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THE NEWS SOURCE FOR HEALTHCARE INFORMATION TECHNOLOGY n APRIL 2016 www.HealthcareITNews.comHIMSS Media / Vol. 13 No. 04

BENCHMARKS: Interoperability. From policy prescriptions to technical specifications, the e’s been some promising recent movement on data exchange. Now it’s time to put it all into practice. PAGE 30

See our ad on page 40

Get readyA new round of HIPAA audits is on the way from OCR. But will they do more harm than good? PAGE 8

Fighting alert fatigueEHR notification overload costs docs an hour per workday.PAGE 21

Out of the woods?During the long run-up to the ICD-10 compliance deadline, a feeling of nervous anticipation was palpable across the healthcare industry. The day itself came and went without incident, and six months later claims are still being processed smoothly. But are the sighs of relief premature?PAGE 4

Incomplete informationmeans incomplete care.

When you bring data together, something amazing happens. You start to gain insights and make connections that weren’t possible before—connections that impact patient care. We built

InterSystems HealthShare® to unify patient data and provide caregivers with a single platform for seamless, connected care

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CONNECTApril 2016 | Healthcare IT News | www.HealthcareITNews.com 3

WHAT’S INSIDECritical decisions“When you’re making decisions and putting data in front of patients, they are as important to CDS as the doctor is – both parties have to be involved,” Dale Sanders tells Healthcare IT News Contributing Editor John Andrews. “The decisions you make about clinical care and strategy at the population level is a different skill set, different strategy and different method than at the patient level,” he says. Sanders, senior vice president of Salt Lake City-based Health Catalyst, advocates for a ‘Three Ps’ approach to clinical decision support: population, protocol and patient. As he sees it, each level has its own self-contained purpose, but together they make for an effective program.

PAGE 32

POLICY 8Making IT workCMS’ Andy Slavitt calls out technology that contributes to ongoing physician frustrations.

Long time comingInteroperability incentives on the way for long-term and post-acute care.

CLINICAL 18Acute stepeClinicalWorks enters hospital market with new inpatient EHR.

Preventative advantage Online records, alerts offer a boost for better care.

BUSINESS 22Big buy for Big BlueIBM Watson acquires Truven Health Analytics for $2.6 billion.

Shopping on the mindPop health, patient engagement top of listfor IT purchases.

DATA 26HIE helpMichigan health information exchange pledges boost for Flint’s infrastructure.

Cerner platformCompany launches open space to spur development of SMART on FHIR apps.

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APRIL16-19: CHIME Healthcare CIO Boot Camp, Chicago

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19-20: HIMSS Media Pop Health Forum, Boston

23-26: WEDI 25th Annual National Conference, Salt Lake City

JUNE13: MobiHealthNews 2016, San Francisco

14-15: HIMSS Media Big Data & Healthcare Analytics Forum, San Francisco

15-17: AHIP’s Institute & Expo 2016, Las Vegas

28-30: AMIA’s Academic Forum Annual Conference, Columbus

JULY23-27: AHIMA Faculty Development Institute, Denver

AUGUST1-2: AHIMA CDI Summit, Washington

FEATURED EVENTHIMSS Media’s Pop Health Forum kicks off May 19 at the Westin Waterfront Hotel in Boston.

SLIDESHOW

Scenes from HIMSS16: Romney keynotes HX360, education sessions thriveThe show floor buzzed with anticipation surrounding Mitt Romney’s keynote speech at HX360 and educa-tion sessions continued to fill quickly with eager-to-learn attendees.

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Preventing EHR lava pits: what healthcare can learn from the gaming industryHealthcare can learn a lot from the finance and retail sec-tors, but there’s another industry that hasn’t been men-tioned where healthcare, and particularly electronic health record systems, can take note: the gaming industry

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Using telemedicine to treat chronic diseaseDespite the widely publicized successes of the ACA, many rural Americans were forgotten by health care reform. Perpetuated by the inability to find and afford care, rural populations face higher incidences of chronic disease. Telemedicine has a crucial role to play.

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VIDEOHIMSS16: Full Event HighlightsWhile HIMSS16 has come to a close, the value of the connec-tions made and the experienc-es gained from the annual conference will extend throughout the year. Hear from attendees themselves as they reflect on the week.

CALENDAR OF EVENTS------------------------------------------------

INSIGHT 16What happened in VegasEncouraging signs on interoperability, cybersecurity, pop health from HIMSS16.

Ready to catch FHIRCMS and ONC pledge to speed adoption of the interoperability spec, which shows pop health promise.

ICD-10: ASSESSING

THE AFTERMATHJOHN ANDREWS, Contributing Editor

COVER STORY www.HealthcareITNews.com | Healthcare IT News | April 20164

IN THE RUN-UP to the Oct. 1, 2015, deadline for filing claims in the ICD-10 format, the feeling of dread within the healthcare

industry was palpable — much like it was prior to Jan. 1, 2000, when it was feared the Y2K computer glitch could sow chaos.

In both instances, fear of the unknown and expectation of catas-trophe caused sleepless nights for many providers, payers and vendors across the U.S.

Fortunately, both dates passed without incident and each event proved to be largely anticlimactic. Yet the situation that exists today may hide more post-deadline pitfalls than Y2K did 16 years earlier, and every-one in the continuum, from CIOs to physicians to coders, must maintain a heightened sense of vigilance. Other-wise, the fears of strangled cash flo caused by waves of claims denials could still come true, experts say.

But first things first: The mass worrying about everything coming to a grinding halt on Oct. 1 did not materialize. In fact, the transition went so well that it even made some folks uneasy.

Turns out, an extra year for imple-mentation helped a lot of the smaller hospitals and physician practices, even though larger hospital systems saw it mostly as an inconvenience. In querying sources from various enti-ties along the supply chain about why things went better than expected, they cited awareness, preparation and education while crediting dif-ferent technologies for facilitating the transition.

There were hiccups, but for the most part they were minor. Not sur-prisingly, the physician sector expe-rienced the most difficult at crunch time, with some practices struggling to make the conversion.

Overall though, “it was not as hard as they thought,” said Mary Jean Sage, president of The Sage Associ-ates, a billing and coding consulting agency.

For Jose Rivera, vice president of physician solutions development at Santa Rosa, Calif.-based VisiQuate, the key to success was two and a half years of preparation.

“Initially we had a little diffic -ty, maybe a 15 percent increase in

claims that were held back for coding reviews because certain physicians took a little longer to choose the right ICD-10 codes, but within a month it was back to normal and overall it was a success,” he said.

To be sure, the extra year made a diffe ence for a lot of healthcare organizations, said Pauline O’Dowd, senior director with Chicago-based Huron Healthcare.

“People woke up on Oct. 2 and found that all was well,” she said. “From a clinical documentation per-spective, we found that people were well prepared. We really haven’t seen any revenue drops — there were the usual denials, but nothing directly related to ICD-10.”

‘RELAXATION PERIOD’All things considered, it appears that the healthcare industry pretty much aced the ICD-10 deadline, and those worries have been put to rest. But have they? The one-year span between Oct. 1, 2015 and Oct. 1, 2016 is being called a “relaxation period,” in which payers are offerin more latitude on claims details and eventually will start enforcing stricter requirements.

“The bottom hasn’t been reached yet because CMS came along and said they wouldn’t be as hard on physi-cians for 12 months after the dead-line,” said Sage. “So we may not have seen things we will see after Oct. 1, 2016. There haven’t been too many denials yet, but that could change.”

The physician sector is more vulnerable to revenue interruption once payers start clamping down on code specification. So far the sector has managed to successfully convert ICD-9 to comparable ICD-10 codes using crosswalk conversion programs and by focusing on the code groups they use most often, she said.

“That is why they’ve done as well as they have so far. But they need to take the next step and start looking at codes beyond their immediate scope and adding more specificit ,” said Sage.

For instance, Sage is conducting a coding audit for a large clinic that regularly performs Well-Child exams and converting the 9 code to 10 isn’t always accurate because of a detail called “normal findings,” she said

“It has to be classified as either ‘with’ or ‘without’ normal finding and if you convert 9 to 10, it translates as ‘without’ normal findings — and that isn’t always the case,” she said.

Rivera concedes that educating physicians on the higher level of spec-ificity was “challenging,” but that progress is gradually being made.

BROADENING PERSPECTIVEIn the acute care setting, concurrent documentation is “refocused” on clinical documentation improvement programs, O’Dowd said.

The thrust of most CDI programs is on improving the quality of clinical documentation, creating an accurate representation of services through comprehensive reporting of diagno-ses and procedures. It affects qual-ity measures, pay for performance, value-based purchasing and other initiatives that require documenta-tion specificit .

“Whether it’s looking at the broad-er spectrum, hospital-acquired con-ditions or population health, people have the chance to refocus on these issues now that they’ve worked their way through ICD-10,” Huron Health-care’s O’Dowd said. “People were overwhelmed by what might happen — it’s a huge elephant to get your arms around. They just focused on what they were supposed to know.”

On the coding side, productiv-ity has gone down by 20 percent, O’Dowd reasons, because the process has become more convoluted.

“It takes longer to get through the process now,” she said. “If a coder could handle three ICD-9 charts an hour, it is a bit less than that with ICD-10.”

INSIDE PHYSICIAN PRACTICESHospitals — especially large health systems — have teams of support personnel to share the responsibility of ensuring that a major event like transitioning from ICD-9 to ICD-10 succeeds without much difficul .

It is quite diffe ent at a physician practice, however, where the labor yoke is typically strapped to one person. It is not an enviable position to be in, say two clinic directors in describing their ICD-10 experience.

Both Tracy Dean and Lora Meikle shared the same trepidation ahead

of the Oct. 1 deadline, but also felt it wane once crunch time actually arrived.

“Our anxiety level was huge, but the closer the deadline got, I real-ized that the payers didn’t seem to be stressing out nearly as much as I was,” said Dean, business office director for OrthoTexas Physicians and Surgeons in Carrollton, Texas.

“It was one of those things where we compared it to Y2K; we were on the hamster wheel and freaking out,” she said. “Yet it turned out to be a non-event, and we handled it like rock stars.”

The ordeal wasn’t without its frus-trations, however, as about one-quar-ter of the clinic’s phy-sicians were skeptical about ICD-10 ever becoming reality, so they thought training was a waste of time, Dean said.

“No matter what I said about it not going away, they didn’t believe me until Sep-tember arrived,” she said. “So we were behind the eight ball.”

Following a logical strategy of studying all ICD-10 codes related to orthopedics, Dean’s management team attended a year’s worth of training, and “took every orthopedic ‘cheat sheet’ we could get our hands on to create something that we could roll out to physicians.”

The mission then progressed into phasing out the doctors’ ICD-9 charge sheets, which had Dean won-dering how it would be received.

“We knew with ICD-10 we would push our charges out of the EMR sys-tem and prevent creating an ICD-9 charge sheet,” she said. “We weren’t sure how it would come out, and after nearly five months there have been a couple stragglers, but they are all pushing the codes out. They are with the program.”

At Cherry Westgate Family Prac-tice in Granville, Ohio, offic manager Meikle admits everyone “was very nervous” at the outset because “we were facing meaningful use and ICD-10 at the same time, and it was one thing after another.”

But disaster didn’t happen, the

revenue stream hasn’t been affecte and, despite “a handful of denials,” claims filing and cash flow has been “consistent overall,” she said.

So for the time being, claims are being accepted, finances are stable and code cross-walks between ICD-9 and ICD-10 are working fin . But for how much longer? And what impact will it have when payers start requir-ing more specificit ?

The transition took a minor toll on OrthoTexas, one of the largest, if not the largest orthopedic groups in the state. In the wake of the ICD-10 deadline, the organization contracted from nine office to seven and from 28 physicians to 25. And while pay-

ers are accepting claims without much static, Dean said she realizes that “eventually they will start denying even though we’re not seeing it now.”

Cherry Westgate is a much smaller practice, comprising five fam-ily practitioners in a single offi . To handle the scope of ICD-10, the

organization turned to Carrollton, Texas-based Aprima for assistance in mapping ICD-9 codes to ICD-10 through a crosswalk program. Though the conversions aren’t per-fect, they have worked well enough to make it beyond the deadline, “and we’re still doing it that way,” Meikle said.

“If there is a 9 code, we have options with 10 — it isn’t exact … sometimes we have to drill down and sometimes we have trouble with unspecified claims,” she said. “We realize that we are able to fil unspecified, and that it will change in October. But there are 69,000 unspecified codes in the book for ICD-10 compared with 16,000 for ICD-9. That is a huge diffe ence. The other challenge is that we cannot manipulate the verbiage, so we will have to figu e that out.”

THE CROSSWALK CHALLENGEFor software developer Aprima, post-ICD-10 represents a very active time for the company. With more than 2,000 practices on the client roster ranging from single-physician prac-tices to groups of more than 250, CEO Michael Nissenbaum says much of what Aprima does centers on evalu-ating each practice on its methods.

“I wish it could be one-size-fits-all, but all physicians practice diffe ent-ly,” he said. “That means we have to listen to how they document, which allows us to modify the workflow for their needs. We don’t see ICD-10 as a challenge, but an opportunity to empower our customers.”

One common theme among pro-viders is that they will need to address the deeper granularity of ICD-10 coding requirements going forward, specifically the addition of “right,” “left,” “upper” and “lower,” body descriptions as well as “firs ” or “second” time on patient visits.

Ultimately the ICD-10 granularity

“THE BOTTOM HASN’T BEEN REACHED YET BECAUSE CMS CAME ALONG AND SAID THEY WOULDN’T BE AS HARD ON PHYSICIANS FOR 12 MONTHS AFTER THE DEADLINE. SO WE MAY NOT HAVE SEEN THINGS WE WILL SEE AFTER OCT. 1, 2016. THERE HAVEN’T BEEN TOO MANY DENIALS YET, BUT THAT COULD CHANGE.”Mary Jean Sage

Diane Rivers

COVER STORYApril 2016 | Healthcare IT News | www.HealthcareITNews.com 5

is key to better care management, Nissenbaum said, because “it puts together a mosaic in the physician’s mind to be more creative than an assembly line worker.”

Nissenbaum acknowledges that multiple areas need to be contempo-raneously updated for the crosswalk, and that as modifications are made,

the company sends out bulletins.“We are the eyes and ears of the

regulatory process,” he said.

‘NINERS’ & ‘TENNERS’In the two years leading up to the ICD-10 deadline, industry figures speculated rampantly about the make-up of coding staff for the new format. Some predicted a mass exo-dus of the ICD-9 coders (“Niners”) and an influx of people trained spe-cifically in ICD-10 (“Tenners”). While the Niners tended to be predomi-nantly composed of middle-aged women unready or unwilling to learn the new code, the new generation was supposed to be younger, more gender diverse and tech savvy.

Have those predictions come true so far? To a certain extent, yes — but the evolution hasn’t been as clear-cut as expected. For one thing, the one-year delay caused some staffin con-fusion within coding departments.

“We saw some Tenners hired a year ago before the delay was announced, so they also had to learn ICD-9, which was resource con-sumptive,” O’Dowd said. “Some of the older coders delayed their retire-ment, while others left.”

The diffe ence in volume between ICD-9 and ICD-10 is staggering: 69,368 diagnosis codes and 87,000 procedure codes under 10, com-pared with 13,500 diagnosis codes and 4,000 procedure codes under 9.

The rationale among many ICD-9 coding veterans: Too much to learn, too late in life… might as well retire.

A self-described “Niner,” Diane Rivers, coding practice director for Jacksonville, Fla.-based CSI Health-care IT, says if things progressed according to that script, she would have followed many of her colleagues out the door. Instead, she ended up becoming an expert in ICD-10.

“I saw the handwriting on the wall in 2012 and thought by the time ICD-10 hit I’d retire and become an artist,” she said. “I reached a crossroads and I could either join my friends in retire-ment or take it seriously. I decided to buckle down and learn it.”

Admittedly, Rivers “begrudgingly” began learning ICD-10 and found the

experience trying at first, but through arduous commitment she began to “see it for what it is — a new lan-guage and a way to keep my mind sharp.” The effo t landed her at CSI Healthcare IT, a third-party coding firm, where she supervises a staff of 60. Among their biggest clients are hospitals where “Niners” have left.

As auditor, coder and supervisor, Rivers is overseeing a team made up of younger generation “Tenners,” who she confirms “includes an influ of young males who are grabbing the job by the horns and showing more confidence about the opportunities that exist.”

WATCHING PAYERSAs a clearinghouse, Jacksonville, Florida-based Availity is a claims conduit for providers and payers, but the concentration is squarely on the payer community, says Matthew Ketterman, director of product and portfolio analysis.

So how complicated has ICD-10 made their operations?

“From a clearinghouse perspec-tive, 5010 was a bigger issue,” he said. “The difference with ICD-10 is that there is very little we can do with the claims — it requires some sort of information for us to translate the codes. Our role is to be the front door of the payer, providing the least path of resistance so that the provider doesn’t have to worry about whether the payer has the setup they need to file the claims.

Because the payer doesn’t have a one-to-one electronic relation-ship with the provider network, Availity scours the landscape to solve any challenges that occur, Ketterman said.

“There are a few things that are spe-cific to 10, such as the need for end-to-end testing, adjusting the system, and mandates based on providers, payers and states,” he said. “ICD-10 says prior to Oct. 1, 2015, you need to use 10 cod-ing schedule. For dates after that, the format must be ICD-10. How do you test that? We had to create a system that accounted for diffe ent partners with diffe ent states of readiness. We had to build in a lot of capabilities that providers could not have done.”

Ultimately, payers were ready for ICD-10 “because they stood to lose so much if they weren’t,” Ketterman said. Provider claims, for the most part, were clean after the deadline, he said, and claims payments have been consistent, with a less than 1 percent rejection rate.

As the “relaxation period” winds down, Ketterman concedes providers will have to get more specific with their codes, but at the same time he is confident that the process will con-tinue unabated.

“Providers understand that ICD-10 is life now,” he said. “There may be some bumps and some issues

with the system upgrades where no more ICD-9 codes are supported by vendors, but those things can be worked out.”

DISSECTING DENIALSClaims are the lifeblood of pro-viders’ operations, and denials are the virus that threatens their financial health. So understanding the reason why claims get rejected — especially with the ultra-granu-larity of ICD-10, is paramount, says Allison Gilmore, principal data sci-entist for healthcare with Menlo Park, California-based Ayasdi.

An advanced analytics firm, Ayasdi develops machine learning applica-tions for claims-denial management. Its apps can extract denial and claim trends from extraordinarily large datasets to recoup millions of dol-lars in lost revenue.

“Denials are important — the data is complex and the providers struggle to report,” Gilmore said. “Denials are not always the same, so when trying to understand denial patterns, it’s a small percentage of claims and the trends are smaller than that. It takes complex analytics to get it right.”

ICD-10 presents a number of chal-lenges, but they can be distilled down to two prominent ones, she said — the speed with which new trends arise and a negative cause-and-effec pattern within code analysis.

In addressing the first challenge, Gilmore notes that “new trends come up fast and to identify them you only have a couple months of data to review so far — the data pool is small.” On the second point, she observed: “When you expand out the number of codes, you decrease the number of claims with any given code. We call that sparsity and ICD-10 just made things harder.”

In the coming months, Gilmore expects to see “very fast change as more adapt to the new envi-ronment.” For Ayasdi, that means a boost in workload so that new trends can be detected quickly even if there isn’t much data.

“There is a lot of change to come, and we have yet to see the other shoe drop,” she said.

FRONT-END IMPACTAt first glance, front-end claims authorization isn’t directly related to ICD-10 coding, but Jay Deady, CEO of Denver-based Recondo, says con-flicts between 9 and 10 could cause interruptions to the revenue cycle for providers.

“We’re hearing that payer by payer, they won’t accept unspeci-fied codes for 9 or 10 and they want more discrete codes,” he said. “The impact from the front end means most facilities won’t have clerks making determinations of which ICD-10 codes to use.

“We’re starting to see our pro-gressive clients adding in nursing case managers and hospitalists to the work groups and are looking at how to provide a higher level of clinical specificity on the front end,” he said. “If that’s not done, the pro-jection is that in a year or year-and-a-half, there will be a spike in claims denials due to no prior authorization on the ICD-10 code.”

With more than 900 clients, Recondo’s ser-vices include patient estimation and eligibil-ity and authorization. Its main focus is on automating authoriza-tion in the area where there is “the biggest latent downstream effec ” — business rule adoption tied to ICD-10 by payers.

“We heard from the Blues, who are being more aggressive and stepping out on their own ahead of CMS,” Deady said.

LANGUAGE BARRIERGetting the specifics of an ICD-10 code correct starts with a seemingly rudimentary process — examining a patient in order to determine a diagnosis and set a course of treat-ment. But with an increasingly non-English-speaking ethnic popu-lation, simple communication can become a difficu and expensive proposition, says David Fetterolf, president of Clearwater, Florida-based Stratus Video.

The language barrier can be over-come with an interpreter either on-site or by telephone, but the process can be cumbersome. What’s more, hiring an interpreter can be costly.

While most of the non-English patients speak only Spanish, waves of immigration in recent years have increased the need for interpreters in Arabic and Mandarin, Fetterolf said.

Stratus takes the best of both face-to-face interpretation and the cost effectiveness of video confer-encing in its solution, which works on iPads and laptops. To arrange an interpreter, the user presses a but-ton for the desired language, and a healthcare-certified interpreter is supposed to join the conference within one second.

By having a face-to-face conversa-tion, even with someone through a screen, it improves the communica-tion so that specificity required for

ICD-10 claims is interpreted with greater accuracy, Fetterolf said.

“Half of what the physician does is interview the patient, and it can’t be diagnosed properly with-out effective communication,” he said. “It leads to better specificit for coding while also preventing readmissions and leading to higher quality care.”

LESSONS LEARNEDIt is five months beyond the ICD-10 “go live” deadline, and the transition ordeal went better than anticipated for most providers. The fears of mas-sive claims rejections, crashing cash flows and full-blown chaos were largely unfounded.

But after a mounting pre-deadline build-up and “sky is falling” admon-ishments — coupled with head-in-the-sand physician denial — it’s

no wonder that those fears existed in the firs place.

Providers have more work ahead of them during the next six or 12 months in order to continue the relatively smooth claims fil-ing and revenue cycle experience they have enjoyed so far, but

there is no discounting the fact that they endured and took away some valuable lessons.

“The build-up and subsequent delay didn’t help matters,” Visi-Quate’s Rivera said. “A good portion of us were ready the year before. We had a minor challenge within the physician population who didn’t conduct their due diligence, but the majority wanted to do the right thing and we got the right response. It is assuring to me that the doctors wanted the best for their patients.”

Huron Healthcare’s O’Dowd says preparation, pragmatism, and priori-tization helped a lot of organizations withstand the storm: “The organiza-tions that succeeded built a strong relationship with their teams — spe-cifically the clinical documentation specialists, physicians and coding professionals.”

Dean, meanwhile, contends that vigilance has been the key to manag-ing the deadline transition as well as staying on course for meeting future challenges.

“We’ve been on guard, we know when the changes are happening, we are working the claims and looking at denials — nothing is too small not to have a conversation with the team,” she said. “We do not assume a denial is a one-time, isolated thing. Each denial could be part of a larger pattern.”

And Sage makes one very impor-tant point: We made it.

“We all hate change, espe-cially when it’s something that is administrative and not clinical in nature,” she said. “The experience has shown that we can make the change, that in the long run the system will be better and reporting will improve dramatically.” n

“Denials are important – the data is complex and the providers struggle to report. Denials are not always the same, so when trying to understand denial patterns, it’s a small percentage of claims, and the trends are smaller than that. It takes complex analytics to get it right.” Allison Gilmore

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POLICYwww.HealthcareITNews.com | Healthcare IT News | April 20168

Slavitt, DeSalvo at HIMSS16: Health IT has to work better for physiciansWhile touting tech successes so far, CMS and ONC recognize physician frustrationsMIKE MILIARD, Editor

IN A CO-PRESENTATION with National Coordinator Karen DeSalvo, MD, at HIMSS16, Acting Centers for Medi-care and Medicaid Services Admin-

istrator Andy Slavitt said physicians “want better technology.”

From both a policy and an innovation perspective, it’s time to give it to them, he said.

Before their dual appearance, Slavitt said, he and DeSalvo read each other’s speeches; the audience laughed when he said she took issue with the tone of his prepared remarks.

“I think your speech comes across as very negative,” DeSalvo told him. “Why don’t you re-read through that lens?”

It was a light moment, but Slavitt had a serious point to make: “She works with the technology community,” he said, which is making tons of progress and, to judge from HIMSS16 so far, “generally pretty happy.”

On the other hand, “I’ve been spend-ing last months with physicians trying to use technology,” said Slavitt. “That may affect y mood just a bit.”

Indeed, health IT has made hugely impressive strides over the past five years, said DeSalvo. U.S. providers have tripled the adoption of EHRs, and the industry continues to build on those early incentives.

On one hand, healthcare is getting

OCR unleashes new wave of HIPAA auditsTOM SULLIVAN, Editor-in-Chief

THE OFFICE for Civil Rights has begun its second wave of HIPAA audits and already the question is arising: Will the program actually succeed

in its effo t to improve privacy and security practices and, ultimately, protect patient data? Or will it have the opposite impact?

Health attorneys aren’t expecting an answer in the short-term. What they are anticipating are plenty of penalties in 2016 as the drum beat of data breaches continues apace.

The initial rounds of audits under the new procedure “will result in a fair amount of fines being levied since that money will go right to OCR and probably help fund the audit program going forward,” said Matthew Fisher, an associate at Mirick O’Connell and chair of the fir ’s Health Law Group.

David Harlow, a health lawyer, consultant and founder of The Harlow Group, explained that OCR is “consistent in saying that the audit process is not a witch hunt.”

OCR described the audit program as an “an important tool to help assure compliance with HIPAA protections, for the benefit of individu-als,” as well as the opportunity to examine mech-anisms for compliance and potentially discover vulnerabilities it might not yet fully understand.

To that end, the second wave will include

approximately 200 audits – most of those being “desk audits” – by the end of 2016.

OCR added that it intends to use the sec-ond wave to identify best practices and, in turn, share that guidance with covered enti-ties. The offi , however, still has to compile and deliver that manner of guidance at some yet-to-be-specified point in the futu e.

Although the forthcoming best practices won’t help those 200 covered entities that get audited this year, Fisher expects OCR to post “a checklist that everyone else should review and use for a self-assessment.”

The problem for now, Harlow said, is that healthcare organizations do not even have a draft audit protocol from OCR: “While OCR is certainly fielding many complaints and taking action on cases before it, we have limited structural, systemic improvements in privacy and security.”

What’s more, earlier pilot audit waves showed that most healthcare organizations had a certain degree of non-compliance with the HIPAA pri-vacy and security laws, Fisher explained.

So even though OCR has yet to clearly outline what healthcare providers should expect exactly, one thing to anticipate is financialpenalties. “Who loses out as a result? Patients,” Harlow said. “The breaches continue, free credit monitoring services are offe ed, and we all move forward with a dimin-ished expectation of privacy and security.” n

HIMSS SEE PAGE 14

HHS gets to value-based goal ahead of schedule

Barely a year after announcing its ambitious plan to tie reimbursement to quality of care, the U.S. Depart-ment of Health and Human Services announced March 3 that 30 percent of Medicare payments are now tied to alternative payment models, such as ACOs. The goal was reached nearly a year ahead of schedule, according to HHS, which touts the

fact that more than 10 million Medicare patients are now getting higher-quality and more coordinated care. “Improving the quality and affordability of care for all Americans has always been a pillar of the Affordable Care Act, alongside expanding access to healthcare,” said HHS Secretary Sylvia Mathews Burwell in a statement. “The law gives us the tools to put patients at the center of their care, improve quality and help make care more affordable over the long term.”

ONC creates Tech Lab, will sunset Standards Framework

The Office of the National Coordina-tor for Health IT has established the ONC Tech Lab to both encourage public input on standards devel-opment and serve as a central connection point for the office’s own work. The development of standards through the lab will help ONC further develop interoperabil-ity standards and to advance work

planned under the Federal Health IT Strategic Plan, which aims to apply the effective use of information and technology to achieve high-quality care. “We will be using the ONC Tech Lab’s organizing structure to help us focus on what we can uniquely contribute to improve existing standards and build consensus around those that best serve specific interoperability needs,” said Steven Posnack, director of ONC’s Office of Standards and Technology.

CIO says VA should rethink VistA, consider other EHRs

U.S. Department of Veterans’ Affairs CIO LaVerne Council said March 2 that the VA needs to reconsider whether its proprietary Veterans Information Systems and Technolo-gy Architecture is the best electronic health record for its more than 1,200 healthcare sites. Council explained during testimony to U.S. House appropriators that changes in the

VA’s healthcare delivery plan, such as emphasis on mobility, security and women’s health, as well as connections with private sector provid-ers, are forcing the reconsideration of VistA. Specifically, Council said it was time to “take a step back” from the planned modernization of the VistA health record and announced VA plans to review whether it should continue upgrading VistA or turn to a commercial off-the-shelf product. “We have not made up our minds about VistA,” Council said.

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CMS backs interoperability for long-term care facilities, behavioral health

A new initiative permits states to request the 90 percent enhanced matching funds to connect a broader variety of Medicaid providers to a health information exchange.BILL SIWICKI, Managing Editor

THE CENTERS FOR MEDICARE and Medicaid Services on Wednesday said it will permit states to request 90 percent enhanced matching

funds to help other healthcare providers such as long-term care facilities, behavioral health providers and substance abuse treatment centers purchase interoperable technology.

The initiative will help bridge an infor-mation sharing gap in Medicaid by CMS to

connect a broader variety of Medicaid pro-viders to a health information exchange. This additional funding will help sustain health information exchanges and lead to increased connectivity among Medicaid pro-viders, CMS said.

“The great promise of technology is to bring information to our fin ertips, connect us to one another, improve our productiv-ity and create a platform for the next gen-eration of innovations,” said Andy Slavitt,

CMS acting administrator, and Karen DeSalvo, the national coordinator for health information technology and acting assistant secretary for health, in an officia CMS blog post Wednesday.

“Technology, when widely distributed and available, enables providers to improve patient care by distributing information and best practices and leading to better experi-ences of care for individuals in the healthcare system. And technology can make a signifi-cant diffe ence in the rapidly modernizing Medicaid program.”

Slavitt alluded to the announcement Tuesday night during a presentation with DeSalvo at the 2016 Annual HIMSS Confer-ence and Exhibition in Las Vegas, where he said, “We’re announcing funding to connect many of the remaining parts of the system that are not part of the EHR incentive pro-grams but serve our neediest patients every day. Finally, we are going to wire up long-term care, behavioral health and substance abuse providers.”

The free flow of information is hampered when not all doctors, facilities or other prac-tice areas are able to make a complete circuit, CMS said. Adding long-term care providers, behavioral health providers and substance abuse treatment providers, for example, to statewide health information exchanges will enable sharing of patients’ health data

between doctors and other clinicians when needed, helping to create a more complete care team to collaborate on the best treat-ment plans and goals for Medicaid patients, CMS added.

“Today’s announcement is another exam-ple of how Medicaid is leading change for its beneficiaries and throughout the health-care system,” Slavitt and DeSalvo said. “But this is more than a technology initiative. It is part of a comprehensive effo t to make sure that the 72 million adults, children, seniors and people with disabilities served by the Medicaid program have access to high qual-ity, coordinated care. Improving population health and addressing the needs of complex populations requires strong health informa-tion technology tools.”

Slavitt and DeSalvo expect a variety of ben-efits from the new initiative, benefits from care coordination to medication reconcilia-tion to public health reporting. For example, exchanging care data can support patients with multiple chronic conditions as they visit specialists, hospitals, primary care practices, home health care providers and pharmacies, the two executives said.

“CMS and ONC look forward to partnering with and supporting states in these and other critical effo ts to modernize and connect the Medicaid program for the millions of benefi-ciaries they serve,” Slavitt and DeSalvo said. n

ICD-10 to get 5,500 new codesCMS said it plans to add about 1,900 diagnosis codes and 3,651 hospital inpatient procedure codesSUSAN MORSE, Contributing Writer

ON OCT. 1, the Centers for Medi-care and Medicaid Services will add another 5,500 codes to the ICD-10 diagnostic library,

official announced in a March 9 meeting. The addition will come exactly one year

after ICD-10, with its nearly 70,000 bill-able codes, replaced the dated, and much more compact, ICD-9 code set.

CMS said it plans to add about 1,900 diagnosis codes and 3,651 hospital

inpatient procedure codes to the ICD-10 coding system for healthcare claims in fi -cal year 2017.

Of the 3,651 new hospital inpatient pro-cedure codes, 97 percent will update the cardiovascular and lower joint body sys-tems, CMS said. There will also be new codes for a face transplant, hand transplant and donor organ perfusion, CMS said.

The large number of new codes is due to a partial freeze on updates prior to the original launch on October 1, 2015 accord-

ing to CMS. The 2016 update will include the backlog of all proposals for changes to the code set.

The new and revised ICD-10-CM (Clinical Modifica-tion) and ICD-10 PCS (Pro-cedure Coding System) codes will be included in the hos-pital inpatient prospective payment system proposed rule for fiscal 2017, which is

expected next month. Diagnostic Related Group changes will also launch on Oct. 1, according to CMS.

Written comments on the codes will be accepted until April 8. n

NQF to HHS: Align MIPS with other federal programsMIKE MILIARD, Editor

THE NATIONAL Quality Forum said aligning measures should be a top priority for MIPS and alternative payment models across all federal

programs and including U.S. states and the private sector.

The National Quality Forum has published its guidance for the new Merit-Based Incentive Pay-ment System. NQF’s Measure Applications Part-nership examined some five-dozen MIPS perfor-mance measures, proposed for implementation in 2017, from which data would be collected to track eligible providers’ performance in 2019.

“As the U.S. healthcare system increasingly shifts to a performance-based payment sys-tem, MAP’s role (is to serve) as an impar-tial advisor bringing stakeholders together from across the healthcare spectrum,” NQF’s chief scientific office Helen Burstin said in a statement.

To that end, MAP offe ed some suggestions to the U.S. Department of Health and Human Services for better aligning with multiple fed-eral healthcare programs, namely the Medi-care Shared Savings Program.

Chief among those was that aligning of mea-sures should be a top priority, and not just for MIPS programs and alternative payment mod-els, but across all federal programs and with states and the private sector where possible.

Indeed, NQF found that gaps still exist across clinician-level programs – most

notably in patient-centered areas such as patient-reported outcomes, functional sta-tus and care coordination. These measures should go beyond patients’ experience with the healthcare system to the impact of health-care on patients’ health and well-being.

Meanwhile, MAP urged continued explo-ration of the impact of socioeconomic status and other demographic factors on measure results, noting that the program should be taking into account when providers are caring for high-risk populations.

NQF also weighed in on measures for pub-lic reporting on CMS’ Physician Compare website. With regard to those most useful for consumers and patients, MAP expressed a preference for those focused on care coor-dination, population health, appropriate care and on outcomes – especially those that are patient-reported. n

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POLICY www.HealthcareITNews.com | Healthcare IT News | April 201612

Report calls out weak FDA stance on medical device cybersecurity

Institute for Critical Infrastructure Technology says feds should do more than just suggest safeguardsMIKE MILIARD, Editor

ARECENT REPORT from the Institute for Critical Infrastructure Tech-nology, a bipartisan collaborative meant to bridge the gap between

federal agencies and private-sector leaders in the interest of protecting the nation’s technol-ogy backbone, claims recent guidance from U.S. Food and Drug Administration for device makers falls way short.

“In practically all matters of cybersecu-rity within the health sector, the FDA seems to be in a constant state of offering subtle suggestions where regulatory enforcement is needed,” write ICIT Senior Fellow James Scott and Drew Spaniel, a visiting scholar at Carnegie Mellon University, in the report.

Specificall , the study, “Assessing the FDA’s Cybersecurity Guidelines for Medical Device Manufacturers: Why Subtle ‘Suggestions’ May Not Be Enough,” knocks the agency for failing to implement enforceable regulations for manufacturers.

“The argument against enforcing cyber-security standards typically centers on the idea that a regulatory presence stifles inno-vation,” they said. “Due to the industry’s continuous lack of cybersecurity hygiene, malicious EHR exfiltration and exploiting vulnerabilities in healthcare’s IoT attack surface continue to be a profitable priority target for hackers.”

The FDA recently published its “Draft Guid-ance for Industry and Food and Drug Admin-istration Staff,” which underscores that cyber-security for medical devices has emerged as a top priority for the healthcare industry.

But while it’s appropriate for FDA to be doing more to highlight the nature of the threat, it’s also worth noting that the medical device community is “compliance-oriented,” Scott and Spaniel said.

“Currently, healthcare device manufacturers and healthcare providers have the ability to ignore the FDA’s recommendations,” they said in the report. “However, it is in the best inter-est of each organization and the community at large if the target audience pays attention to the FDA’s underlying message to adopt a com-prehensive risk-based cybersecurity program.

“Interested stakeholders have 90 days from

the January release of the guidelines to sub-mit comments and suggestions to the FDA about the guidelines,” they added. “It may be beneficial to healthcare providers, healthcare payers, and legislators to petition the FDA to make the guidelines regulatory. Otherwise,

medical device manufacturers could ignore the guidelines altogether.”

This isn’t the first time FDA has been criticized for issuing public statements that call attention to the severity of device secu-rity but do little to enforce safety practices by manufacturers.

In 2013, for instance, a so-called “safety communication” from the agency called on manufacturers, clinical staff and hospital IT and security departments to safeguard against cyberattacks but did little to enforce change.

Noting that FDA “is at a critical point in this ecosystem to correct the path of vendors, manufacturers and administra-tors,” information security expert Gunter Ollmann told Healthcare IT News at the time said the communication was “wishy-washy in its description of the threat and actions to correct the threat. It’s as if it had to pass through multiple committees and each watered it down to become what it is today. It should have been a call to arms, with a clear communication of how serious the problem is.” n

“The FDA seems to be in a constant state of offering subtle suggestions where regulatory enforcement is needed.”

ICIT’s report, “Assessing the FDA’s Cybersecurity Guidelines for Medical Device Manufacturers: Why Subtle ‘Suggestions’ May Not Be Enough,” knocks the agency for failing to implement enforceable regulations for manufacturers.

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POLICY www.HealthcareITNews.com | Healthcare IT News | April 201614

better at spending smarter and having healthier patients. But there are chal-lenges, she said, emphasizing that data needs to flow mo e freely.

“On the supply side, we have built up an amazing amount of health information,” said DeSalvo. “We have to set it free.”

HHS Secretary Sylvia Burwell Monday evening announced that a who’s-who of private-sector vendors, providers and health organizations have committed to more open sharing of data, which DeSalvo called a step in the right direction.

“I couldn’t be more thankful,” said the ONC chief.

But Slavitt – who said he and DeSalvo have “been working together for months” on some of these new policy initiatives, to the point where they can finish each other’s sentences – said still more was needed.

“I’m certainly not bashful about what we need to do better, and I’m not going to be bashful here, even in the face of some very good reasons for optimism, about ways we need to take our game up across the board – all of us,” he said.

The health IT industry has made a great

start, said Slavitt. “But we’re still at the stage where technology often hurts rather than helps physicians providing better care.”

CMS is committed to taking a user-centered approach to designing policy, he said.

“I’m asking you to do the same. Step back and look at what you don’t think is working, and make it work better.”

Slavitt said CMS has recently under-taken its most concerted effo t ever to lis-ten to physician feedback, working with those on the front lines to understand their pain points.

He read a number of physician quotes that should sound familiar to many: Meaningful use has become “too much of a burden,” said one doc. “Most of what I’m doing during the day is entering data into the EHR,” said another. One joked (or half-joked) that “to order aspirin takes eight clicks; to order full-strength aspirin takes 16.”

Physicians feel hampered and frustrated by lack of interoperability, said Slavitt. They think federal regulations in their cur-rent form slow them down and distract from care. They also find EHR technology hard to use and cumbersome.

The good news, he said, is that doctors

are “not describing problems we don’t know how to solve. That makes Karen and me optimistic.”

CMS is “still a few months away from having details available on the proposed MACRA rule,” said Slavitt. But he did share some principles of the agency’s pol-icy approach in the near future.

“Job one is to bridge the gulf between our public policy work and what’s actu-ally happening with patient care,” he said. “That has to become an integral part of how we do things.”

Second, he said CMS would hear phy-sicians’ requests to “stop measuring our clicks” and “give us more flexibility to suit our practice needs and, ultimately, more control.”

Third, providers wherever possible “favor a pull, versus a push for incentives” that lets “outcomes, rather than activities, drive the agenda,” said Slavitt, indicating that CMS has received that message.

Meanwhile, he said the agency would continue to use what levers it could to spread interoperability.

“We’re announcing funding to connect many of the remaining parts of the sys-tem that are not part of the EHR incentive programs but serve our neediest patients every day,” said Slavitt. “Finally, we are going to wire up long-term care, behavior-al health, and substance abuse providers.”

But in the private sector there are still too many barriers to interoperability, he said, from legal clauses to commercial impediments to intellectual property. That’s not an excuse, said Slavitt.

“The companies that live up to their commitments here will be recognized and applauded,” he said. “And I strong-ly encourage you to recognize those that don’t.” n

HIMSSCONTINUED FROM PAGE 8

HHS to enact stricter rules to protect patient privacy of substance use disorder recordsRule would bolster health information exchange of critical personal data while also addressing confidentiali y issues.JESSICA DAVIS, Associate Editor

THE DEPARTMENT OF HEALTH and Human Services has proposed new rules on patient record disclosures to ensure substance use disorder

patients can participate in new integrated healthcare models without risk of having their records shared inappropriately.

The revisions to the Confidentiality of Alcohol and Drug Abuse Patient Records regulation would also facilitate health infor-mation exchange and address legitimate pri-vacy concerns of patients seeking treatment for substance use, HHS said.

“This proposal will help patients with substance use disorders fully participate and benefit from a healthcare delivery system that’s better, smarter and healthier, while protecting their privacy,” HHS Secretary Sylvia Burwell said in a statement.

The proposal reflects the changing health-care landscape, including the development of an electronic infrastructure that focuses on managing and exchanging patient data and an increased focus on performance measurement and quality improvement.

The current rules, sometimes referred to as “Part 2,” were created in 1975 amid concerns that potential substance use dis-order treatment information used in crimi-nal prosecutions would deter individuals from seeking necessary treatment. It was last updated in 1987. Part 2 rules are more

stringent than other federal protections, including the Health Insurance Portability and Accountability Act, due to its targeted population.

“We’re moving Medicare and the health-care system as a whole toward new integrat-ed care models that incentivize providers to coordinate and put the patient at the center

of their care, and we’re modernizing our rules to protect patients,” Burwell said.

The public comment session on this pro-posal is open until 5 p.m. Eastern on April 11. n

Andy Slavitt

“This proposal will help patients with substance use disorders fully participate and benefit f om a healthcare delivery system that’s better, smarter and healthier, while protecting their privacy,” said HHS Secretary Sylvia Burwell.

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systems back to service. A decision only he and the leadership of that hospital could make and one I’m sure not easily arrived at.

In most instances the majority of security and law enforcement professionals would advise against paying the hackers, because, 1) there is no guarantee you will get the decryption key, and 2) there is the fear that it will encourage others to follow suit. I would argue that is easy advice to give if you are not the one looking down the barrel of the ransom note. Until you have walked in those shoes you don’t really know what you will do.

The hospital in this case applied practical triage logic to the patient and took the hand to save the arm. I think it is basically unfair to second guess its decision, after it was faced with more than a week of downtime, and was facing poten-tially longer disruption and mounting costs.

But what is not unfair to ask is how ready was it for this situation? What level of protection was in place? What detection capabilities were pres-ent to identify this situation earlier? And how ready were its contingency plans? Many of the ransomware programs we see in these attacks are well-known and detectable with the right solutions in place ― but were they?

Other hospital leadership teams need to ask these questions because ― to dispel one of those fears above ― others will follow suit. Additional attacks are already happening. It’s not a matter of if, but when.

There needs to be a fundamental shift in our thinking about security today. More prior-

ity needs to be given to detection and response, but detection and response without protection will be less effective and can fail. Systems that look for anomalous behavior or traffi first have to understand what is normal or correct. And response-approaches need sound architectures and systems to enable identification, isolation and containment of infect-ed or affected information assets

Things that undermine this are: lack of proper and real segmentation; weak access controls and protections of credentials, particularly elevated privileges; lack of disci-pline in hardening, patching and change con-trol processes; lagging refresh cycles and end of life equipment; shadow IT and rogue applica-tions; inadequate user education and awareness; not adhering to a recognized standards-based approach to controls; irregular testing and assessment; lack of external review; and inad-

Ransomware: What will it take to be prepared?Much of the ransomware seen in attacks like the one at Hollywood Presbyterian is well-known, and detectable with the right tools and strategies in place

MAC MCMILLAN, CynergisTek

LAST WEEK we all read another sobering account of the disruption that cyber incidents can cause. The ransomware attack at Hollywood Presbyterian

Medical Center was despicable in its nature and alarming in it what it says about the overall pre-paredness of healthcare to deflect these threats.

Healthcare is one of our most critical infra-structures and important to every American. The CEO for this institution eventually opted to pay the ransom to return his institution’s

MAC McMILLAN

SECURITY SEE PAGE 25

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What happened in VegasEncouraging signs at HIMSS16

AFTER SPENDING a week at the Sands Expo and Convention Cen-ter this past month with 41,885 of my closest friends, it took a few

days to sort through and put into perspective some of the big thematic takeaways of health IT’s biggest event.

Perhaps appropriately for a city that loves its lucky 7s, this was my seventh trip to the HIMSS Annual Conference & Exhibition, and it’s pretty remarkable to com-pare how diffe ent things are from my first isit in 2010.

Back then, with meaningful use just coming into focus, this still paper-heavy industry was trying to figu e out how to put those bil-lions of newfound dollars to use. It’s amazing to contemplate how far things have progressed in less than a decade.

The technology has evolved, of course. But so has healthcare providers’ willingness to embrace it and put it to work, their readi-ness to really accomplish some substantial successes with health IT.

And not just providers. Vendors and policy makers seemed to be energized by this new data-rich era and committed to driving inno-vation on the road to value-based care.

You could see it, for instance, when most

of the biggest EHR vendors (Epic, Cerner, MEDITECH, Allscripts athenahealth et al.) and largest health systems signed on to HHS’ pledge for better patient data access, more transparency and standards for interoperabil-ity. You could hear it when CMS chief Andy Slavitt reemphasized the agency’s commit-ment to physicians, calling out technology that still “often hurts rather than helps” and pledging to take a “user-centered approach”

to designing policy.There was a sense that maybe

(just maybe!) the forthcoming Merit-based Incentive Payment System rules – alluded to often at HIMSS16 but still a ways off from taking final shape – might offer a more manageable and less onerous path toward account-able and technology-enabled care than the meaningful use

program, which did so much to spur tech uptake early on but caused so much con-sternation (while also arguably stifling innovation) in its latter years.

There was encouraging news on several fronts with regard to interoperability –

whether it was the continued evolution and innovation around HL7’s FHIR protocol (see Tom Sullivan’s “Innovation Pulse” column on page 17) or, potentially, the rule floated by the Offic of the National Coordinator to add

some teeth to the well-meaning words, certi-fying technology directly to ensure IT systems “speak and listen in the same language.”

There were plenty of buzzwords, of course – “population health,” “cybersecu-rity” – heard all over a sprawling exhibit floor crowded with 1,300 vendors of all stripes. But there was also the feeling that they were starting to really mean something for healthcare providers large and small across the country.

I talked with many healthcare chief infor-mation officer at HIMSS16, and they offe ed all sorts of anecdotal evidence that their orga-nizations were starting to notch some real pop health wins using targeted data analytics and patient engagement strategies.

On the privacy and security front, clearly the stakes are higher than ever. The good news is that more CIOs than I can remember told me data security has become their top priority, and many are using new and enve-lope-pushing tools to keep their data secure from snoops and cyber crooks.

All told, the feeling at HIMSS16 was one of maturity, if not yet critical mass. The sense was that the many various stakeholders in this transformative enterprise – the hospitals and physician practices, the technology ven-dors, the federal rule-makers – are coming closer together in alignment and agreement on the way forward.

The technology is already is there. Even as it continues to advance and evolve, the existing tools are enough to get us where we need to go: smarter, safer, more effective and affo dable care. Now what’s needed is the will to put it work, and to innovate together on those achievable goals. Amid the loudly flashing lights of Las Vegas, that seemed to be happening more than ever. n

MIKE MILIARD, Editor

“The technology has evolved, of course. But so has healthcare providers’ willingness to embrace it and put it to use, their readiness to really accomplish some substantial successes with health IT.”

INSIGHTApril 2016 | Healthcare IT News | www.HealthcareITNews.com 17

equate oversight or governance.Organizations with a good defense-in-

depth strategy, advanced detection capabili-ties and solid response/contingency plans will fare far better when attacked. Make no mis-take about it: Protecting information assets is a business issue, and organizations that don’t recognize this will pay for it.

The ransomware threat is particularly rel-evant for healthcare today and a real threat as we are seeing. That threat continues to evolve as well, and new ransomware variants continue to appear like the one thought to be affectin

organizations now called “Locky.”Locky was first reported a little more than a

week ago, and immediately researchers began to see instances ― upwards of 100,000 per day ― of infected systems. It took some period of time for A/V vendors to acquire the new signature and update their software to detect and block this threat. Depending on how long it took orga-nizations to update its system or how well its environment was covered, it gave Locky more time to operate undetected.

Locky is reportedly spread through a Microsoft Word attachment containing mali-cious macros that, when the recipient clicks on them, downloads the Locky malware and executes it. These ransomware tools are creat-ing serious problems, as the folks in Califor-nia experienced. And for healthcare they are particularly scary because they represent the worst scenario possible ― a serious disruption to the ability to deliver care services.

Ransomware attacks in healthcare affect the reputation of the institution, undermine the confidence of patients and staff, and represent real financial costs

Right now there is a clamoring for more infor-mation on the threat. This always happens right after an event like this, and then fades with time, as does the attention to the problem, but the threat doesn’t go away. This is a persistent issue, requiring a persistent solution. Ransomware is not new ― it has been around since at least 2009, which just happens to coincide with meaningful

use and the mandate to digitize patient infor-mation in the electronic health record, making healthcare more susceptible to hacking and electronic extortion.

Symantec, a leading provider of security solutions and threat monitoring, published an excellent report in 2012, “Ransomware: A Grow-ing Menace,” which provides a brief history of ransomware, some examples of diffe ent types of ransomware attacks known at that time, and strategies for mitigation. While a bit dated today, it no less will bring two things home to those you share it with.

First, this is not something new, but rath-er just the electronic version of an old crime: extortion. Second, any and every organization is susceptible to this threat, and it is definitel persistent. I recommend sharing this with non-technical leadership.

What is especially frustrating about this crime is that most of the ransomware types are well known and there are solutions out there if acquired, implemented properly and allowed to be enforced that would stop this threat dead in its tracks. We have seen disciplined organi-zations achieve this, but it takes enlightened leadership and investment.

We may never know the specifics of the Hol-lywood Presbyterian Medical Center incident ― organizations, for good reason, are reluctant to discuss those things. What I do hope is that the CEO of that hospital will find a way to share with his or her counterparts in our

industry just what this experience meant to his or her institution, how it affected them, and just how it felt to be at the helm during such a trying situation. Executive teams need to understand the cyber risks they face. Mean-while, here are eight areas to think about when building a resistance to these threats:

1.Education. Ensure users know now to identify anomalous behavior and avoid com-mon threats though practical training and realistic exercises.

2. Vigilance. Maintain currency in the IT envi-ronment, refresh systems, keep patches up to date, and harden according to recognized stan-dards, mind configu ations and change control.

3. Layer defenses. Use multiple layers in protective technologies and controls at the end points, on the network, at the host level, etc.

4. Compliment controls. Deploy both sig-nature based and heuristic based detection solutions.

5. Enhance detection. Deploy next generation fi ewalls, malware filters, A/V filters, automate log management, IDS/IPS, etc.

6. Plan smartly. Update contingency plans, back up everything (offline), and think of the worst case in exercises.

7. Be ready. Establish external support rela-tionships, acquire tools, conduct simulations and practice for a real event.

8. Be objective. Use independent third par-ties to perform regular readiness audits, test-ing of controls and assessments. n

SECURITYCONTINUED FROM PAGE 16

FHIR setting the stage for population healthAt HIMSS16, CMS and ONC promise to not only accelerate adoption of the interoperability spec but also have some providers looking ahead at ways they can put it to use.

THE EMERGING PROTOCOL known as FHIR has been most closely asso-ciated with interoperability so far. The acronym, after all, stands for

Fast Healthcare Interoperabil-ity Resources. But if the stan-dard succeeds in its mission of enabling widespread data exchange, FHIR might soon have a higher calling to serve as a foundation for population health management.

“FHIR is a better-designed Lego,” said Doug Dietzman, executive director of Great Lakes Health Connect, a self-sustaining health information exchange in Grand Rapids, Michigan. “I’m looking for-ward to having it in my toolbox.”

FEDS BACK FHIR, BIG-TIMEThere is certainly no lack of public support for FHIR right about now. National coordi-nator Karen DeSalvo, MD, started the fi e at HIMSS16 by launching a $625,000 triptych of developer challenges. One focuses on patient-facing apps, the second on software geared toward providers and for the third ONC is hoping the funding and recognition inspire someone to create what essentially would be an app store for housing these FHIR-based apps and making them avail-able for download.

DeSalvo described the developer chal-lenges as an opportunity for the federal government to engage private sector entre-preneurs in building technologies that make more effective use of health data for patient-centric care.

“It’s time for us to see some digital divi-dends,” DeSalvo said, “to really make that data sing.”

That’s going to require much more than these developer challenges. In fact, DeSal-vo’s announcement came just days after ONC unveiled the Interoperability Prov-ing Ground, which the director of ONC’s

office of standards and tech-nology, Steve Posnack, called a “Match.com for FHIR.”

As of March 10, there are currently 61 projects in the Interoperabi l i ty Prov ing Ground. While those are not limited to FHIR, the idea is to build a central hub that connects the community of people working on interoper-ability projects to share les-

sons learned, best practices and, indeed, to prove the progress already being made.

The MITRE Corp., meanwhile, also used the occasion HIMSS16 to post an open source tool, a web UI called Cru-cible. Available at ProjectCrucible.org, it enables developers to run 228 test suites comprising some 2,000 tests of the FHIR specification. Entrants are classified as API, resources or administrative, displayed in a graphical map to pinpoint bugs and, ulti-mately, given a pass or fail grade.

MITRE lead systems engineer Andre Quina cut to the chase: “Having a standard alone isn’t enough to achieve interoperabil-ity,” he said. “Ambiguities in the standard can be disastrous.”

NASCENT PROGRESS ON POP HEALTHAmong the early success stories of FHIR in action is the work Duke School of Medicine is doing with FHIR and Apple’s HealthKit to integrate standards-based apps such that it can, in the words of Duke’s director of mobile technology strategy Ricky Bloomfield, MD, “liberate electronic health records data.”

Another perhaps less-covered initial FHIR success is the rheumatology app that Geising-er Health System’s innovation unit xG Health Solutions built with FHIR to communicate between Epic and Cerner EHRs basically straight out-of-the-box.

Duke and Geisinger’s work offers a glimpse into the much larger potential FHIR holds.

Indeed, at Great Lakes Health Connect, Dietzman is already thinking about the big picture — as is Corey Waller, MD, medical director at the Spectrum Center for Integra-tive Medicine, which participates in the Great Lakes HIE.

HURDLES AHEAD Dietzman and Waller acknowledged that FHIR

alone won’t get the nation to ubiquitous popu-lation health management, of course. No single technology or specification existing today can manage that.

Many in the industry, rather, maintain that technology is not the hardest obstacle. Healthcare organizations haven’t received strong guidance from the government, Waller said, while Dietzman added that issues such as informed consent and compliance with federal mandates are also inhibiting infor-mation exchange.

That said, what FHIR at least has the prom-ise of enabling is something akin to a reliable pathway into data about patient populations.

Waller said he can envision looking at patient records relative to a particular geog-raphy to know in which neighborhood to set up, say, an addiction clinic. And that’s just one example.

“I can only imagine what we’ll be able to do when we have that data,” Waller said. “I know I have the keys to a health-ier community. I just can’t use that data effectively yet.” n

TOM SULLIVAN

INNOVATION PULSE

FHIR was a hot topic at HIMSS16, with big excitement for its pop health potential.

It’s unfair to second guess Hollywood Presbyterian’s decision to pay ransom to hackers. What is not unfair to ask is: How ready was it for this situation?

CLINICALwww.HealthcareITNews.com | Healthcare IT News | April 201618

eClinicalWorks makes big move into acute care EHRsThe electronic health record vendor debuted early components of new cloud-based technology at HIMSS16BILL SIWICKI, Managing Editor

E CLINICALWORKS IS into the acute care EHR space, and it show-cased early work on the new technology at HIMSS16.

Expanding on some international effo ts dipping its toe into the acute care market, eClinicalWorks has entered a joint devel-opment agreement with South Carolina’s Tidelands Health, a three-hospital health system with more than 40 outpatient loca-tions, to bring an acute care EHR to market.

Named eClinicalWorks 10i, the cloud-based EHR platform will enable provider organizations to connect care within inpatient, outpatient and allied health set-tings, and is slated to launch in early 2017.

“We’ve got a lot of ambulatory cli-ents who use our product that believe the way we’ve worked with them with

cloud computing health records is lack-ing on the inpatient side,” said Girish Navani, CEO and co-founder of eClini-calWorks. “They also say the current state of acute care technology is very different from ambulatory, and that it costs too much. Client/server is a very rigid system that does not cater to a model of care delivery that requires both agility and speed. And usability is a question, with many acute care prod-ucts looking like they were developed 30 years ago.”

Navani said eClinicalWorks has met with success on the acute care front over-seas, where it launched an inpatient EHR system at 80 hospitals.

“For the U.S., we’re taking an approach that is very collaborative,” Navani said of

ECW SEE PAGE 20

Kaiser: Online tools increase likelihood patients will get preventative careRates of preventive health screenings, vaccinations remain low, according to the studyJESSICA DAVIS, Associate Editor

P ATIENTS WITH ACCESS to their online health information who received timely alerts about gaps in care were more inclined to receive pre-

ventative tests and screenings compared with patients who didn’t use the service, according to a Kaiser Permanente study published in the American Journal of Preventative Medicine.

Rates of preventive health screenings, chronic disease management tasks and vaccinations around the country remain low, according to the study. More than 20 to 80 percent of adults fail to obtain the health services they need.

“Making sure patients receive appropriate tests and screenings is a critical part of provid-ing high-quality healthcare, but it can be chal-lenging and time-consuming to get patients to follow through due to a variety of reasons,” the study’s lead author Shayna L. Henry, Kaiser Permanente Southern California Department of Research & Evaluation, said in a statement.

The study found that 8.8 percent of patients who used an online portal were more likely to receive colorectal cancer screenings than those members who didn’t, and online users were 11.9 percent more likely to complete their HbA1c testing than non-users.

Additionally, 9.1 percent of online users were

more likely to visit providers for mammogram screenings, while 6.1 percent were more likely than non-users to receive a Pap smear. Howev-er, there was no noticeable diffe ence between online and non-registered members when it came to receiving vaccinations.

Researchers analyzed the EHRs of 838,638 Kaiser Permanente members in Southern Cali-fornia. Around 40 percent of these members use the online Patient Action Plan, or oPAP, a Web-based system launched in 2012 that provides access to personalized health data.

It also sends emails to members if they’re in need of preventative care based on their last appointments for preventative screen-ings and specific health conditions, such as smoking and diabetes.

“Our study demonstrates that by creating a customized and personalized communi-cation to patients about their care needs, healthcare providers can directly engage patients and close important gaps in care, particularly for preventive screenings for cancer,” Henry said.

“Although the findings represent only a small segment of the overall KPSC membership, and the effect sizes are modest,” the study’s authors said, “the results of the present study indicate the oPAP has considerable potential to be a model for cost- and resource-effective patient engagement in health maintenance and disease prevention.” n

Cerner, xG Health ink population health pact, will share platforms

Cerner has announced that Ge i s i nge r Hea l t h Sys t em subsidiary xG Health Solutions will use Cerner’s HealtheIntent population health management platform and, in turn, Cerner will use xG Health’s clinical content. xG Health’s care management clinical content automates the

assessment of a variety of hereditary, socio-economic, physical, behavioral and environmental risk factors, as well as warning signs and symptoms associated with specific conditions. Cerner clients will be able to use xG Health’s clinical content within HealtheCare, Cerner’s community care management solution that provides algorithms with the ability to identify, stratify and prioritize individuals for assignment to aligned care managers.

HIMSS, SIIM join to ensure com-plete electronic health records

The Healthcare Information and Management Systems Society and the Society for Imaging Informatics in Medicine are making progress tackling the issues associated with incomplete data in patients’ digital health records. Founded a year ago, the HIMSS-SIIM Enterprise Imaging Workgroup is focused on unmanaged

— and sometimes missing — imaging data in patients’ electronic health history. The group offers a platform for sharing enterprise imaging strate-gies, creating awareness that images are an essential part of the electronic health record, inclusive of, yet broader than the more pervasive radiology or cardiology domains. The joint effort “provides timely resources that offer organizations insights on how to manage and share imaging data across the enterprise,” said Joyce Sensmeier, HIMSS vice president of informatics.

Mass General teams with Cogito on behavioral health

Massachusetts General Hospital and MIT spin-off Cogito have partnered on a National Institute of Mental Health-funded project aimed at addressing depression and bipolar disorder. MGH is the largest hospital in the Bay State, and serves as the teaching hospital for Harvard Medical

School. Cogito, a startup spinoff from the Massachusetts Institute of Technology, specializes in behavioral analytics. “We focus on automatically measuring behavior and understanding behavior,” said Cogito CEO Joshua Feast. “We’re interested in the way people move and react. On the healthcare front, Cogito technologies are aimed at helping organizations understand, manage and care for patients.

Girish Navani

"By creating a customized and personalized communication to patients about their care needs, healthcare providers can directly engage patients and close important gaps in care.”

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CLINICAL www.HealthcareITNews.com | Healthcare IT News | April 201620 CLINICAL

the agreement with Tidelands Health before HIMSS16 took place. “We’re engaging with staff throughout the entire ecosystem, from every inpatient department, from OR to ER to rehab ― everyone is participating in the design sessions with us. We’ll showcase the

product that is in the works at HIMSS.”For its part, Tidelands Health, an ambu-

latory EHR client of eClinicalWorks since 2009, is excited to be able to have such input into the creation of an acute care EHR.

“We’ve seen the prototypes and are very pleased,” Tidelands CIO Todd Rowland, MD, added. “We’ll be going live with the system,

which will provide one continuous patient record for inpatient and outpatient, in 2017. For example, under OneCare, our internal name for the system, an emergency room physician calling up a patient record will see the most comprehensive and current medical record from that patient’s primary care and specialist physicians ― in contrast to what an ER physician has today, which maybe is information on the last time the patient was in the ER, which is not very helpful.”

On another front, Rowland added that 50 percent of Medicare payments by 2018 will be made using performance-based mecha-nisms, and that many other payers are fol-lowing suit. “Our current IT systems are not capable of dealing with this,” Rowland said. “eClinicalWorks has shown a shared com-mitment to the OneCare approach, which will cost-effectively deliver a solution that

enhances patient care.”IDC Health Insights research director

Judy Hanover said that eClinicalWorks innovation in the ambulatory fray signals potential to offer those technologies in the acute care space.

“It is quite clear from IDC’s research that there is opportunity for innovation in acute care EHR, particularly as existing products do not deliver on the need for flexible mobile workflows, do not offer significantimprovements to provider productivity or operational efficiency, and fail to deliver value for cost,” Hanover said.

EHR vendors that are able to leverage the cloud to deliver resilient applications with superior fl xibility, usability, mobil-ity, performance and cost of ownership will certainly find opportunity in acute care, Hanover added. n

eClinicalWorks co-founder and CEO Girish Navani said the company has met with success on the acute care front overseas, where it launched an inpatient EHR system at 80 hospitals.

ECWCONTINUED FROM PAGE 18

EHRs trim odds of hospital-acquired infections, adverse events: AHRQBut of more than 45,000 patients at risk for nearly 350,000 adverse events in the study sample, only 13 percent had fully electronic recordsMIKE MILIARD, Editor

A RECENT STUDY FUNDED by Agency for Healthcare Research and Qual-ity suggests that patients with fully electronic health records experi-

enced fewer adverse events such as hospital-acquired infections.

In order to be considered a fully electronic EHR, “physician notes, nursing assessments, problem lists, medication lists, discharge summaries and provider orders are electroni-cally generated,” according to researchers.

Using 2012 and 2013 Medicare Patient Safe-ty Monitoring System data, AHRQ examined outcomes for cardiovascular, pneumonia and surgery patients ― specifically with regard to occurrence rates of 21 adverse events in four clinical domains: hospital-acquired infections, adverse drug events, general events (falls or pressure ulcers, for instance) and post-pro-cedural events.

“To assess the role of EHRs in preventing adverse events, the researchers measured to what extent care received by patients in the 1,351 hospitals was captured by a fully elec-tronic EHR,” said Amy Helwig, MD, depu-ty director of AHRQ’s Center for Quality Improvement and Patient Safety, and Edwin Lomotan, MD, medical office and chief of clinical informatics at AHRQ’s Center for Evidence and Practice Improvement, in a blog post.

The findings of the study, published in the Journal of Patient Safety, show that, of more than 45,000 patients at risk for nearly 350,000 adverse events in the study sample, 13 percent were exposed to fully electronic health records.

Among all patients examined in the study, the occurrence rate of adverse events was 2.3 percent, or 7,820 adverse events. Patients with

EHRs, meanwhile, had 17 to 30 percent lower odds of any adverse event.

Helwig and Lomotan said that health IT has shown patient safety gains, but research to prove it has often looked at just one healthcare provider at a time.

“A question that remains unanswered is the impact of fully installed electronic health records systems used in multiple organiza-tions,” they wrote. “Another big question: Can EHRs go beyond improving safety-related pro-cesses to actually preventing adverse events, such as potentially deadly hospital-acquired infections, from reaching patients?”

The findings from “Electronic Health Record Adoption and Rates of In-hospital

Adverse Events” suggest hospitals with EHRs can offer more coordinated care from admis-sion to discharge to reduce the risk of patient harm.

They note, however, that adverse event odds varied by medical condition and type of event.

“For example, patients hospitalized for pneumonia and exposed to a fully electronic EHR had 35 percent lower odds of adverse drug events, 34 percent lower odds of hospi-tal-acquired infections, and 25 percent lower odds of general events. Among patients hos-pitalized for cardiovascular surgery, a fully electronic EHR was associated with 31 percent lower odds of post-procedural events and 21

percent fewer general events,” they wrote.Helwig and Lomotan caution that the

AHRQ study raises a few questions.“The findings showed a significant rela-

tionship between fully electronic EHRs and adverse drug event rates for patients hospital-ized with pneumonia, but not for those with cardiovascular disease or needing surgery,” they wrote. “This may be due to the fact that certain high-alert medications, such as opi-oids, which are often associated with adverse drug events, were not included in the MPSMS measures.”

Still, the authors said as more hospitals mature in their use of EHRs, those systems can play a key role in preventing adverse events. n

Patients hospitalized for pneumonia and exposed to a fully electronic EHR had 35 percent lower odds of adverse drug events, 34 percent lower odds of hospital-acquired infections, and 25 percent lower odds of general events, according to AHRQ.

CLINICAL 21April 2016 | Healthcare IT News | www.HealthcareITNews.com

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EHR notification overload is costingdoctors an hour each workday, JAMA saysPrimary care doctors are subject to twice as many notifications asspecialists, researchers found, but both are facing information overloadJACK MCCARTHY, Contributing Writer

PRIMARY CARE doctors now lose more than an hour a day to sort-ing through approximately 77 elec-tronic health record notifications

researchers at Baylor University found."Information overload is of concern

because new types of notifications and ‘FYI’ (for your information) messages can be easily created in the EHR (vs in a paper-based system)," the researchers wrote in the Journal of the American Medical Asso-ciation Internal Medicine.

Making the workload harder to endure, reading and processing these messages is uncompensated in an environment of reduced reimbursements for office-based care, according to the study.

Physicians are receiving these increasing

amounts of notifi-cations in EHR-based inboxes such as Epic’s In-Basket and General Elec-tric Centricity’s Documents. The messages include t e s t r e s u l t s , responses to refer-rals, requests for medication refills, and messages from phys i c i ans and other healthcare professionals.

The system is cry-ing out for change the researchers wrote. "Strategies to help filter mes-sages relevant to high-quality care, EHR designs that support team-based care, and staffing models that assist physicians in managing this influx of information are needed."

What’s more, optimistic predictions that EHRs would improve patient care through better doctor-patient communications have not ubiquitously materialized.

"Unfortunately, we are far from this promise and now also grapple with the

unintended consequences of EHRs," Joseph Ross, MD wrote in an editorial accompany-ing the research.

In fact, electronic "paperwork" has bur-dened doctors and reduced the time for patient care.

Ross advocated that inbox notification capabilities be periodically reviewed to be sure EHRs are working in the best inter-ests of patient care and not creating an

unnecessary burden on physicians.In addition, doctors should be reim-

bursed for time spent reviewing EHR notifications.

"Although many of these notifications are in the service of patients," Ross wrote, "we need to be sure that physicians’ reimburse-ment, particularly for primary care physi-cians, is taking into account the full time needed to manage patients’ care." n

"Information overload is of concern because new types of notifications and ‘FYI messages can be easily created in the EHR," according to Baylor University researchers.

BUSINESSwww.HealthcareITNews.com | Healthcare IT News | April 201622

eClinicalWorks, HIMSS among 7 new organizations joining CommonWellMIKE MILIARD, Editor

THE COMMONWELL HEALTH Alli-ance has signed on one of the biggest ambulatory electronic health record vendors, the top

healthcare IT advocacy organization, an image-sharing network and others to the private-sector interoperability group.

eClinicalWorks, a cloud-based EHR used by more than 115,000 physicians, has joined CommonWell as a contributor member and will commit to offering its interoperability services to its customers.

HIMSS, the global nonprofit organiza-tion focused on improving health through information technology, will also join Com-monWell as a general member.

Other new contributor members include lifeIMAGE, a medical image sharing net-work with 150,000 users and 1.5 billion exams exchanged; MediPortal, a developer of patient engagement tools; and Modern-izing Medicine, whose clinical and fina -cial technology is geared toward physician

practices and ambulatory sites.Other general members include Imag-

eTrend, maker of Web-based emergen-cy response and health information exchange technology, and Mana Health, a platform-as-a-service that links patient data from EHRs, apps and devices.

“The diversity in our membership is representative of our commitment to reach the full continuum of care and to help ensure pertinent patient informa-tion is available to patients and caregiv-ers regardless of where care occurred,” said Jitin Asnaani, executive director of CommonWell Health Alliance.

The addition of Westborough, Massa-chusetts-based eClinicalWorks – with some 70,000 facilities running its technology is per-haps the biggest EHR get for CommonWell since MEDITECH signed on in April 2015.

CommonWell official say alliance mem-bers represent 72 percent of the hospital EHR market and 34 percent of the ambula-tory EHR market. n

IBM Watson buys Truven Health Analytics for $2.6 billionExecs say the purchase adds a massive repository of data to the Watson Health Cloud, and an extensive client rosterBERNIE MONEGAIN, Editor-at-Large

IBM ANNOUNCED in February that it will pay $2.6 billion to acquire Truven Health Analytics for its Watson Health unit.

The buy will mark IBM’s fourth major acquisition for Watson Health, a strategic move designed to boost IBM’s capabilities in the emerging field of value-based ca e.

IBM executives say the purchase adds not only a massive repository of health data to the Watson Health Cloud, but also an extensive client roster to IBM’s Watson Health unit.

The deal is projected to close later this year, subject to satisfaction of customary closing conditions and applicable regula-tory reviews.

Truven brings hundreds of types of cost, claims, and quality and outcomes data. Once integrated into the Watson Health Cloud, that information can be leveraged to deliver insights-as-a-service based on IBM’s data repository that will now top approximately 300 million patients.

The deal nearly doubles Watson Health’s worldwide footprint and brings to IBM Watson Truven’s marquee roster of clients – which spans life sciences, providers, payers

and government agencies.“With this acquisition, IBM will be one

of the world’s leading health data, analyt-ics and insights companies, and the only one that can deliver the unique cognitive capabilities of the Watson platform,” Debo-rah DiSanzo, general manager for Watson Health, said in a press statement announcing the pending deal.

She added that Truven’s offerings would complement Watson Health’s broad-based team, capabilities and offerings and would help Watson Health to scale globally to help clients apply cognitive insights in a value-based care environment.

Today, Truven provides cloud-based health-care data, analytics and insights to more than 8,500 clients, including U.S. federal and state government agencies, employers, health plans, hospitals, clinicians and life sciences compa-nies. Data and insights from Truven inform benefit decisions for 1 in 3 Americans

Just about a year ago, at HIMSS15, IBM acquired population health company Phytel, cloud-based intelligence company Explo-rys and medical imaging company Merge Healthcare. IBM has also compiled a roster of partners and clients that include Apple, Medtronic, Johnson & Johnson, Teva Phar-maceuticals, Novo Nordisk, and CVS Health.

With the acquisition of Truven, the employee number for the Watson Health unit will total more than 5,000. n

ONC proposes direct review of health IT certification

Health IT products will be certified directly by the Office of the National Coordinator under a proposed rule change, officials announced in the National Coordinator Spotlight ses-sion March 1 at HIMSS16. Senior members of the ONC described the change as necessary to make sure that medical record sharing

becomes a reality. The proposed rules will enable ONC to “directly review certified health IT products, including certified electronic health records systems, and take necessary action to address circumstances such as potential risks to public health and safety.” Comments are due by May 2, 2016. Medical records should be able “to speak and listen in the same language,” said Elise Adams, acting director of policy at ONC.

UPMC invests in Vivify population health technology

UPMC Enterprises, the commercial arm of the Pittsburgh-based UPMC health system, has become both a customer and an investor of Vivify Health, a Plano, Texas-based company that promises to break down the walls when it comes to delivering care. Neither UPMC nor Vivify would disclose how much UPMC invested in the company. Vivify Health’s

technology is in play at some of the largest health systems in the country. The technology is deployed by 500 hospitals and payer organizations to manage, monitor and engage patient populations of all sizes and risk levels, execu-tives said. “Health plans and providers are laser focused on population health management right now, but they’re struggling to take the vital step of engaging patients in a way that makes it easy for patients,” said Eric Rock, CEO of Vivify.

CPSI launches EHR financin program for hospitals, nursing

Newly expanded health IT vendor CPSI has introduced nTrust, a program designed to help community hospitals and skilled nursing facilities improve financial operations while moving into an electronic health records system with no upfront costs. Through nTrust, hospi-tals and senior care facilities outsource

revenue cycle management operations to TruBridge business services, which recently has been strengthened by the addition of revenue cycle management tools from Rycan Technologies, CPSI officials said. “There are many providers that are unhappy with their EHR, but they don’t have the financial capability to make a switch,” said Boyd Douglas, CPSI president and CEO. “With nTrust, we help providers in acute and post-acute settings improve business operations” while “funding the purchase of their EHR with no advance payment required.”

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BUSINESS www.HealthcareITNews.com | Healthcare IT News | April 201624

Population health, patient engagement top healthcare purchasing plans in 2016Report also claims 23 percent of healthcare organizations are planning to look for new EHR vendors in 2016MIKE MILIARD, Editor

HEALTHCARE ORGANIZATIONS are making big investments in popu-lation health and patient engage-ment platforms as they prepare to

move past meaningful use and toward value-based reimbursement, according to “The Big Mega HIT Purchasing Report,” released Feb. 22 by market research firm peer6 .

Electronic health records remain core to healthcare IT, according to the report, which gathered 567 responses from CEOs, CIOs, nursing and financial leaders and others with purchasing authority at hospitals and medical practices. However, many customers are still dissatisfied ith their products.

Projected EHR replacement rates for 2016 show 23 percent of health providers (inpa-tient and outpatient combined) planning to look for new vendors, according to peer60.

Still, “population health and patient engage-ment are the hottest areas by a wide margin,” wrote peer60 executive vice president Chris

Jensen in the report. “It’s really no surprise these two segments continue to lead the way among hospital IT upgrades considering their impact on successful migration to value-based care and value-based purchasing.”

As for pop health, peer60 sees some stabi-lization in contracting plans. In 2015, roughly 25 percent of providers were certain they’d keep their population health vendor; in 2016, that amount has doubled.

“The pressure is on for vendors that have not already made their mark in this market because they’re about to be squeezed by increasing renewal rates and a declining pool of hospitals that have not already adopted,” said Jensen.

But when it comes to patient engagement, authors see the opposite. “More enterprise vendors are capturing more of the minds of providers, while interest in the best of breed crowd is beginning to dwindle,” Jensen said.

Other big purchasing trends are also unsur-prising. Data security, enterprise analytics and revenue cycle management are all in play. Security technology, especially, has seen a big jump in provider interest.

“In 2015 it was at the bottom of the list of top IT priorities and placed third this year,” said Jensen. “Since this is not a growth mar-ket with 90 percent of hospitals already employing a true data security solution, the jump in interest in this area likely means the replacement market for more robust solutions in this very critical segment is heating up.” n

Mount Sinai Health forms ACO with AetnaThe New York provider already has ACO arrangements with the CMS, Healthfirst andEmpire Blue Cross Blue ShieldJESSICA DAVIS, Associate Editor

MOUNT SINAI HEALTH PARTNERS – a network made up of the Mount Sinai Health System and a vol-untary provider group – has cre-

ated an accountable care organization with Aetna, the companies announced Feb. 16.

The three-year agreement will allow Aetna commercial plan members who receive care at Mount Sinai to benefit from quality and cost efficienc improvements from the pro-gram and establishes a new payment model that will reward physicians for meeting established quality measures.

The partnership is just another step in Mount Sinai’s strategy to improve care delivery from traditional fee-for-service models into population health management, by working with health plans like Aetna to improve care value for both the patients and providers.

“As a health system, we’re moving

aggressively toward population health,” Niyum Gandhi, chief population health offi-cer, Mount Sinai Health System, said. “Our strategy is toward moving into savings for all. When the opportunity came about, that aligned incentives around keeping patients healthier – we jumped on it.”

Currently, Mount Sinai has ACO arrange-ments with the Centers for Medicare and Medicaid Services, Healthfirst and Empire, as well as similar contracts in the works that will be made official throughout the coming year. Mount Sinai hopes to have these arrangements with every insurer in its system.

“Our goal here is align our incentives across all payers,” Gandhi said. “We’re arranging resources to keep patients healthy and out of the hospital. This allows us to align the reward model to reap the benefits.

The agreement includes the more than 3,100 Mount Sinai employees and affiliat physicians. Aetna provides benefits to more than 1.1 million members in New York.

“Our new agreement with Mount Sinai puts consumers at the center of a health care system that promotes wellness, provides bet-ter care for chronic conditions and uses eco-nomic incentives to reward positive health outcomes,” David Kobus, Aetna senior vice president, New York market, said in a state-ment. n

Electronic health records remain core to healthcare, according to “The Big Mega HIT Purchasing Report.” But many customers are still dissatisfied with their products

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Michigan HIE gives $250K to buoy healthcare infrastructure around Flint for water crisis Collaboration with Greater Flint Health Coalition hopes to improve health IT infrastructure, long-term care coordination goals in the areaJESSICA DAVIS, Associate Editor

MICHIGAN HEALTH INFORMATION

exchange Great Lakes Health Connect is investing $250,000 to lay the groundwork for better

care coordination among healthcare provid-ers across Genesee County to better prepare them for the long-term health effects likely to stem from the ongoing Flint water crisis.

GLHC will partner with Greater Flint Health Coalition to connect dozens of medi-cal practices and improve analytics capa-bilities to address some of the looming care requirements for those patients contaminated by lead in the water supply.

The organization hopes to “give those responding to the healthcare needs of Flint’s residents the tools needed to coordinate care and positively impact the health and well-being of Flint’s citizens over the long term,” said Tom Bres, GLHC board chair, in a statement.

More than 420,000 Flint residents have been exposed to water contaminated by lead, including 6,000 to 12,000 children ―

who will require intensive treatments dur-ing the course of their lives. The United Way of Genesee County has already launched a $100 million fundraising campaign for medi-cal treatments for up to 15 years.

GLHC believes data exchange among all providers will improve communication for more accurate, secure and timely care. Addi-tionally, the partnership with Greater Flint Health Coalition will facilitate better care response for tracking lead exposure.

“This integrated network of providers holds the potential for establishing the great-er Flint region as the benchmark model for a care-connected community in the United States ― a virtual environment where informa-tion can be shared quickly among healthcare providers, leading to more effectiv , efficienhealthcare services,” Bres said.

$100,000 will be earmarked to create the Community Interface Grant to pay for the infra-structure necessary to connect 40 physician office across the county, say GLHC official while $90,000 is set for a dedicated implemen-tation consultant to coordinate the program.

Another $50,000 will back an analyt-ics engine for improved communications and data analysis for the coming years, and $10,000 will establish a grant to train all involved with the program. n

Cerner launches open platform to spur development for SMART on FHIR appsLaunches its new Cerner Open Developer Experience to spur wider collaboration with third-party and client developersMIKE MILIARD, Editor

CERNER HAS LAUNCHED its new Cerner Open Developer Expe-rience ― known as “code_” ― in a bid to spur wider collabora-

tion with third-party and client develop-ers for SMART on FHIR applications.

SMART on FHIR tools run on top of electronic health records, giving physi-cians access to the apps from within their workflo , enabling them to more easily interact with health data.

Developers who visit code.cerner.com can begin coding immediately with the SMART on FHIR tools and browse current apps that are available or in development. Cerner offi-cials say code_ is designed with open com-munications and robust API documentation in mind, meant to offer access to tools that enable innovative app development.

“Cerner is committed to taking a lead-ership role to support third-party devel-

opers and help further health information technology,” said David McCallie, MD, senior vice president, medical informat-ics, at Cerner, in a statement.

“Encouraging innovators to develop apps that work across existing health records can help the industry advance the way care is delivered through improved interoperability capabilities,” he added.

Fifteen new SMART on FHIR apps are in development or in production and were showcased in Cerner booth at HIMSS16, which took place Feb. 29 to March 4, at Sands Expo Center in Las Vegas.

“Fostering new ideas from the developer community enables us to reach a broader market of potential users,” said Bob Robke, Cerner’s vice president of interoperability, noting that the platform “has potential to unlock the next cutting-edge solution that could benefit not only our entire client base, but the industry as well.” n

Providers protect wrong data, putting patient health at risk

Too many healthcare organizations are focused on securing the wrong assets, leaving them vulnerable to cyberattacks and putting patients at risk, a new report from Indepen-dent Survey Evaluators claims. When healthcare leaders focus primarily on protecting patient data, they often fail to address actual cybersecurity threats

that directly affect patient health, the report said. ISE studied 12 healthcare organizations, two healthcare data facilities, two active medical devices, two Web applications and other devices found on healthcare networks over the course of two years to determine the possibility of remote attacks and the readiness of these institutions to keep data secure. “We found hospitals were antiquated in their network designs and unsure about the technologies that could effectively help them,” the study’s authors said.

CSF certification could reduce cyber insurance costs

The Health Information Trust Alli-ance has joined with insurance broker Willis Towers Watson for a new program that could enable providers and vendors certified under HITRUST Common Security Framework to save on insurance premiums. The two groups have worked together to educate cyber insurers about HITRUST CSF, and to encourage them to consider it

during the cyber risk underwriting process. They said that CSF’s comprehensive controls framework, which aims to accurately and consistently measure residual cyber risk, has shown some appeal to insurers looking to cover healthcare organizations operating in a fraught cybersecurity threat environment.

Oracle debuts next-gen analytics suite at HIMSS16

IT giant Oracle unveiled its Oracle Healthcare Foundation March 1 at HIMSS16, a next-generation ver-sion of Oracle Enterprise Healthcare Analytics, which provides healthcare organizations with a consistent and complete patient-centric view of their clinical, financial and genomics data across an enterprise. The modular

data integration and analytics system is designed to help various types of professionals throughout an organization study clinical care, per-form financial analyses, streamline administrative services and support research efforts. The aim of Oracle Healthcare Foundation is to enable an entire healthcare organization to treat each patient with a personal touch while achieving high-quality, value-based care in an operationally effi-cient environment, the vendor said.help them,” the study’s authors said.

“Encouraging innovators to develop apps that work across existing health records can help the industry advance the way care is delivered through improved interoperability capabilities,” said Cerner’s David McCallie, MD.

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DATA www.HealthcareITNews.com | Healthcare IT News | April 201628

HIMSS presses NIST to keep cybersecurity framework voluntary for organizations

Framework could be used as a tool to develop a common set of processes for risk managementBERNIE MONEGAIN, Editor-at-Large

HIMSS IS PUSHING the National Institute of Standards and Tech-nology to keep its Framework for Improving Critical Infrastructure

Cybersecurity voluntary.HIMSS, which represents more than

52,000 health IT professionals, wrote to NIST Feb. 8 in response to its request for information. NIST extended the original Feb. 9 comment deadline to Feb. 23.

NIST noted it was looking for ways in which the framework is being used to improve cybersecurity risk management; how best practices for using the frame-work are being shared; the relative value of diffe ent parts of the framework; the pos-sible need for an update of the framework; and options for long-term governance of the framework.

As HIMSS sees it, the framework could be used as a tool to develop a common set of consensus-based, private sector-led guide-lines, best practices, methodologies, proce-dures and processes in relation to privacy and information security risk management.

Since many healthcare organizations

could benefit from improving their risk man-agement process and better address cyber-security risks, HIMSS supports the idea that the Framework could be useful in helping healthcare organizations improve their secu-rity posture, wrote HIMSS President and CEO H. Stephen Lieber and HIMSS Board Chair Dana Alexander in their response.

They also discussed how NIST’s Cyber-security Framework serves to inform orga-nizations that are in need of either creat-ing or updating their own risk manage-ment program. Whether an organization is standing up a new cybersecurity program or has a sophisticated program already in place, the Framework has the potential to serve organizations well in advancing the capabilities of organizations in addressing cybersecurity risk.

NIST first released Version 1.0 of the framework in February 2014. It is among a handful of security best practices and guidance standards gaining purchase in healthcare, including HITRUST Common Security Framework, ISO/IEC 27002 and Control Objectives for Information Tech-nology, or COBIT.

Responses will contribute to shaping NIST’s decision-making about how to strengthen the framework and, ideally, the nation’s critical infrastructure. n

IT managers are hacking their own systems, even in healthcare, survey findsA high percentage of IT workers admit to not following the same security protocols they are expected to enforceBERNIE MONEGAIN, Editor-at-Large

AHIGH PERCENTAGE OF IT workers admit to not following the same security protocols they are expect-ed to enforce, according to a new

survey conducted across the United States by Absolute, a Canadian security firm

In fact, 33 percent admitted to successfully hacking their own or another organization, and 45 percent admitted to knowingly cir-cumventing their own organization’s secu-rity policies.

“The big surprise for us in this survey is that the gatekeepers are really the gatecrash-ers,” said Stephen Midgley, vice president of global marketing for Absolute. Moreover, he said, while the survey of IT department managers included several industries, the findings apply across the board, with health-care no exception.

“Given that IT is the security gatekeeper for an organization, it was alarming to see such high incidents of noncompliant behav-ior by IT personnel,” he said. “Even if these actions are being performed to validate exist-ing infrastructure, senior leadership should be aware that this activity is occurring. It may

also be worthwhile to consider third-party audits to ensure adherence with corporate security policies.”

IT decision-makers bear the brunt of responsibility. Of those surveyed, 78 percent said the organization’s security is primarily IT’s responsibility. The report also showed that 65 percent of IT decision makers believe they would likely lose their job in the event of a security breach.

“The gaps in current data breach response plans and in upholding general best practice policies must be addressed,” Midgley said.

As he sees it, when it comes to security ― especially in healthcare, but also in other sectors ― there’s an accountability divide.

“That is a very precarious space for IT to be in,” Midgley said. “They are tasked with data security, but aren’t actually responsible for the device that contains that data.”

“I think in healthcare it’s magnified,” he added, “because of HIPAA, HITECH, PHI. So, you can have all the security in place, but at the end of the day, IT is reliant on the employee to ensure security is implemented correctly. Yet, what we find is those very same employees try to find ways to circumvent the security policies that have been put in place.”

There’s a lot of work for IT in terms of bridging that gap, he said, and recommend-ed that organizations implement technology that is adapted to their environment that

gives them complete visibility and control of the devices.

Midgley mentioned the example of one healthcare entity that has a policy of auto-matically wiping data from any device ― lap-top, tablet or phone ― that goes beyond a certain location.

“They assume that device has PHI on it,” he

said. “It’s mitigating the risk of a data breach.”The survey ― which polled 501 U.S. adults

who work in information security manage-ment roles in companies or organizations with 50 or more employees ― found that secu-rity remains at the top of the IT spending list, with 87 percent of respondents expecting increased investment in security this year. n

As HIMSS sees it, the NIST framework could be used as a tool to develop a common set of consensus-based, private sector-led guidelines, best practices, methodologies, procedures and processes in relation to privacy and information security risk management.

HIMSS CEO H. Stephen Lieber

“The big surprise for us in this survey is that the gatekeepers are really the gatecrashers,” said Stephen Midgley, vice president of global marketing for Absolute.

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Interoperability gains steam at HIMSS16 BY MIKE MILIARD, Editor

A T HIMSS16 this past month, “interop-erability” was a word heard once or twice. From policy makers to IT professionals, doctors to vendors,

the term was repeated like a mantra. But how close, after all this time and talk, are we to really getting there?

There was some encouraging news out of Las Vegas. HHS Secretary Sylvia Burwell announced that health IT heavy-hitters representing some 90 percent of electronic health records (Cerner, Epic and MEDITECH among them) had pledged – along with some of the largest health systems in the country – to commit to using standardized APIs, forswearing informa-tion blocking and making patient access easier.

And on both the private and public-sector sides, there were promising advancements announced at HIMSS16. For instance, CHIME Board Chair Marc Probst, chief informa-tion officer at Intermountain Healthcare, announced that CHIME’s the $1 million National Patient ID Challenge, launched in January, has already signed on more than 170 innovators to solve the “vexing problem” of cross-system patient matching.

The Offic of the National Coordinator for Health IT, meanwhile launched an Interoper-ability Proving Ground for FHIR, Consolidated CDA, eHealth Exchange, Direct, the Semantic Interoperability Framework and more, and proposed direct review of IT certification with an eye toward improved interoperability.

Still, there’s much more work to be done. And in a prime time keynote, Acting Centers

for Medicare and Medicaid Services Admin-istrator Andy Slavitt said patience is wear-ing thin. There are too many excuses thrown around for lack of interoperability, he said.

“The companies that live up to their commitments here will be recognized and applauded,” he said. “And I strongly encour-age you to recognize those that don’t.”

National Coordinator Karen DeSalvo, MD, echoed the call: “The most recurring themes I hear from consumers is they want their data to be free,” she said.

STANDARDS ON DISPLAYOne of the most encouraging demonstra-tions of that data liberation was the HIMSS Interoperability Showcase, which for years has offe ed technology vendors, HIEs and others the chance to show secure and stan-dards-based interoperability in real-time, in the real world.

This years’s showcase featured more than a dozen use case scenarios simulating continuity of care in multiple diffe ent settings: ambulatory, hospital, emergency, chronic care, public health and more. One demo, called “911 Continuity of Care,” showed how IHE and HL7 specification could enable IT systems of all types to talk to each other – across the U.S. and even abroad.

The imaginary scenario concerned one “Robert Hartman,” a 40-year-old male who’s an Italian citizen visiting the U.S. In St. Louis, he receives care at a community hospital for one of his chronic conditions. Later, while visiting Philadelphia to see the Pope this past Septem-ber, he is in a car accident.

As Robert is transported to the emergency department, paramedics stabilize him and gather clinical data that’s communicated to the ED. Clinicians at the hospital are also able to gain access to his historical medical data once he arrives. A summary of his care is shared with his care providers in St. Louis and also in Italy.

EHR vendors Epic and MEDITECH took part in the demonstration. So did Surescripts, Zoll (developer of emergency medical services tech-nology) and HealthShare Exchange of South-eastern Pennsylvania, or HSX, the region’s health information exchange.

It showed the promise of seamless data exchange – from the ambulance to the ED, from the primary care offi , to the HIE and back.

“At every place along the way, you can use interoperability standards to get the outside data and take care of Robert better,” said Epic

technician Zach McQuiston.The journey starts in St. Louis, where Rob-

ert is treated for diabetes at a MEDITECH-equipped community hospital. “We see that his condition is a bit more serious than expected, so we eventually admit him,” explains MEDITECH Senior Project Coordinator Joe Wall. “Eventu-ally when the patient is discharged, we generate the continuity of care document,” using HL7’s Consolidated CDA standard.

It’s an example, he said, of “leveraging work we’ve been doing with the Argonaut Project” – a collaborative of major EHR vendors and health systems to speed the development and adop-tion of HL7’s FHIR framework – “with all of us playing in the same sandbox.”

All the discharge packet information gets put into the continuity of care document on the MEDITECH side. Since everything is structured,

Rakesh Mathew, program manager at HealthShare Exchange of Southeastern Pennsylvania, explains how the HIE set up an international exchange with Italy during the Pope’s visit to Pbiladelphia.

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“we’re able to display right on the Epic side,” said Wall. “On the ambulance side, they’ll cap-ture additional information so that will be avail-able for the ED as well.”

During transport, paramedics interview Rob-ert and learn he has hypertension, for which he takes medication. They assess his head lacera-tion and examine him for neurological symp-toms and take his vitals. They document the treatment rendered: oxygen, lead monitoring, fluids, wound care. At the end of the ambulance ride, they document that he was transferred to an emergency department.

When the record is complete, it’s packaged into an HL7 CDA patient care report. When Robert arrives in the hospital ED – which uses Epic – care providers there already have the pre-liminary information they need.

“I open this chart and can see I don’t know anything about this patient,” said Epic’s McQuiston. “He’s never been here before, he’s from out of state. But what I do have is this information here that Zoll has captured. All the information that they documented I have right in my normal workflow in Epic: I can see the concussion, can see my patient is diabetic, and a lot of other things.”

As Robert is being cared for, the ED staff is also able to query Surescripts’ record locator service in an effort to learn more about him; meanwhile, they can also check in with Philadel-phia’s health information exchange to see what else they might find out

“All of these transactions are standards-based IHE transactions; they are all being piloted or are live,” said McQuiston.

“We’re going to do three diffe ent things with those queries,” said Surescripts’ Bryan Nelson. “First, we’re going to pass along the IHE standards, the XCPD patient demographic

lookup and the PLQ patient location query, onto other IHE-connected participants. These might be other hospitals, clinics or technology vendors who are connected to our network. Second, we’re going to take a look at our own master patient index, which contains 140 mil-lion patients and that number is ever-increasing.

“By doing this we’ve identified two instances where Robert has received care during his trav-els across the U.S.,” he said. “We’re able to com-pile those locations into a patient care CDA that we then send back to Epic via the IHE profil so that can be presented at the point of care.

“Lastly, with the IHE profiles, we’re adapt-ing them to the HL7 FHIR resources so we can communicate with Robert’s hometown of St. Louis, where he receives primary care for his chronic disease management. So we’re translating the IHE transactions into the FHIR resources so we can query the MEDITECH sys-tem and pull the CCD that was compiled at the outset of this demo from the urgent care visit. We’re then taking that CCD and adapt-ing it back into the IHE profiles to send back to Epic at the point of care so the provider can make the most important clinical devisions.”

Meanwhile, Rakesh Mathew, program man-ager at Philadelphia’s HealthShare Exchange, explains how, during the the papal visit, the HIE set up an international exchange with Italy – one of the first times an HIE in the U.S. has set up an international exchange to receive clinical data from other countries. “We’ve received a CCDA document from Robert, and we share that with Epic.”

Back in the emergency department, a look at Robert’s chart shows that it’s now popu-lated with much more critical data than it otherwise might have been.

“Before, we didn’t have anything,” said

McQuiston. “Now you can see all the external data I’ve received. I have the MEDITECH information that Surescripts told me about. I can see the information returned to me by the HIE, the Italian system. Because this is standards-based structured data I can also interact with it – so as I go through and review the information I can see that Robert is allergic to morphine and penicillin; he’s also diabetic and suffers f om hypertension.”

Thanks to all of this outside information, “I’m able to take really good care of Robert,” he said. “I can avoid aggravating his allergies and I can release him in just a couple days. He makes a really quick recovery.”

During the discharge process, “the docu-mentation I’ve done in the ED is going to be packaged up in a CDA discharge summary – standards-based, with discrete data – and sent back to the his primary care provider and to the HIE so it might be available to other people who might treat Robert in the future.”

It’s all very impressive, to be sure. And encouraging. The key now, said Philip DePalo, who oversaw the HIMSS16 Interop-erability Showcase as senior technical proj-ect manager, its to take these real-world accomplishments and see them spread more broadly in the real-world, beyond the

walls of a demonstration pavilion.“It all looks great here,” said DePalo.

“But the uptake of some of this stuff is not as large scale as we make it appear. If you went to 10 different places, maybe three would have this technology. Or one has it, but the next part your healthcare sys-tem doesn’t, so you really can’t exchange anything.

“It isn’t about the technology, it’s the uptake of that technology,” he added. “The technology is growing, for sure – how could it not? But they’re creating more than peo-ple are actually using.”

Thankfully, we appear to be at an pivot point that could see these advances pro-liferate faster than ever, said DePalo: “The strides we’re making on restful APIs, such as FHIR, are making it a little easier for people to incorporate and to use this tech-nology on a cheaper budget.” n

Robert’s data followed him everywhere he went on his trip to the U.S.

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TRENDS www.HealthcareITNews.com | Healthcare IT News | April 201632

Better clinical decision support

‘THREE PS’ NEEDED FOR CDS IMPROVEMENT.JOHN ANDREWS, Contributing Editor

C LINICAL DECISION support is designed to deliver the most rel-evant patient data to the physi-cian at the time it is most needed

– namely, when a critical care decision has to be made. It is not a new concept, and the healthcare industry certainly has the technology available to make it work at an optimal level.

Still, there is room for improvement on both the provider and vendor ends, say spe-cialists in the CDS field

“The traditional definition of CDS is what you can do within the electronic health record to support better decisions,” said Dale Sanders, senior vice president of Salt Lake City-based Health Catalyst.

“You have spots of innovation in some areas, but as an industry CDS at the EHR level is really bad,” he said. “On a scale of

one to 10, I’d give it a three or four. But there is great movement around improving it, so we’re optimistic.”

The keys to optimizing clinical decision support are three levels that Sanders calls the “Three P’s – population, protocol and patient.” Each level has its own self-con-tained purpose, but together they coalesce into an effective p ogram.

“When you’re making decisions and put-ting data in front of patients, they are as important to CDS as doctor is – both par-ties have to be involved,” Sanders said. “The decisions you make about clinical care and strategy at the population level is a diffe -ent skill set, diffe ent strategy and diffe ent method than at the patient level.

“The next level down is the protocol level, where you narrow the number of patients affected. Within the population, it is about developing specifics for clinical protocols of a certain type – the temporal dimension of decision making, measured in months and weeks. The final tip is delivering to the per-sonalized level for the patient.”

In grading the industry based on his “three p’s” benchmark, Sanders says effo ts at the protocol and population levels get “pass-ing grades” due to increased emphasis on making them better. However, he imposes “a failing grade” at the patient level due to

“When you’re making decisions and putting data in front of patients, they are as important to CDS as doctor is – both parties have to be involved,” says Dale Sanders of Health Catalyst.

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TRENDS 33April 2016 | Healthcare IT News | www.HealthcareITNews.com

needed for value-based care“a lack of vision, priority and leadership” around the topic.

EXTRACTING ACTIONABLE DATAThe machinery is in place for deploying CDS, but the industry has faced various obstacles in getting it up to speed, says Foad Dabiri, chief technology office at San Francisco-based Wanda. Principally, he says, the challenge has been with extracting actionable information from the various system silos.

“It is getting actionable information – what you can collect and record,” Dabiri said. “The question is, what informa-tion is the physician looking for and how can it be seen?”

Having instant access to actionable data is paramount when making decisions to keep chronic dis-ease patients from costly hospital readmis-sions, Dabiri said. Diagnosing the symptoms of a homebound patient with congestive heart failure, for instance, requires enough granular information so that the physician can determine if an episode such as flui retention can be handled with a remote intervention or if the situation is more urgent in nature.

“A patient can show signs of something wrong, but that is very diffe ent than a tan-gible outcome,” he said. “What we do is combine various symptoms and vital signs, and through analysis correlate the historical value and combine it into a single decision.”

Technology has advanced to the point where CDS should be readily utilized, but

Dabiri maintains that many provid-er organizations are still overly reliant on propri-etary legacy sys-tems that prevent mobile access.

“The industry recognizes the need to upgrade – providers need to move from an in-

network system to a cloud-based system,” he said. “That would provide more scalability, reliability and access to electronic records.”

SEEKING ‘KNOWLEDGE’For physicians contemplating implement-ing a CDS system in their practices, there are some considerations they need to make, such as determining what type of CDS is most suitable as well as adhering

to HITECH Act requirements.Allan Ridings, senior risk management

and patient safety specialist with the Coop-erative of American Physicians concedes that there have been “trust issues” with CDS in the physician community, which is why the sector is not as proficient in its utilization as it should be. Moreover, he says EHRs evolved

in a backwards fashion, starting with the claims and financial data and moving to clinical diagnos-tics instead of the other way around.

In looking at CDS sys tems , physicians will find two kinds: a knowledge-based

system and a data mining system. It is essential they know the diffe ence, Ridings said.

A knowledge-based system obtains patient data from a result engine and “reveals all dis-coveries based upon the data being enquired upon,” he said. “This type of system is also known as ITTT – ‘if this-then that’ and could be used for determining drug interactions.”

Data mining is based on algorithms, artificia intelligence and machine learning from previ-

ous entries. “They might be used to examine a patient’s medical history in conjunction with reliable clinical research,” Ridings said.

Whichever system they decide upon, physicians need to make reducing risk and maximizing patient safety their highest pri-ority, he said.

REPLACING THE ‘GUT’As a physician himself, David Delaney, MD, chief medical offi-cer for the SAP Public Services and Health Care Industries team in Newtown Square, Pa., understands the traditional medical process of “using your gut, intuition and experience” in decision making. And while some old-school docs might still prefer that method, Del-aney realizes the tremendous

clinical advantages of CDS.“The ability to leverage organizational

knowledge to bring better decisions has been lacking in the industry,” he said. “The data also includes claims and financial data that are needed to understand the ‘value’ in value-based care. I believe we are ready to pivot into an era where if there is informa-tion available that can impact a decision, it must be brought to bear.” n

Allan Ridings David Delaney, MD Foad Dabiri

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BENCHMARKS: Big ideas for 2016. The great EHR buying spree may be over, but hundreds of hospitals are making huge investments in new technologies for quality and efficienc . PAGE 50

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NEW PRODUCTSWolters Kluwer releases management platformDENVER – Wolters Kluwer launched its enterprise terminology platform to improve health system integration, interoperability and analytics. Health Language Enterprise Terminology Management Platform stan-dardizes and normalizes clinical, claims and administrative data to maximize stored data, analytics and population health man-agement tools. The software includes the LEAP Map Manager module, which sup-ports advanced clinical decisions, predictive analytics and quality reporting to accurately leverage clinical and claims data. LEAP con-tains top search algorithms, over 1 million clinically-curated synonyms and an updat-ed content library of 180 standard and pro-prietary terminologies to improve analytics.

MDLIVE, Zenith American Solutions collaborate for telehealthTAMPA – Zenith American Solutions, Inc., a third-party benefits administrator, has signed an agree-ment with MDLIVE, a provider of integrated tele-health, medical and behavioral health services, to expand its capabilities to include telehealth services. The partnership will allow patients round-the-clock access to board certified doctors and therapists through MDLIVE’s Virtual Medi-cal Office platform for medical consultations and treatments via phone, video conference or email. Through the platform, patients can have access to providers within 16 minutes of a call and can also be prescribed medications, as needed.

Elsevier launches mobile app for clinician researchPHILADELPHIA – Elsevier, an information solu-tions provider, released its mobile app version of ClinicalKey and ClinicalKey for Nursing,

which provides users access to evidence-based, peer-reviewed clinical information. Clinicians can access the largest collection of clinical resources on their mobile device, including data from medical, surgical and nursing specialties. The app boasts an intui-tive search function with auto suggest, search history and filters, access to full-book texts and journals, guidelines, images and more, and can be synced with the web application. Clinicians can even earn and track continuing medical education credits. ClinicalKey is available in both Android and iOS formats.

New analytics platform from Iatric Systems, Inc.BOXFORD, MA – Healthcare IT company Iatric Systems, Inc. launched its new analytics solu-tion, Analytics on Demand. The platform is designed to meet the needs of healthcare orga-nizations transitioning into value-based care with rapidly delivered clinical and financial data. The new software will help providers achieve incentives and avoid penalties with crucial decision-making data for both ambulatory

and hospi-tal settings. The pre-built d a s h b o a r d maps data targeted by

providers to track and analyze data, including modules for quality measures management and reporting, meaningful use compliance, sepsis management and readmission management.

Commvault launches clinical data sharing platformLAS VEGAS – Commvault, an enterprise data protection and information management tech-nology provider, through its integration with the vendor Laitek, unveiled Commvault Clinical Archive — a system designed to modernize the way healthcare organizations manage, migrate and share clinical data. The platform seeks to

address the need for organizations to control costs and improve care with a centralized infor-mation management system. Clinical Archive breaks down data silos, reduces storage costs and complexity, enables better data-sharing and eliminates costs of legacy systems’ main-tenance and support.

ZeOmega releases value-based care performance management systemLAS VEGAS – ZeOmega, population health man-agement technology vendor, introduced Jiva for Performance Management, a software-as-a-service system that enables healthcare organi-zations to quickly manage the clinical and fina -cial performance of their pay-for-performance and readmission reduction programs across multiple payers, including Medicare, Medicaid and commercial contracts. Jiva integrates with about three dozen disparate health data sys-tems, and healthcare organizations can use this single platform to measure and manage per-formance across multiple populations, multiple payers and different types of value-based care contracts. The system can be deployed in just a few weeks and can quickly integrate claims and electronic health records data.

UnitedHealthcare, Qualcomm partner for mobile wellness appLAS VEGAS – UnitedHealthcare and Qualcomm, a 3G, 4G and next-generation wireless tech-nologies provider, released UnitedHealthcare Motion, a mobile health program designed to boost wellness by linking financial incentives with the use of wearable devices that run on Qualcomm Life’s 2net Platform. The idea is for UnitedHealthcare plan participants enrolled in high-deductible health plans to improve their health and save money by encouraging daily walking, while testing and building new con-

nected health technologies for consumers. The program provides plan participants with wearable devices at no extra cost and enables them to earn up to $1,460 per year by meeting certain health goals.

drchrono platform now captures insurance, credit cards

MOUNTAIN V IEW,

CA – drchrono, Inc., an electronic health record and practice management plat-form, released a new

version of the software to include the electronic photo capture and storage of patient insurance cards and credit cards, which is compatible with the iPad, iPhone app and web portal. Phy-sicians can take a photo of the paper insurance card with the app and move it into the drchrono platform, while patients can also complete this process and send the data to their providers. The company executives say it’s the first and only EHR to provide fully integrated electronic photo capture and storage of insurance cards.

American HealthTech, Medtelligent launch senior care management systemLAS VEGAS – American HealthTech joined forces with Medtelligent to offer owners and managers of senior care facilities a new care and manage-ment system, dubbed Assisted Living Solution. The platform helps providers navigate the tech-nology challenges of caring for seniors who move across the care spectrum from assisted living to skilled nursing facilities and other pro-vider organizations. Post-acute organization owners and managers can use the platform to provide accurate, detailed electronic care records for seniors; the system also tackles financial management and workflow tool

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Fusion PPT www.fusionppt.com

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35JOB SPOTApril 2016 | Healthcare IT News | www.HealthcareITNews.com

Advanced credentials pay off for healthcare IT staff, boost some salaries above $130,000Research from HIMSS, others also found a correlation between higher education and job satisfactionBILL SIWICKI, Managing Editor

ADVANCED DEGREES and credentials literally pay off for health IT pro-fessionals. Additional credentials such as certifications, in fact,

roughly double the chances professionals have of earning an annual salary greater than $130,000, according to a new survey from the University of South Florida Morsani College of Medicine, Bisk Education and HIMSS.

While 29 percent of survey respondents said they make more than $130,000 annually, only 12 percent without credentials rank in that category. Women lead in the realm of furthering education, with 232 reporting additional credentials compared with 150 male survey respondents, the survey said.

The majority of health IT professionals earn salaries greater than $80,000 per year, the study found, and 140 survey respondents said they were very satisfied with their career in health informatics compared with only 18 describing themselves as very dissatisfied

The survey included 404 health IT pro-fessionals from seven countries and 42 U.S. states. There is a correlation between the level of education and job satisfaction: Profes-sionals with advanced degrees (master’s and doctorates) are more likely to be very satisfie (89 respondents) or at least somewhat satis-

fied (55) with their career choice, compared with people who are very dissatisfied (4), the survey determined.

Of the 404 survey respondents, 303 report-ed unique job titles. The potential exists to categorically break down job titles and dis-

cover how the diffe ent categories correlate with income and education, the University of South Florida Morsani College of Medi-cine said; however, there is a larger narra-tive here concerning the profession’s many niches, which require professionals with a

wide range of skills and backgrounds.Health IT professionals overwhelmingly

see career growth during the next five years: 337 survey respondents believe their career will continue to grow, compared with only 41 who do not. nThe best way to

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PEOPLE www.HealthcareITNews.com | Healthcare IT News | April 201636

ON THE MOVEPam Ballou-Nelson was appointed senior consultant of Medi-cal Group Management Association’s Health Care Consulting Group. Orion Health appointed Wayne Oxenham president, North America; he most recently served as executive vice president of Orion’s Europe, Middle East and Africa region. Divurgent, a healthcare IT consulting firm, has named Ste-phen Eckert president and chief operating officer he has 20 years of industry experience and most recently served as the partner for Encore’s National Client Services. Keith Fernandez,

MD, was named senior physician executive of Privia Health, LLC, a national physician practice management and population health technology company. MedyMatch, an artificial intelligence healthcare startup, has hired former Philips’ CEO Gene Saragnese as chairman and chief executive office Kathy Kaminsky was appointed chief population health offic of Englewood Hospital. Bellevue-based Atigeo, a technology company and developer, has named Doug Cusick chief growth officer Brad Boyd was promoted to president of Culbert Healthcare Solutions, a healthcare management consulting firm; he previously served as the company’s vice president of sales and marketing. Thrive 4-7, a mobile health company, appointed Deborah Hylton president and CEO. Melinda D. Whit-tington joined Allscripts Healthcare Solutions, Inc. as senior vice president finance and chief financial officer Singular Medical Technologies, a single- and multi-PACS designer and developer, named Gregory Burnell as CEO and David Logan as vice president of strategy; both will join the company’s board of directors. CTG, an IT solutions and services provider, appointed Laura Momplet as chief operations office and chief clinical officer Marie Murphy as delivery director, optimization and implementation; Scott Gildea as delivery director, strategic programs; and Amy White quality analyst lead. Drew Hamilton was named chief sales officer of Kareo, a cloud-based medical office software and services platform. entrotech life sciences has appointed former U.S. Surgeon General Kenneth Moritsugu, MD, to its board of directors. Christopher Libby, a third-year student at the University of Massachusetts Medical School, was elected to represent all U.S. medical students at the American Medical Association Medical Student Section.

ONC elects Chartese Day office directo , Office of the Chief Operating Offic

Chartese Day was named office director of the Office of the Chief Operating Offi-cer, ONC Deputy National Coordinator for Operations, to support the ethics function recently transitioned into the office Day will provide senior leadership and program direction for the Executive Secretariat and Freedom of Information Act, which the OCOO will now handle. She’ll be supported by Acheeria Walters and Carolyn Holden. Day most recently served as the director of the Office of Public Affairs and Com-munications, which will now be filled by

Megan Roh. Roh joined the ONC from Senator Tammy Baldwin’s office where she was the deputy communications director.

VisualDx hires William Bria, MD, as chief medical information officeWilliam Bria, MD, was appointed chief med-ical information officer of VisualDx, a diagnos-tic decision support system. Bria is a critical care physician and pulmonologist with more than 30 years of clinical and medical infor-matics experience and currently serves as the Advisory Board chairman of the Association of Medical Directors of Information Systems. He most recently served as CMIO of Shriners Hospitals for Children and the University of Michigan.

Jeff Brown named permanent CIO,SVP of Seattle Children’s Hospital

Seattle Children’s Hospital appointed Jeff Brown as senior vice president and permanent chief information office . He had been the acting interim CIO since April 2015. Before joining Seattle Chil-dren’s, Brown served as chief information office at Lawrence General Hospital in Massachusetts. He previously served in senior management positions in organizations that include Partners

HealthCare and Steward Health Care Network.

Chartese Day

Doug Cusick

Drew Hamilton

83%say there’s insufficient recognition of women execs in health IT*

Healthcare IT News and HIMSS are committed to empowering women in the health IT field.

After hearing from 900 women about the current state of women’s professional needs in health IT, HIMSS identified a need for more recognition of women industry-wide. That’s why we’ve launched new initiatives honoring the contributions of women & adding gender-focused resources for networking, mentoring & career advancement.

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NEWSMAKER www.HealthcareITNews.com | Healthcare IT News | April 201638

SKIP SNOW, Contributing Writer

JUDY FAULKNER, founder and CEO of Epic Systems, is one of the most pow-erful leaders in the healthcare industry. In an interview, she explains how she

grew the company, founded as Human Services Computing in 1979 with a small pool of inves-tor customers, to its current dominant position, with annual revenues of nearly $2 billion.

When Faulkner spoke with Healthcare IT News, her affect was down-to-earth, candid and sharp, with an engineer’s attention to detail. She spoke about her computer science beginnings, discussed Epic’s long history and addressed the future of software in healthcare. She touched upon familiar issues with interoperability, patient identifi ation and more. Here’s what else she had to say.

Computer science education was key to her success. So was an early clini-cal mentor.Starting at the beginning, I was a math undergradu-ate major, and then I went to the University of Wis-consin for computer science. Originally I applied in math, and UW and Stanford both switched me to computer science, all by themselves, and I thought, “Hey, that’s cool. I like that idea.”

I took courses in computers and medicine. The professors were physicians. Warner Slack, MD, asked me to work with him, so I then went to Beth Israel (Deaconess Medical Center, in Boston). This was at a time when the vendors were just selling systems for billing and lab. No vendors I’m aware of were doing clinical systems. This was in the early ‘70s. I took the class in the late ‘60s, but this was asked of me in the very early ‘70s. After a while, I got called in by some of the other physicians and (was) asked to create a system that would keep track of clinical information.

The foundation of Epic predates com-mercial relational database manage-ment systems.This was before dBase. I think Oracle was build-ing its system at this time, but we didn’t know the words “database management system.” There was a little system in use that was a little tiny database management system that was pretty nifty and I took a look at that, but mostly I was

on my own to figu e out how to build this.Neil Pappalardo, the CEO of MEDITECH,

was the guy who invented MEDITECH Inter-pretive Information System (MISS), and Mas-sachusetts General Hospital Utility Multi-Pro-gramming System, or MUMPS – he has said that if he had understood how important it would be in healthcare computing, he would not have given it such a silly name.

What Neil Pappalardo developed was writ-ten specifically for healthcare data, so the underlying infrastructure of MIIS was won-derful for dealing with healthcare because you have sparse arrays. Back then you had Fortran and you had COBOL. Neither of them could deal with sparse arrays. The ability of MIIS to deal with sparse arrays was terrific because you might have 100,000 data elements but only some would be filled ith data.

Some things never change, like your birth date. Some things occasionally change – your address, your insurance, your primary care physician, your surgeries – and you don’t want to have to store them every single time. There’s a look-back capability that lets you get to the last one right away. Then some things, like your vital signs, change all the time, so built into Chronicles was a sense of how to handle time, which was really important. The other thing that was built into it was a sense of what you might call the joins. You might have three problems, three diagnoses, three treatments, three outcomes; how do you keep everything together? How do you understand what goes with what? That was built into MIIS too.

Both MIIS and Chronicles were built for healthcare. The other vendors were hardcoding everything. Line by line, everything was hard-coded, and if you wanted to change anything, you didn’t have a database management system underneath it to allow you to make those changes.

‘I was a normal programmer and I had no idea how you start a company.’After I built it, I went around to a lot of diffe -ent departments in UW and worked with them. I remember one department had money for six months for a programmer to do something. There were only 20 data elements, and I remember charg-ing them for 45 minutes of time. You can see why customers all around the country told people, “Look

what they are doing.” They’d call me up and say, “Start a company,” and I would laugh and say, “No.”

This went on for about two years. Finally I said yes. You have to realize I wore blue jeans. In the summer I wore T-shirts; in the winter I wore sweatshirts. I cut my hair with scissors, no makeup. I was a normal programmer and I had no idea how you start a company.

So I went to somebody who had spun off from the university, and he said three things: One, get permission from the university, get a good lawyer, get a good accountant. I did all three. It was great advice.

I started the company, valued it at $70,000, and I invited my customers to join in and be part of the original shareholders. There are a lot of people then who helped start Epic. We divided it up, so if you had 5 percent of the company, you paid $3,500, and that got us started. We started with one and a half people. I had a morning assistant and an after-noon assistant. We were in a basement of an apartment house.

That was it. We signed a bunch of contracts and never took outside money from venture capital or went public or anything like that.

Semantic standards are keyIf you’re going to do interoperability between organizations, which I think is critical, it’s limited because you have to define and no -malize and harmonize the data so that that

each group could understand each other.Let’s examine gender. I may have one for

male, two for female, and then two other kinds of genders, ambiguous and something else. On the other hand, they may have one for female and a range of other values. How do you move that over when different groups have different ways of doing that? You need standards. There’s a limited number of stan-dards that we have to be able to transmit the data. I use such a simple example as gender, but as you go into the drug and other data-bases, there is even greater complexity.

Within your organization you want to share. It’s critically important to also get informa-tion back and forth from other groups who aren’t yours.

Unique patient ID has to happen.I think each person should have a medical iden-tity. I don’t care whether it’s federal or not. How-ever, the lack of this is not an excuse. You can do a lot of patient matching based on other attri-bute checking and so the identity would make it easier, but it is not an absolutely critical thing.

Remote care is the future.Healthcare going to stay local to a great extent. I think it’s going to also move to telemedicine much more than it is right now because we have to reduce the resources that we’re using and the expense that we have in healthcare. n

Q&A: Judy Faulkner on Epic’s early years and future plansCEO discusses company’s roots, interoperability, need for patient ID and more

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