a critical time, as well as stressing the local health systems were there to be an adverse event.

Also from the announcement: “HIMSS20 exhibitors and attendees will be contacted with further information regarding booth contracts and registrations. Please contact exhibitors@himss.org for immediate booth concerns.”

The CHIME (College of Healthcare Information Management Executives)/HIMSS CIO Forum symposium on Sunday 8th-Monday 9th is also canceled, per a comment on HISTalk. The only indicator on their website as of now is a large ‘CANCELLED’ on their event list. Later this month is the 5G Executive Forum on 25-26 March in Plano, Texas; is that now being reevaluated?

Neither will be rescheduled for this year. Further chatter on the 3/6 HISTalk centers on what to do with all the promotional items and after-action assessments of losses to marketing and sales. There are companies which center their annual budget and marketing efforts on HIMSS, perhaps not the best ‘eggs in one basket’ strategy, but one that many follow. Hat tip to HISTalk and their ace staff

For our UK and European Readers, Naidex is one of the largest conferences for independent living and healthcare. So far, it is on at Birmingham NEC from 17–18 March, they are taking a long list of precautions based on guidelines set by the WHO and local authorities, but according to their site statement by the event director, it is a fast-moving situation and may change based on those advisories. POSTPONED 10 March–see 12 March update.

Original article follows:

There is a growing list of exhibitor and attendee cancellations for HIMSS20 in Orlando, Florida, starting next Monday the 9th. HIMSS is one of the largest global healthcare conferences, and is a ‘must attend’ for a wide swath of healthcare-related companies, including clinical and monitoring technologies, software from the giants (Microsoft, Cisco) to the startups, hospital systems, payers, telecoms, and all sorts of governmental entities like CMS. (When the opening keynote speaker is President Trump, you know it’s important.)

Health IT website HISTalk, a regular exhibitor at HIMSS, has been tracking the cancellations as of today, doing their own research and following reader leads and public announcements, with a follow up article dated tomorrow. It’s well above 50, with major companies like Humana, Siemens, IBM, and the aforementioned Cisco and Microsoft, on the list. Modern Healthcare has an update.

Based on the comments and HIMSS’ own advisory, HIMSS is accepting cancellations from the CDC’s Level 3 or 4 alert countries, but other cancellations are not being refunded (likely pushed to 2021). Hotels/airlines may not be refundable based upon policies and the clout of travel bookers. Onsite, HIMSS is preparing onsite medical offices for care and screening, as well as promoting the HIMSS elbow bump in lieu of the handshake. It’s regrettable as there are hundreds of staff involved year to year who are responsible for all the planning, marketing, logistics, and security for HIMSS and any conference of this size.

The major reason? Many companies, including healthcare companies, have indefinitely canceled non-essential travel across the board for the next 30 to 60 days as a matter of institutional policy. The large destination conferences taking place March-June are the most affected by this. Consider that for the immunocompromised, attending any large conference is dicey, but COVID-19 is one large red flag.

IBM has canceled Think 2020 in May, which regularly attracts 30,000 attendees to San Francisco. Mobile World Congress Barcelona, the largest in the telecom sector which crosses over to mobile-based healthcare, canceled two weeks before starting on 24 February. The American Physical Society (physics) canceled this week’s conference in Denver the day before it started. The LA Times has a roll call of canceled conferences including Facebook and Google I/O. Others remain on, but monitoring the situation:  the American College of Healthcare Executives Congress on 23 March and EPIC 2020 in Croatia 19-21 March [TTA 16 Jan].

Small, local conferences and meetings are the least affected, so you’re probably safe in London and NYC. The King’s Fund has a full roster of London meetings, including the Digital Health and Care Congress 2020 on 20-21 May. Upcoming are also DHACA Day on 18 March and the NYC meetings listed last week. (Don’t go if you’re sick, steer clear of the inconsiderate, avoid buffets, and wash your hands!)

HISTalk’s 5 March article (scroll down) reports on the findings from the leader of the WHO team which spent two weeks in China studying their COVID-19 response. China is moving patients from their best hospitals to ‘routine care’ to accommodate COVID-19 patients. Children do not seem to become infected or be carriers. The trend in infection there is trending down. Overall, it seems to be a series of global outbreaks, not a global pandemic. And they came away with a fatality rate in China of 1-2 percent, which seems low based on other reports.

EHR system-generated emails/inbasket messages contributing to burnout in 36% of doctors: study

That crispy feeling is real. Unlike the overflowing paper forms, charts, and faxes of olden days (!), doctors and clinical staff now not only deal with paper, but also with what physicians call their ‘electronic masters’. The volume is astounding and has led to numerous studies of physician burnout. One of the latest has been published in Health Affairs (free access), a directional study which will not cheer up anyone concerned with doctor health and retention in the field.

A study of over 900 physicians at the Palo Alto Medical Foundation found that almost half (114, 47 percent) of the 243 weekly in-basket messages received per physician, on average, were algorithmically generated out of their Epic EHR. This far exceeded emails from colleagues (53), from themselves (31, e.g. reports), and patients (30). Other findings from the study:

  • 36 percent of the physicians reported burnout symptoms
  • 29 percent intended to reduce their clinical work time in the upcoming year
  • 45 percent with burnout symptoms received greater-than-average numbers of weekly EHR-generated in-basket messages
  • Receiving more than the average number of system-generated in-basket messages was associated with 40 percent higher probability of burnout and 38 percent higher probability of intending to reduce clinical work time
  • EHR message volume was highest for internal medicine, family medicine, and pediatrics

While this is only one group of physicians in one location, and limited by specialties,this excerpt from the concluding discussion tends to say nearly all:

Therefore, both perceived and realized loss of autonomy over their work schedules could leave physicians feeling defeated, even though some of these system-generated messages have been shown to improve certain processes of care for patients with chronic illnesses.

Health care organizations need to reconsider some of their approaches to improving the quality of care and population health. Physicians might not be the most appropriate recipients of some system-generated messages. Payers and government regulators may need to be part of the solution in enabling physicians to practice at the top of their license. EHR design engineers also need to reconsider whether system-generated automatic messages are the best way to ensure quality of care. It may be time to examine whether every reminder to order routine chronic disease management lab tests (for example, periodic glycosylated hemoglobin A1c tests) must be signed and placed by a physician.

Health care organizations may benefit from engaging with their physicians in creating optimal policies on email work, in addition to helping them with such work. (e.g delegation to non-physician clinicians–Ed.)

Add to that phone calls and endless prior authorizations from insurers–should we have a ‘Be Kind To Your Doctor Week’? Hat tip to HIStalk.

China’s getting set to be the healthcare AI leader–on the backs of sick, rural citizens’ data privacy

Picture this: a mobile rural health clinic arrives at a rural village in Jia County, in China’s Henan province. The clinic staff check the villagers, many of them elderly and infirm from their hard-working lives. The staff collect vital signs, take blood, urine, ECGs, and other tests. It’s all free, versus going to the hospital 30 miles away.

The catch: the data collected is uploaded to WeDoctor, a private healthcare company specializing in online medical diagnostics and related services that is part of Tencent, the Chinese technology conglomerate which is also devoted to AI. All that data is uploaded to WeDoctor’s AI-powered cloud. The good part: the agreement with the local government that permits this also provides medical services, health insurance, pharmaceuticals and healthcare education to the local people. In addition, it creates a “auxiliary treatment system for general practice” database that Jia County doctors can access for local patients. According to the WIRED article on this, it’s impressive at an IBM Watson level: 

Doctors simply have to input a patient’s symptoms and the system provides them with suggested diagnoses and treatments, calculated from a database of over 5,000 symptoms and 2,000 diseases. WeDoctor claims that the system has an accuracy rate of 90 per cent.

and 

Dr Zhang Qiaofen, in nearby Ren Zhuang village, says the system it has made her life easier. “Since WeDoctor came to my clinic, I feel more comfortable and have more confidence,” she says. “I’m thankful to the device for helping me make decisions.”

The bad part: The patients have no consent or control over the data, nor any privacy restrictions on its use by WeDoctor, Tencent, or the Chinese government. Regional government officials are next pictured in the article reviewing data on Jia County’s citizens: village, gender, age, ailment and whether or not a person has registered with a village health check. Yes, attending these health checks is mandatory for the villagers. 

What is happening is that China is building the world’s largest medical database, free of those pesky Western democracy privacy restrictions, and using AI/machine learning to create a massive set of diagnostic tools. The immediate application is to supplement their paucity of doctors and medical facilities (1.5 doctors per 1,000 people compared to almost double in the UK). All this is being built by an estimated 130 private companies as part of the “Made in China 2025” plan. Long term, the Chinese government gets to know even more intimate details about their 1.3 billion citizens. And these private companies can make money off the data. Such a deal! The difference between China’s attitude towards privacy and Western concerns on same could not be greater.  More on WeDoctor’s ambitions to be the Amazon of healthcare and yes, profit from this data, from Bloomberg. WeDoctor is valued at an incredible $5.5 billion. Hat tip to HISTalk’s Monday morning update.

Mismanaging a healthcare IT transition: what’s the cost?

Many of our Readers may consult HIStalk on occasion, especially the provocative weekly columns by a physician known as Dr. Jayne. She has a great deal to do with HIT for her practice, was a CMIO, and her Monday Curbside Consult is about the high cost of changing EHR platforms in a healthcare organization–an event that’s happening a lot lately (think DoD and VA). It’s the story of her friend who worked in IT for a health system that migrated to a single vendor platform and practice management system. The friend was given the option to remain with the legacy platforms support team for the transition, with the employer promising that those people would move to the new platform team following the migration. Routine, correct?

Not so routine when the cutover completion resulted in two weeks notice for those perhaps two dozen people. It wasn’t about headcount, because the organization posted jobs, but all new hires are required to be certified on the new system which the transition staff were not. And this health system, a non-profit, spent half a billion dollars for an EHR migration.

What’s the cost, in Dr. Jayne’s book?

  • The health system jettisoned a group of its most experienced people, with 15-20 years experience on average, with long-standing customer relationships (customers being doctors, practices, and health facilities). The knowledge base and track record they have in handling ‘Dr. Frazzled’s high maintenance billing team’, now wrestling with a new system, walked out the door.
  • These people, due to age, may never work, or find positions at the same level, ever again–and may very well wind up in the uncompensated healthcare system.
  • The health system may, through getting rid of experienced people, evaded the hard work on its own legacy of people and process. She points out that they “treated this migration simply as a technology swap-out” versus an “opportunity for further standardization and clinical transformation”. New people can freshen an organization, but will they be allowed to, or be fitted into the same stale setup?

Dr. Jayne is optimistic about her friend finding a new position. This Editor will let her write the conclusion which applies beyond HIT in how healthcare is being managed today, from small to giant organizations:

Too often, however, that mission is keeping up with the proverbial Joneses rather than being good stewards. It reminds me of when I was in the hospital this winter, when I didn’t get scheduled medications on time due to a staffing shortage. Is it really cheaper to risk a poor outcome? When did people become less valuable of an asset than mammoth IT systems or another outpatient imaging facility or ambulatory surgery center? And do we really need another glass and marble temple to healing when the actual patient care suffers?