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Is Interoperability Worth Paying For?

Posted on August 18, 2016 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manager doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst, a role he recently repeated for a Council member.

A member of our extended family is a nurse practitioner. Recently, we talked about her practice providing care for several homebound, older patients. She tracks their health with her employer’s proprietary EHR, which she quickly compared to a half-dozen others she’s used. If you want a good, quick EHR eval, ask a nurse.

What concerned her most, beyond usability, etc., was piecing together their medical records. She didn’t have an interoperability problem, she had several of them. Most of her patients had moved from their old home to Florida leaving a mixed trail of practioners, hospitals, and clinics, etc. She has to plow through paper and electronic files to put together a working record. She worries about being blindsided by important omissions or doctors who hold onto records for fear of losing patients.

Interop Problems: Not Just Your Doc and Hospital

She is not alone. Our remarkably decentralized healthcare system generates these glitches, omissions, ironies and hang ups with amazing speed. However, when we talk about interoperability, we focus on mainly on hospital to hospital or PCP to PCP relations. Doing so, doesn’t fully cover the subject. For example, others who provide care include:

  • College Health Systems
  • Pharmacy and Lab Systems
  • Public Health Clinics
  • Travel and other Specialty Clinics
  • Urgent Care Clinics
  • Visiting Nurses
  • Walk in Clinics, etc., etc.

They may or may not pass their records back to a main provider, if there is one. When they do it’s usually by FAX making the recipient key in the data. None of this is particularly a new story. Indeed, the AHA did a study of interoperability that nails interoperability’s barriers:

Hospitals have tried to overcome interoperability barriers through the use of interfaces and HIEs but they are, at best, costly workarounds and, at worst, mechanisms that will never get the country to true interoperability. While standards are part of the solution, they are still not specified enough to make them truly work. Clearly, much work remains, including steps by the federal government to support advances in interoperability. Until that happens, patients across the country will be shortchanged from the benefits of truly connected care.

We’ve Tried Standards, We’ve Tried Matching, Now, Let’s Try Money

So, what do we do? Do we hope for some technical panacea that makes these problems seem like dial-up modems? Perhaps. We could also put our hopes in the industry suddenly adopting an interop standard. Again, Perhaps.

I think the answer lies not in technology or standards, but by paying for interop successes. For a long time, I’ve mulled over a conversation I had with Chandresh Shah at John’s first conference. I’d lamented to him that buying a Coke at a Las Vegas CVS, brought up my DC buying record. Why couldn’t we have EHR systems like that? Chandresh instantly answered that CVS had an economic incentive to follow me, but my medical records didn’t. He was right. There’s no money to follow, as it were.

That leads to this question, why not redirect some MU funds and pay for interoperability? Would providers make interop, that is data exchange, CCDs, etc., work if they were paid? For example, what if we paid them $50 for their first 500 transfers and $25 for their first 500 receptions? This, of course, would need rules. I’m well aware of the human ability to game just about anything from soda machines to state lotteries.

If pay incentives were tried, they’d have to start slowly and in several different settings, but start they should. Progress, such as it is, is far too slow and isn’t getting us much of anywhere. My nurse practitioner’s patients can’t wait forever.

How Complicated Is It to Simplify Medication Adherence?

Posted on November 17, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site ( and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Of all the things that irrationally inflate health costs, one of the top concerns is people who just don’t take their prescribed medications. Medication adherence doesn’t sound like a high-tech issue, but a lot of interesting technology is being thrown at the problem.

One pharmacist (obviously harboring an interest in increasing orders) estimated that we’d save 290 billion dollars a year if everybody took the medications prescribed for them. But don’t dismiss their claim as self-serving–the Centers for Disease Control suggests they may be right. It also says that half of all medications are discontinued too early. As the “fee for value” movement starts extending to the performance of medications, concerns that patients actually follow through on prescriptions will increase.

At the recent Connected Health Conference I talked to several companies taking on the difficult adherence problem from different angles. Medisafe aids patients in self-monitoring, Insightfil creates convenient packaging that groups pills the ways patients take them, and Dose doles out medication at prescribed times.

Medisafe is one of a wave of firms that address medication adherence, representing an advance over jotting down daily practices in a paper journal. These services share a good deal in common with other solutions in the marketplace that carry out patient monitoring, care planning, and the patient-centered medical home. In all these areas, services boast of tracking behavior, providing feedback to both patients and clinicians, promoting communication, and similar aspects of the connected health vision.

Medisafe handles patients’ nonadherence in multiple ways, including importing the patient’s medication list, along with vital signs such as blood pressure. Visualizations help both the patient and the doctor see the relationship between taking medication and the relevant vital signs. Patients can manage their doctor office visits or when they have been assigned a change in medication, and monitor the effects of such events on adherence through Medisafe. Finally, doctors will be able to compare data on patients within their practices, grouping them by condition, by medication taken, by demographics, or by behavior traits.

Other medication solutions try to reduce the burden of compliance that falls on the patient–or to look at it in another way, reduce the patient’s discretion. At something of an extreme, Proteus inserts a tiny radio device into each pill and makes the patient wear a patch that can detect the presence of the pill in the body. People have suggested one or two use cases for this intrusive system (for instance, during a drug trial, to guarantee accuracy) but in general, treating patients like criminals doesn’t encourage healthy behavior.

A lot of people, especially the elderly and those with the most severe medical conditions, need so many pills and capsules that it’s hard to remember which ones to take, and when. I’ve seen relatives loading little pillboxes every Sunday morning with the pills for the upcoming week.

Insightfil hopes to take all the manual labor, and consequent chances for error, out of this process. It ships each person a customized blister pack with a week’s worth of medications, offering up to four compartments per day to cover different times. This may seem like a simple problem, but it’s actually a major logistical feat.

First, according to founder and CEO Ted Acworth, his company had to develop a robot that could recognize different pills and accurately load them into the blister packs. Then they had to find a pharmacy with nationwide reach and room in its warehouse for the robot.

Dose solves the problem a different way, through a dispenser into which a patient or caregiver can pour bottles of pills. The dispenser, which has been configured to know the patient’s medication regimen, can automatically separate the pills and release them at the right time.

Once the pills are in the box, control can be removed from the patient. This can be important for doling out opiates or other drugs that can be dangerous or that patients have a tendency to abuse.

Dose’s dispenser is a very smart machine, supporting some of other goals of connected health I mentioned. Clinicians, caregivers, and patients can get alerts about doses taken or missed. The device has bi-directional programming capabilities with a web portal and mobile app, and clinicians can change regimens over the Internet. Biometric devices can be attached to let users map medication adherence to vital signs, or to report a user’s exercise and eating habits. The device’s forward facing camera can be used for scanning the barcode of a pill bottle, as well as for video consultations with a clinician. Along with these features, the device is integrated with an FDA Drug Database and therefore an accurate drug list, along with information about potential drug interactions is readily available.

On many levels, then, advanced technology can help patients with the apparently simple problem of opening a bottle at the right time and popping a pill in their mouths. This article has been a limited look at the problem–I haven’t dealt with over-prescription or side effects, but just the question of how to get patients to take the drugs that are understood to improve their health. We’ll see over time which of these solutions–perhaps all of them at different times–can help of hundreds of millions who regularly take prescription drugs.

MinuteClinic Goes With Epic – What’s It Mean?

Posted on March 12, 2014 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Retail clinic operator MinuteClinic has decided to purchase and roll out the Epic EMR, upgrading from its home built system it’s used until now.  MinuteClinic, a division of CVS Caremark, expects the rollout to take about 18 months.

This is a big win for Epic.  An estimated 274,000 physicians will use the company’s EMR, and roughly 51% the US population will have a record in Epic when its current customer rollouts are complete.

And MinuteClinic has big expansion plans, which will bring Epic to a wide range of new environments.  According to Andrew Sussman, MD, president of Minute Clinic and senior vice president/associate chief medical officer, CVS Caremark,  the company is expanding rapidly, having added more than 350 clinics in the past three years, and planning to reach 1,500 clinics by 2017.

“EpicCare will take us to the next level by offering enhanced connectivity with other providers, more advanced patient portal capabilities and key analytics to run our practice more efficiently and improve patient care,” Sussman said in a press statement.

What’s particularly interesting about this deal is not just that Epic has racked up another big customer, though keeping an eye on their progress is definitely important. No, what’s more newsworthy is the possibility that epic is slowly but steadily changing its strategy, from selling only to large hospitals to exploring other customer relationships on the ambulatory side.

Not only is Epic rolling out a large ambulatory deal with MinuteClinic, the EMR vendor has struck a deal with the Cleveland Clinic and Dell under which the Clinic and Dell offer providers EMR consulting installation configuration and hosting service for Epic.  Bearing in mind the needs of ambulatory providers, the Cleveland Clinic deal even allows buyers to have the Epic EMR hosted mostly by Dell.

Certainly Epic won’t stop pursuing big hospital deals, but the MinuteClinic and Cleveland Clinic agreements suggest that Epic may be looking for other markets beyond the large hospital market. It looks like ambulatory is on their radar and we know they’ve been working hard to grow internationally.

Drop In Clinics: Another EHR Quandary

Posted on March 5, 2014 I Written By

When Carl Bergman isn't rooting for the Washington Nationals or searching for a Steeler bar, he’s Managing Partner of the last dozen years, he’s concentrated on EHR consulting and writing. He spent the 80s and 90s as an itinerant project manager doing his small part for the dot com bubble. Prior to that, Bergman served a ten year stretch in the District of Columbia government as a policy and fiscal analyst, a role he recently repeated for a Council member.

If you go to a walk in health clinic, you’re in good company. These clinics and their users are growing rapidly. So, too, is their using EHRs to document your stay. That EHR use is both good and bad news.

 Clinic Types

There are two basic types of these no appointment, walk in clinics: Retail Health and Urgent Care:

  • Retail Health. These treat minor problems or do basic prevention that usually doesn’t require a physician visit. For example, they give flu shots, treat colds, ear infections, and strep throat, etc. The clinics are often one person operations staffed by a nurse practitioner. You can find them in stand alone settings, but more frequently now they are in major, retail chains such as Target, Wal-Mart, CVS, etc. In addition to their location accessibility, these clinics usually have evenings and weekend hours.
  • Urgent Care Clinics. These perform all the services of retail clinics, and also have extended hours. Importantly they add physician services. For example, they will treat burns, sprains, or run basic lab tests. These clinics usually are part of a clinical chain or may be associated with a local hospital. Unlike retail health clinics, they generally are in their own store fronts.

While their services and settings differ, both accept health insurance. With the projected growth of the insured population under the ACA, their managers are expanding their networks.

Clinic EHR to PCP EHR Problem

Unlike practices and hospitals that have undergone, often painful, transitions from paper to EHRs, these clinics, skipped that phase and have, by and large, used EHRs from the start.

EHRs give them a major advantage. If you visit Mini-Doc Clinic in Chamblee, Georgia and then go to one in Hyattsville, Maryland, the Maryland clinic can see or electronically get your Georgia record. This eliminates redundancy and gives you an incentive to stay with a service that knows you.

If you only go to Min-Doc for care, then all your information is in one place. However, if you use the clinic and see you regular doctor too, updating your records is no small issue. Coordination of medical records is difficult enough when practices are networked or in a HIE. In the case of a clinic, especially one that you saw away from home, interface problems can compound.

With luck, the clinic you saw on vacation may use the same EHR as your doctor. For example, CVS’ Minute Clinic uses Epic. However, your clinic may use an EHR tailored to walk ins. Examples of these clinic oriented, tablet, touch optimized EHRs are:

Your physician may not have the technical ability to read the clinic’s record. Getting a hospital to import the clinic’s data would require overcoming bureaucratic, cost and systems problems for what might be a one time occurence. Odds are the clinic will fax your records to your doctor where they will be scanned or keyed in, if at all.

This is not a hypothetical issue, but one that clinic corporate execs, patient advocates and physicians are concerned about. There is no easy solution in sight.

Recently, on point, NPR’s Diane Rehm show had a good discussion of the clinic phenomena, and included the clinic to PCP EHR record issue. You can hear it on podcast. Her guests were:

  • Susan Dentzer. Senior Policy Adviser, The Robert Wood Johnson Foundation and on-air analyst on health issues, PBS NewsHour.
  • Dr. Nancy Gagliano. Chief Medical Officer, CVS MinuteClinic.
  • Dr. Robert Wergin. Family Physician, Milford, Neb., and President-elect, American Academy of Family Physicians, and
  • Vaughn Kauffman. Principal, PwC Health Industries.

All the actors in this issue know that the best outcome would be transparent interoperability. However, that goal is more honored in the breach, etc., for EHRs in general. The issue of clinic to PCP EHR is only at a beginning and its future is unknown.

Retail Clinics Buddy Up with HIT and MU Lessons from a 3 Year Old

Posted on August 23, 2012 I Written By

As Social Marketing Director at Billian, Jennifer Dennard is responsible for the continuing development and implementation of the company's social media strategies for Billian's HealthDATA and Porter Research. She is a regular contributor to a number of healthcare blogs and currently manages social marketing channels for the Health IT Leadership Summit and Technology Association of Georgia’s Health Society. You can find her on Twitter @JennDennard.

It seems I can’t read a blog, tweet or even old-fashioned newspaper these days without coming across some headline having to do with retail health clinics buddying up to healthcare IT. Announcements from two companies come to mind.

The first involves SoloHealth – developer of health and wellness kiosks. It received FDA approval for its product earlier this summer, and followed that development up with news of financial investment from benefits company WellPoint. It also has announced plans for a national rollout of its kiosks sometime this fall. Assuming its website is up to date, there are SoloHealth Stations across the country at retailers like Walmart, Safeway, Publix, Sam’s Club and Schnucks. CVS appears to be its only traditional retail clinic customer at the moment.

The second involves Greenway Medical – well-known developer of electronic health records for a variety of healthcare organizations, including Walgreen’s Take Care Clinics. It currently has placed its PrimeSuite EHR in more than 700 Take Care pharmacies, and just this week announced plans to implement a custom EHR – WellHealth – to coordinate other types of care in Walgreen’s locations. I’m assuming the two EHRs will play nice with other from an interoperability standpoint. Implementation of all WellHealth systems is expected to be finalized by the end of next summer.

I can’t help but point out that both of these companies are based in Atlanta, and I know for a fact that their team members congregate at similar networking events, so I wonder if we’ll see some synergy between them in the near future.

In any case, if predictions of retail clinic growth prove to be true – a recent Rand Report notes that use of retail health clinics quadrupled between 2007 and 2009, and will continue to grow – it seems likely that we’ll see HIT companies popping up in clinics across the country.

On a completely unrelated note, my daughters and I joined the rest of my company’s team members at the annual Lekotek Run 4 Kids last weekend. We had a great time and enjoyed helping out a great cause. I was a bit apprehensive that my youngest would enjoy it. Before the race began, she came up to me with number in hand and asked, “Is it okay if I lose?” Happily, she declared herself a winner after crossing the finish line and receiving a medal along with her sister and all the other kids.

I wonder if this is a sentiment physicians in smaller practices sometimes have as they consider implementing an EHR in the hopes of receiving Meaningful Use incentive money. Do some just want to throw in the towel and “lose?” Do some not want to even start the race? I’m always looking for additional Meaningful Use wisdom from the under-6 set, so please enlighten me in the comments below.