On Tuesday afternoon, Amazon's S3 cloud-based hosting service experienced outages that caused a number of major websites and apps – including many across healthcare – to stop working optimally.

AWS hosts images for a range of websites, as well as entire sites and app back-ends. According to the AWS service health dashboard, the issues occurred thanks to "high error rates with S3 in US-EAST-1."

By 2:30 EST, AWS officials had "repaired the ability to update the service health dashboard." But AWS was still experiencing high error rates at the time of publication.

"We are working hard at repairing S3, believe we understand root cause and are working on implementing what we believe will remediate the issue," officials said.

AWS partners with variety of healthcare technology vendors, such as Calgary Scientific, PracticeFusion, Syapse, Philips and Cognizant, to name a few.

The outage has also affected many of the nearly 150,000 websites and apps hosted by AWS, such as Quora, file sharing on Slack, Giphy and Business Insider.

Even AWS' status dashboard was affected, as the site is showing all services green despite the outages. Further, the majority of errors appear to be centralized to Virginia. AWS has data centers throughout the northern part of the state.

One EHR vendor, Doctorsoft, whose system is aimed at ophthalmology specialists, noted on Twitter that its systemd had been impacted:
 

Amazon Storage Services is experiencing technical difficulties that are affecting Doctorsoft EHR performance at the moment.

— Doctorsoft EHR (@DoctorsoftEHR) February 28, 2017

Healthcare IT News has so far heard back from two vendors who'd been affected by the S3 outage to varying degrees.

AWS partner Aptible, which makes security and DevOps tools, reported that "the situation is stabilizing, but we're still seeing numerous errors connecting to AWS APIs. According to AWS we can expect a full resolution shortly. App operations are still on lockdown for us-east-1 stacks now, but we'll unlock them as soon as we get confirmation that the incident has been resolved on the AWS side."

"We are closely monitoring the situation and fortunately this has not been a full outage for AWS but appears to be performance impacting for some customers of AWS," said James Lawson, chief solutions officer at Verge Solutions, which develops a platform for healthcare risk management.

"We do have contingency plans but in reality, this is no different than any other hosting provider having issues," he added. "It just happens to be that there are a number of other companies that are impacted because of the dominance of AWS in the competitive hosting environment."

Outage effects will vary on the site and services used by AWS. We'll update with more information as it becomes available.

Healthcare IT News Editor-in-Chief Tom Sullivan contributed to this story.

Twitter: @JessieFDavis
Email the writer: jessica.davis@himssmedia.com

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The Government Accountability Office is urging the Department of Health and Human Services to step up its efforts to encourage the use of EHRs in long-term care facilities, the better to boost the exchange of critical information between care providers.

HHS has not measured the effectiveness of its efforts to promote the use of EHRs, and it also lacks a comprehensive plan to meet its goal of increasing the proportion of post-acute care providers who are electronically exchanging health information, GAO found. Moreover, the lack of measurement of the effectiveness of its efforts “is contrary to leading principles of sound planning.” The GAO concluded.

“Many patients who leave hospitals receive care in post-acute settings such as skilled nursing facilities and long-term care hospitals,” GAO noted in its report dated January 2017. “Exchange of accurate and timely health information is particularly important in these transitions, and technology like EHRs could help to improve quality and reduce costs.”

The government watchdog recommended HHS evaluate its efforts to increase the use of EHRs and data exchange and to adopt a “comprehensively plan” for how to reach its goals in post-acute care settings.

GAO interviewed stakeholders, including experts on EHRs in post-acute care settings, and found five key factors that affect EHR use and the electronic exchange of health information in these settings: Cost, the variability in implementation of health data standards, workflow disruptions that come from EHR rollouts; technological challenges and lack of staff with the expertise to use EHRs, along with high staff turnover. 

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com

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CVS has tapped Epic Systems as the electronic health record system for CVS Specialty's care management programs for complex and chronic conditions, the company announced on March 3.

CVS launched Epic at its MinuteClinic locations in 2015. This rollout will expand its reach, officials said, help improve care coordination and clinical processes for CVS subsidiaries such as Accordant, which provides services for patients with rare diseases.

"As the specialty pharmacy of choice for many payors and patients, we are focused on creating the most clinically advanced specialty pharmacy experience to help improve care and outcomes for our patients," said Alan Lotvin, MD, executive vice president of CVS Specialty, in a statement.

[Also: CVS connects with providers via Epic]

"We are pleased to transition our care management programs onto the Epic platform, which will enable immediate information sharing with other health care providers across the patient's entire care team," he said. "This connectivity is integral in providing the best possible coordinated health."

CVS Specialty delivers advanced clinical services for patients needing care for rare or complex conditions – including therapy management, dispensing and infusion services and counseling to help ensure appropriate and safe medication use and achieve positive health outcomes.

Eligible patients get assistance with benefits verification, coordination with multiple providers, comprehensive patient education and adherence management help.

Epic will support these programs by enabling connectivity with providers nationwide currently using the platform.

"By transitioning to the Epic EHR, we can further coordinate care across health care disciplines and settings, which promotes more effective and informed health care decision making," said Trip Hofer, president of Accordant.

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

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Mercy Technology Services, the IT arm of the Catholic health system, is partnering with Tahoe Forest Health System to deploy an Epic electronic health record system at its locations in California and Nevada.

Mercy is the first U.S. provider accredited by Epic to extend services to other hospitals. MTS helps with EHR implementation and optimization and offers data analytics services.

"What I really like about Mercy is, even though it's a large organization, it shares our entrepreneurial spirit and it's agile – always pushing technology forward in its quest to best serve patients," said Jake Dorst, Tahoe's chief information and innovation officer, in a statement.  
 
"Moving from seven different EHRs to a single, unified patient record is a high priority for TFHS," he added. "This will help us build on our population health and community outreach initiatives, and coordinate better care between systems and specialties."
 
Mercy echoes Tahoe's stance on technology as a patient care game-changer, and sees extending services as a way to share best practices among providers while benefiting a broader patient community.
 
"With Mercy, Tahoe will have a mission-centered partner to grow with into the future with near-term strategic value from EHR services, and the option for mid- and longer-term solutions like big data analytics and virtual care to reach patients in hard-to-reach places," said Gil Hoffman, Mercy CIO.

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

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The HCI Group, which works with major providers on end-to-end implementation of electronic health record systems, offering support for Epic, Cerner and others, will be acquired by Tech Mahindra in a $110 million deal.

The HCI Group, which is based in Jacksonville, Florida and employs 500 IT professionals worldwide, offers enterprise-wide advisory services focused on EHR implementation and training, in addition to service lines in integration, testing, go-live, clinical adoption, optimization, cybersecurity and HIMSS EMRAM. Its revenues were $114 million for the 12 months that ended September 30, 2016.

Tech Mahindra will make an initial payment of $89.5 million for an 84.7 percent stake in HCI, aquiring the 15.3 percent balance over the next three years. The initial transaction is expected to close by April 2017, subject to regulatory approvals.

"Healthcare is one of the few sectors globally that is driving adoption of digital technologies," said CP Gurnani, CEO of Tech Mahindra, in a statement. "The acquisition will not only position Tech Mahindra as a significant player in the healthcare provider space, but will also provide an opportunity to go deeper in this space via EMR implementation and surrounding services route."

"I truly believe that Tech Mahindra is the right partner for us to improve the healthcare industry through a combination of disruption, innovation and cost reduction," added Ricky Caplin, CEO, The HCI Group. "What better way to support our customers than by joining with the global leader in digitalization and connected technologies."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

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The cost of payment fraud

At its core, payment fraud is a byproduct of medical identity theft. Individuals either misrepresent their identities to receive care, or they provide proper identification but use unauthorized forms of payment for services. Along with duplicate records and identity theft, payment fraud is one of the “big three” challenges within the health delivery system that must be eliminated for the emerging value-based care model to be successful.

The financial ramifications of payment fraud are astronomical. At present, payment fraud costs health delivery organizations $28 billion annually, with an additional loss of $272 billion within the U.S. Medicare and Medicaid programs.¹ These numbers are corroborated by the U.S. Department of Justice, which obtained more than $1.9 billion in settlements and judgments from civil healthcare fraud cases in 2015.²

Ultimately, the ability to efficiently deliver quality care for better patient outcomes is dependent upon eliminating payment fraud. And because fraud is inextricably related to patient identity, it is this quality-of-data issue on which industry attention must be focused. Moreover, correctly identifying patients and accurately matching them to their medical records across healthcare settings results in additional auspicious outcomes. The risk of misdiagnosis decreases, treatment plans become more effective and duplicate records become a thing of the past. But what can providers and health delivery organizations do to address this costly issue?

Health IT solutions

It is imperative for health IT to directly confront the costly issues associated with care delivery fraud. But how? The answer is simple: Implement a proven patient identity solution that validates the right patient and the right record, every time.

Patient identity solutions help to automate patient check-ins and admissions with greater security using technology that creates one “single and true” identity for all locations across the entire care continuum and myriad locations. Providers can capture and verify a patient’s ID and associated records, validate and permanently match patients with their correct medical records, and eliminate duplicate patient records that can lead to medical inaccuracy. Patient safety is markedly enhanced, and patient satisfaction is bolstered. And, most relevant to payment fraud issues, by linking a patient ID directly to his or her active insurance and payment information, data and billing accuracy are improved.

Because payment for services—and the associated payment fraud issues—are intertwined with medical identity theft and duplicate records, the same patient identity solution will effectively address payment fraud. By assigning a Unique Health Safety Identifier (UHSI), coupled with the use of a biometric or other equally strong second factor, a patient is verified and linked to an address, insurance plan and payment information. With this in place, it will become impossible for any person to falsely claim to be someone else, or attempt to fraudulently pay for services rendered.

The health IT industry must not only recognize the importance of eliminating the roadblocks to effective value-based care, but also create viable solutions to these challenges.

By Tom Foley, Director of Global Health Solutions Strategy

1. “The $272 Billion Swindle.” The Economist. May 31, 2014.


2. “Justice Department Recovers Over $3.5 Billion from False Claims Act Cases in Fiscal Year 2015.” The U.S. Department of Justice: Office of Public Affairs. December 3, 2015.


The HIMSS17 conference in Orlando late last month spanned the gamut of technology topics — from artificial intelligence to more open EHRs to population health and security, among others. 

IBM CEO Ginni Rometty, in fact, delivered the opening keynote wherein she said the industry is on the verge of a golden era for cognitive computing, artificial intelligence and machine learning technologies and that transforming healthcare is now within our power.

That’s not to say achieving such change will be easy. The current administration’s back-and-forth about the fate of the Affordable Care Act is demonstrating how hard forging the path forward can be. After months of chanting "repeal and replace," now that the Republicans control both branches of Congress and the White House, in fact, questions persist about what exactly repeal means and what a replacement might look like.

Former House Speaker John Boehner said Republicans will "never ever agree" on the best way to replace Obama’s signature piece of legislation and that some provisions will remain in place.

[HIMSS17 big gallery: Memorable pics from this year's health IT conference]

Michael Leavitt, who has served as Utah Governor and Health and Human Services Secretary, meanwhile, predicted a repeal will pass by April's end but the legislation will include provisions to defer major changes for two to four years and echoed Boehner’s sentiment that some of the provisions will survive repeal. (Full video:Boehner on stage with HIMSS CEO Steve Lieber and former Pennsylvania Governor Ed Rendell.)  

Also striking a pragmatic and even optimistic note, former CBS anchor Dan Rather said that while Americans have faults, being afraid is not among those. “Whatever happens with the Trump administration, we’ll get through this,” Rather advised. "But depending on your political orientation, it will be a long dream or a long nightmare."

Technology, as it is every year, was also a big part of HIMSS17. The artificial intelligence, cognitive computing and machine learning theme that Rometty set in motion Monday morning continued throughout the week — while analytics, big data and population health all permeated.

NTT Data and Oracle, for instance, announced a collaboration to integrate NTT Data’s analytics with Oracle’s Healthcare Foundation platform.

Analytics specialist Health Catalyst, which announced the catalyst.ai initiative to embed machine learning in all its applications just before HIMSS17, banded together at the conference to commercialize Regenstrief’s natural language processing technology dubbed nDepth.

Jvion, meanwhile, scooped up Predixion in a move it said signals a beginning to market consolidation in the predictive analytics space.

Alongside the technological optimism, American Medical Association CMIO Michael Hodgkins said that EHRs are falling short. How and why?

"The innovator community knows a lot about technology," Hodgkins explained. "What they often don’t know a lot about is how healthcare professionals think."

That said, a study that HIMSS published during the show found that health IT’s impact overall is positive but that challenges remain, notably that provides are still struggling to find and retain top talent even though budgets are on the rise — while the disconnect between providers and vendors on clinical priorities persists.

EHR maker Epic's CEO Judy Faulkner, meanwhile, revealed that two less expensive versions of its software are in development, while Allscripts CEO Paul Black said the vendor is working to foster an ecosystem of innovation on its platform and Cerner president Zane Burke talked up an open to approach to interoperability; Black and Burke said APIs are the key.

The matter of information security was pressing at this year’s conference, with a Symantec study determining that healthcare is getting better, but much too slowly. Another piece of research announced at HIMSS17, from Thales Data, found that 81 percent of participants plan to ramp up security spending this year.

What healthcare organizations need most for successful cybersecurity, experts agreed, is more boardroom support and culture change.  

And in the realm of just plain cool, Battelle brandished NeuroLife technology that one real live patient is using to translate brain waves into physical movements. 

This article is part of our ongoing coverage of HIMSS17. Visit Destination HIMSS17 for previews, reporting live from the show floor and after the conference.

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Columbia, S.C.-based Palmetto Health has called on health IT giant Cerner to expand the health system’s Millennium Revenue Cycle technology across four of its acute care facilities.

The rollout will include integration with the health system’s EHR.

Cerner’s revenue cycle management platform is designed to integrate clinical and financial workflows to achieve a single patient record and take advantage of clinical automation. The goal is to help reduce revenue cycle functions, which have in the past been done manually, Cerner executives say. Included with the platform are Cerner Transaction Services and Cerner Acute Case Management.

The technology gives Palmetto Health clinicians and staff access to patient information when they need it without logging in and out of systems, and system integration helps users to consistently perform the right activities at the right time, which can result in avoiding denials.

“Cerner delivers the foundational elements we need to achieve an integrated, enterprise-wide Millennium environment to help us work toward better patient experiences, team member experiences and financial results,” Benjamin Cunningham, system vice president of finance at Palmetto Health, said in a statement.

Jeff Hurst, senior vice president, Cerner Revenue Cycle Management and president of Cerner RevWorks noted that Cerner’s Clinically Driven Revenue Cycle is designed to enable clinicians and staff to update the billing process throughout the patient’s visit and streamline clinical documentation to help improve reimbursement and limit claims errors.

Patients will benefit, Hurst added, by having direct access to their clinical results and a streamlined experience across facilities, including visibility into their financial liability, all from a single source.

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com

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Hospitals in New York are finding big quality and efficiency gains thanks to the ability to access patient EHR data via a regional health information exchange.

A new study just released by HealthlinkNY, which operates the HIE connecting providers and patients in more than a dozen counties across the Hudson Valley and Southern Tier of New York, finds that use of the exchange reduced the patient's length of stay both in the ED and inpatient stay.

Moreover, according to the report– which examined 86,000 encounters at hospital EDs with access to patient records through the HIE – it also lowered the likelihood that patients would be readmitted to an ER within 30 days and reduced the number of physicians needed to examine them.

New York State exchange infrastructure comprises a public network of regional HIEs, stitched together through SHIN-NY, the Statewide Health Information Network of New York, enabling providers to exchange patient data statewide.

"The results of our study leave no doubt that HIE access improves quality of healthcare and operational efficiency," said study co-author Emre Demirezen, assistant professor of operations and supply chain management at SUNY Binghamton's School of Management.

"While common sense tells us that access to the patient's entire medical history would benefit both the patient and the healthcare provider, my co-authors and I have confirmed that it does by conducting one of the first empirical investigations into the benefits of HIE use at the individual patient level."

[Also: Health information exchange: E pluribus unum?]

The study examined ED encounters at four different emergency rooms – comprising 46,270 patient visits and 326 number of attending doctors – over a period of 19 months from 2012 to 2014. All four had the ability to access the HealthlinkNY HIE.

"We chose to examine emergency room visits because ER clinicians deal with a diversity of clinical conditions in a very high-pressure environment, and they need to gather as much information about a patient as quickly as possible," said Demirezen.

The research homed in on three major gains in quality and efficiency: Length of stay, risk of readmission and number of physicians needed for each encounter.

Use of the HIE reduced the average length of stay in the hospital (including time spent both as an emergency department and inpatient patient) by 7.04 percent, from 22 hours and 23 minutes on average, to approximately 20 hours and 48 minutes.

Accessing patient records through the HIE reduced the odds of readmission to any emergency department, not just the initial facility, within 30 days of discharge by 4.5 percent, according to the researchers, who also compared readmission rates over a 60-day period, with the number remaining consistent.

And HIE use also reduced the odds of a patient being seen by multiple physicians by 12 percent. Often, attending physicians seeing patients with chronic conditions beyond their area of expertise, enlist a a specialist to help evaluate the patient. But if the attending physician can look up the patient's history and review recent encounters with the patient's own specialists, such consultations may not be necessary.

Demirezen noted that physicians who use the HIE regularly, and are therefore more comfortable in using it, exhibited better outcomes than novice users: "Providers should actively promote and support clinician use of the HIE and invest time and effort into training them on its use," he said.

Christina Galanis, president and CEO of HealthlinkNY said the results should give providers "the evidence they need to make HIE use a priority for their organizations."

She expects further ROI to come for New York hospitals, she said, noting that the report "clearly states that the benefits of using the HIE are greater when it contains a robust amount of patient data and when the physician has had experience using the HIE."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

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Top executives at three electronic health record companies — Allscripts, Cerner and Epic — revealed that they're working to make their EHRs more open.

That means embracing APIs as a means to enable third-parties to write software and apps that run on their platforms.

"We need to continue to push the entire industry forward around interoperability and really open our platform to take advantage of all the bright minds in healthcare today," Cerner President Zane Burke said at HIMSS17. "We’re working with third parties today in the standards way and collaborating on multiple levels to really get the full value of all the investment in healthcare."

[Also: Health IT execs favorite dirty word? Take a guess]

Allscripts CEO Paul Black said publishing APIs that third parties can use to create apps for its platform "is a big deal" and, in fact, the company has some 5,000 developers certified to do just that: Some 2 billion API data exchanges have been conducted on its platform since 2013.

"I want people creating an ecosystem that I’m the center of, of course, from which I encourage people to pull information out so they can take better care of their patients," said Black said in a pre-HIMSS17 Q&A.

Epic, for its part, is working on two new versions of its EHR and developing Kit to go with its Caboodle data warehouse (as in Kit and Caboodle). CEO Judy Faulkner said Kit "is making everything very open," such that third-parties can write Kit-based apps to access data in Caboodle.

"Kit is all the data that a customer has, all the data that comes from interfaces," Faulkner explained. "It’s there for the customer to choose who they feel should have access to their data and then give them that access."

The increasingly open platforms will ideally enable more effective interoperability of health data for care coordination, patient identification and population health management.

"There’s still a lot of work to be done around patient identification and matching – the fidelity of the patient matching," Cerner’s Burke said.

Allscripts Black echoed Burke’s sentitment that it’s going to be important for EHR vendors to keep pushing forward.

"Instead of saying ‘that was great we’re done’ and sitting back in a rocking chair now it’s, 'Holy Moly we have all of this data what are we going to do with it?'" Black said. "And how do we use all this data to drive more efficient, effective care that produces better outcomes for people who have serious issues?'"

Healthcare IT News Editor-at-Large Bernie Monegain contributed to this report. 

Twitter: @SullyHIT
Email the writer: tom.sullivan@himssmedia.com 

The Healthcare IT News annual EHR Satisfaction Survey:
⇒ Comparison chart: How readers rated their EHR in 2016 vs. 2015
⇒ 2015 Healthcare IT News EHR satisfaction survey
⇒ Health IT executives have a new favorite dirty word 
⇒ EHR interoperability: Ripe for disruption?

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VA Secretary David Shulkin, MD, told House Committee on Veterans Affairs' members on March 8 that the VA would be moving to a commercial electronic health record system.

"I've come to the conclusion that VA building its own software products and doing its own software development inside is not a good way to pursue this," said Shulkin. "We need to move toward commercially-tested products.

"If somebody could explain to me why veterans benefit from VA being a good software developer, then maybe I'd change my mind," he added. "But right now we should focus on the things veterans need us to focus on and work with companies who know how to do this better than we do." 

[Also: Allscripts, Cerner, Epic signal more open EHRs ahead]

The initial plan was a single, integrated EHR system for both the VA and the U.S. Department of Defense. Last year the groups announced the agencies would instead build separate systems – after two years of discussion and planning.

Since then, VA has been trying to modernize its self-developed VistA EHR system – and failing.

In fact, it's been the focus of numerous Congressional hearings, where members have expressed frustration with delays in the rollout and the struggles to develop an in-house, interoperable system. Congress has long pressured the VA to move into an off-the-shelf EHR.

Even the Government Accountability Office is fed up: It named VA healthcare and IT systems on its High-Risk List in 2017 for the second time. Shulkin and his team met with Comptroller General Gene Dodaro to discuss GAO recommendations.

During a separate House Committee on Veterans Affairs in February, Acting Assistant Secretary for Information and Technology and Acting CIO of the Office of Information and Technology for the VA Rob Thomas told members that the VA would be going with a commercial EHR – prior to Shulkin's confirmation as secretary.

"My goal, my charge, is that we go commercial to the greatest extent possible," said Thomas. "We don't have a great track record with developing software."

Committee Chairman Rep. Phil Roe, R-Tennessee, echoed those sentiments: "This is the third major attempt to modernize VistA in the past decade," he said. "Retaining or replacing VistA is a make-or-break decision for VA and must be made deliberatively and objectively. The VA must judge VistA Evolution realistically against concrete goals. If it falls short, moving the goalposts is unacceptable."

Twitter: @JessieFDavis
Email the writer: jessica.davis@himssmedia.com

The Healthcare IT News annual EHR Satisfaction Survey:
⇒ Comparison chart: How readers rated their EHR in 2016 vs. 2015
⇒ 2015 Healthcare IT News EHR satisfaction survey
⇒ Health IT executives have a new favorite dirty word 
⇒ EHR interoperability: Ripe for disruption?

Like Healthcare IT News on Facebook and LinkedIn

DeepMind, the Google-owned artificial intelligence company, is developing a new technology similar to blockchain for secure tracking of patient health data.

In a blog post, London-based DeepMind said its new Verifiable Data Audit project could be the first steps toward a "a service that could give mathematical assurance about what is happening with each individual piece of personal data, without possibility of falsification or omission."

The aim is to enable hospitals, and eventually patients, to gain real-time insight into where and how data is being used.

"For example, an organization holding health data can’t simply decide to start carrying out research on patient records being used to provide care, or repurpose a research dataset for some other unapproved use," according to DeepMind. "It’s not just where the data is stored, it’s what’s being done with it that counts. We want to make that verifiable and auditable, in real-time, for the first time." 

[Also: Blockchain's potential use cases for healthcare: hype or reality?]

In DeepMind's capacity as data processor for hospitals, the currently creates an auditable log any time it comes into contact with patient information. With Verifiable Data Audit, it will expand on that: "Each time there’s any interaction with data, we’ll begin to add an entry to a special digital ledger. That entry will record the fact that a particular piece of data has been used, and also the reason why – for example, that blood test data was checked against the NHS national algorithm to detect possible acute kidney injury."

Company officials note that the ledger system shares similarities with the concept of blockchain in that the ledger will be "append-only," meaning that once data use is recorded, it can’t be erased. The ledger will also enable third parties to verify that the entries have not been tampered with or altered.

The end result, according to DeepMind will be "an improved version of the humble audit log: a fully trustworthy, efficient ledger that we know captures all interactions with data, and which can be validated by a reputable third party in the healthcare community."

The goals: a way to enable providers to run automated queries on the data, set alarms to be triggered if anything looks amiss and, eventually, give others – such as patients – the opportunity to check in on the data processing.

There are many technical and other hurdles along the way, said DeepMind, but "we’re hoping to be able to implement the first pieces of this later this year."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

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Every time Carolinas HealthCare System gets rid of server or storage hardware, someone in the IT department takes out a roll of red tape. They cut off two pieces and lay those down on the floor in the shape of an X, as in: Do not put any new hardware here. 

"I used to be so proud of my datacenter," Carolinas Chief Information and Analytics Officer Craig Richardville said. "Now I just can't wait to get rid of my datacenter." 

Other healthcare executives are of a similar mind. Count Beth Israel Deaconess Medical Center CIO John Halamka, MD, among those. 

"I predict that five years from now none of us will have datacenters," Halamka said. "We're going to go out to the cloud to find EHRs, clinical decision support, analytics."  

Underway already
Some enterprising providers and payers, such as the Centers for Medicare and Medicaid Services and Children's Mercy in Kansas City, are already reaping big dividends from hosting data and services in the cloud. 

The Centers for Medicare & Medicaid Services, for instance, created a cloud-based analytics platform that eliminated $5 million in underutilized infrastructure spending, said Jessica Kahn, director of the data and systems group at CMS. 

And Children's Mercy uses Microsoft's Azure Cloud services to host an app and data that literally save lives of at-risk pediatric patients by tracking them after they leave the hospital, according to Richard Stroup, Children's Mercy director of informatics.  

What's more, Stroup explained that putting the app on Microsoft's cloud also enabled it to make the service available to other Children's hospitals. Seattle Children's was the first to tap into it, and Cincinnati Children's signed on to use it in February.

History repeating itself
The notion of a widespread migration to the cloud is not entirely new. Nicholas Carr wrote a 2003 Harvard Business Review article titled "IT Doesn't Matter," in fact, that sent a virtual shock wave through the enterprise technology realm — though few in healthcare probably felt it back then — by suggesting that IT is going to be commoditized. 

"IT is best seen as the latest in a series of broadly adopted technologies that have reshaped industry over the past two centuries — from the steam engine and the railroad to the telegraph and the telephone to the electric generator and the internal combustion engine. For a brief period, as they were being built into the infrastructure of commerce, all these technologies opened opportunities for forward-looking companies to gain real advantages," Carr wrote at the time. "But as their availability increased and their cost decreased — as they became ubiquitous — they became commodity inputs. From a strategic standpoint, they became invisible; they no longer mattered." 

Think: power. Whereas companies of various sorts used to frequently build facilities next to a river so they could harness power, they eventually realized it was not a core competency and, as such, outsourced that function as utilities emerged that could generate power for many customers. 

Today one would be hard-pressed to find a fistful of companies that consider generating their own power a competitive advantage — some hospital systems, rather, are harnessing cloud infrastructure services to innovate in ways they could not if they needed to build or buy adequate storage and compute power.  

A similar shift is underway in healthcare, said James Lawson, chief solutions officer at Verge Health, a risk management vendor. 

"Several years ago it was 'you're crazy if you think we'll put patient data in the cloud,'" Lawson said. "Today, it's 'you're crazy if you think you're going to put patient data in my servers.'"

And while Lawson said a wholesale shift to the cloud may take longer than five years, he explained that once the move gains steam, inert hospitals risk falling behind technologically.

"When you're the last man standing with a datacenter, and your competitors are using that capital to generate revenue, the upside of moving to the cloud will become crystal clear," Lawson added. 

Datacenter of the future
While Carr's assertion that technology no longer really matters has not exactly rung true yet, the industry is poised for a seismic shift in its thinking about putting health data in the cloud. 

Carolinas' CIAO Richardville said the system is making big movements into the cloud, and that includes Cerner, Epic, Microsoft 365, among many other apps. 

BIDMC's Halamka, meanwhile, explained that healthcare organizations at this point have to plan for a federated approach, even those that are moving to a single EHR. 

And Children's Mercy's Stroup offered an amusing prediction of his own. 

"The onsite datacenter of the future will have only two employees: a man and a dog," Stroup said. "The man will be there to feed the dog; the dog will be there to guard against the man messing with the datacenter." 

Twitter: SullyHIT
Email the writer: tom.sullivan@himssmedia.com

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Epic announced with little fanfare that its App Orchard is now officially open for business. And the EHR vendor is inviting third-party developers to highlight their best work, not only with FHIR, but also other open application programming interfaces.

Epic competitors. including Allscripts and Cerner, are also pushing what their top executives describe as a more open approach to data interoperability based on APIs and creating platforms that third-party developers can use to build software.

Verona, Wisconsin-based Epic, in fact, received trademark approval for the App Orchard back in 2015, prior to which the working name for the marketplace was "App Exchange.” 

[Also: Allscripts, Cerner, Epic signal more open EHRs ahead]

App Orchard will make it simpler for developers to connect customers to Epic and to each other, Epic Senior Vice President Sumit Rana, told Xconomy during HIMSS17. Rana added that more than 1,000 companies had set up connections to Epic’s software.

Epic CEO Judy Faulkner also said at HIMSS17 that the company is developing two new less expensive versions of its EHR and a technology called Kit to make data more open.

Epic is taking the App Store-like approach with Orchard, it also offers a SMART on FHIR developer sandbox for testing applications – and Cerner announced a similar initiative last year ahead of HIMSS16 called code.cerner.com. 

Twitter: @Bernie_HITN
Email the writer: bernie.monegain@himssmedia.com

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Health information technology holds enormous potential for improving patient safety, but only when implemented and used correctly. A new study from ECRI Institute spotlights EHR information management practices and clinical decision support as two areas of particular concern.

"The 10 patient safety concerns listed in our report are very real," says Catherine Pusey, RN, associate director, ECRI Institute Patient Safety Organization. "They are causing harm – often serious harm – to real people."

This list for 2017, which derives from PSO event data, focuses on concerns raised by provider organizations and ECRI experts:

1. Information Management in EHRs
2. Unrecognized Patient Deterioration
3. Implementation and Use of Clinical Decision Support
4. Test Result Reporting and Follow-Up
5. Antimicrobial Stewardship
6. Patient Identification
7. Opioid Administration and Monitoring in Acute Care
8. Behavioral Health Issues in Non-Behavioral-Health Settings
9. Management of New Oral Anticoagulants
10. Inadequate Organization Systems or Processes to Improve Safety and Quality

With regard to EHR information management, ECRI said provider organizations should approach IT safety processes holistically: engaging with health information management experts, IT professionals and clinical engineers on patient safety and risk management programs.

Other strategies include ensuring that EHR end users understand the systems' capabilities and potential problems, according to ECRI, and that involves encouraging them to report any concerns to be followed up with accordingly. Engaging patients to help with integrity of their own health information could also be a boon to safety.

"Health information needs to be clear, accurate, up-to-date, readily available, and easily accessible," said Lorraine Possanza, program director, Partnership for Health IT Patient Safety at ECRI.

Along those lines, implementation and use of clinical decision support rounded out the top three of the 2017 list. Tools to "ensure that the right information is presented at the right time within the workflow" can lead to be big improvements in quality, said Robert Giannini, patient safety analyst and consultant at ECRI.

If they're implemented incorrectly or used in the wrong way, however, those opportunities can be negated, resulting in patient harm.

The group says healthcare organizations should design CDS systems carefully, and suggests that providers avail themselves of guides published by ECRI, the Office of the National Coordinator for Health IT and others for best practices.

A multidisciplinary team should have oversight of CDS rollouts, and users should be trained to properly use specific systems, and health organizations should monitor the effectiveness and appropriateness of CDS continually – evaluating their impact on workflow, and reviewing staff response to alerts, then redesigning when necessary.

The 2017 report also highlighted patient identification as an "issue that most healthcare providers recognize as a significant problem,” according to William Marella, executive director, PSO operations and analytics at ECRI Institute.

Leaders should fully support patient ID initiatives, prioritizing the issue, engaging clinical and nonclinical staff and asking them to identify barriers to safe identification practices, the report suggested. Redundant processes for ID can decrease the likelihood of misidentification. Standardization of electronic displays and ID bands, and well-deployed barcoding systems can also help.

Number 10 on ECRI's list focuses on inadequate organizational systems and processes for quality and safety improvement.

"Numerous studies show a link between error prevention and a culture of safety," according to the report. "Nevertheless, healthcare organizations have been slow to adopt all the necessary features of a high-reliability organization. Proactive strategies can be used to examine processes, identify what can go wrong, and make the process less vulnerable to error before mistakes occur. Strong preventive strategies, such as standardization and automation, should be explored."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

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Precision medicine holds the key to better health. And as the industry moves more toward value-based care, its evidence-based principles can help providers ease into the transition.

"It's a big step to go from trial-and-error medicine to evidence-based medicine," said Jim Adams, executive director of research at The Advisory Board. "Even for evidence-based care and precision medicine, genomics data is really important. But it's not one-to-one.

"You can get to precision medicine without genomics data," he added. "There's a lot of work that can be done without the genomic data to achieve precision medicine while we wait for the technology and industry to catch up."

One way would be to better leverage analytics on existing data pools, for instance. It's about finding ways to improve overall health, said Deirdre Saulet, senior consultant of research at The Advisory Board.

[Also: Genomics, patient generated health data to be top information sources in five years, survey finds]

While current research is largely focused on molecular changes, precision medicine is more than that, she said. Everyone needs to be involved to make it a reality. A lot of academic centers are leading the way, but many community providers and oncologists are moving into the field, as well.

But for precision medicine to become a reality, Saulet said, there are five challenges to overcome:

• Building a case for precision medicine. Many insurers have rigorous guidelines for what will be covered. There's also a need to demonstrate how precision medicine supports all overall goals of the organization.
• Physician support. Healthcare leaders must ensure physicians have the time, education and confidence to handle precision medicine, while reducing the existing care gaps to appropriately put precision medicine into practice - like addressing how few platforms support precision medicine.
• Patient empowerment. Healthcare organizations are trying to figure out the role of patients when it comes to precision medicine. Further, regulations are murky around testing, making it complicated to determine how to empower patients to use this information to better their care. Some organizations have worked towards patient policies, but we need to be talking about it as a country to figure out the best steps going forward.
• Clinical Trials. Clinical trials must be easier to accomplish, while genomics testing should be more affordable to create more specific treatments.
• Data. Looking ahead, data is the most sizeable challenge when it comes to how the data is collected. Further, there are issues with integrating the data into EHR workflow. The healthcare industry needs to consider how to build upon this data to make better care decisions.

Right now, the biggest issue is that if one provider orders a genomics panel, it comes back as a PDF file, Saulet explained.

"No one is going to open that up and use the data in a routine visit," she said.

Twitter: @JessieFDavis
Email the writer: jessica.davis@himssmedia.com

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Once again this year, HL7's FHIR specification was a hot topic at HIMSS17, a burning issue discussed ardently across the show floor. (Our apologies, but heat- and flame-related puns seem to be required when writing about FHIR. Thankfully, we've gotten them out of the way early.)

But while many vendors were touting their embrace of the interoperability spec, and while the promise it holds for enabling faster and easier exchange of data is very real, the open API isn't going to supplant existing HL7 standards such as Version 2 and CDA any time soon. That means the industry will be taking a hybrid approach to interoperability standards for the foreseeable future.

We recently spoke with HL7 board member Russell Leftwich, MD, senior clinical advisor of interoperability at InterSystems and co-chair of both HL7's Learning Health Systems Workgroup and its Clinical Interoperability Council, for his perspective on FHIRs place in healthcare now and prospects for the future.

Q. How do you see FHIR's place right now in the larger ecosystem of interoperability standards?
A. Number one, it will be the preferred technology for new development, particularly when it involves accessing data across many servers. That's one of the driving forces for developing FHIR – that the existing standard are based on technology of a previous era. Really, interoperability in the '80s, when those standards were first developed, meant connecting two systems together. And then we managed to extend those standards to connect one system to multiple systems. But the reality of today is that there's data across many systems, for an individual or a population – and that's happened steadily over the past decades. The amount of data has grown, and so has the number of places where it exists. 

[Reality check: FHIR, population health and the patient experience]

The inspiration for FHIR was to be able to see that data from one point in real time, the way we do in other industries: The way e-commerce works, the way Google and social media work, where you're connecting across the entire internet network from one place, and seeing the data that's out there. Not necessarily downloading it, because that's becoming harder and harder to do, based on the amount of data, but to see the data you're interested in. That's the technology that FHIR is based on.

Q. When a vendor touts FHIR capabilities what does that mean? Should it be taken with a grain of salt, or should we temper our enthusiasms? Or is FHIR as exciting as everyone says it is?
A. Well, it is exciting. And I think what you should take from that is they're excited about it. And they understand that. I don't know what "FHIR-compatible" means to any one vendor, there's not a good definition of that. But that said, there are a number of apps that have been developed around FHIR and are actually in use and production.

There was recently an event at Duke called the FHIR Applications Roundtable where something like 35 different FHIR apps were demonstrated by the developers. Now, most of those early apps are not about connecting across systems but about accessing the data in your own systems – or your own closely held systems – to more easily access it in the flow of particular user, of particular clinical domains, where they would like to see the data and see it in a way that they can easily use it, as opposed to having a huge pile of data they have to sort through. FHIR makes it easy to access just the data you need, which was not the case with previous standards.

Q. At HIMSS17, Micky Tripathi made a very compelling case about how beneficial FHIR can be, and how much progress has been made in a relatively short time. But in the near term, how do you see it coexisting with other standards in actual practice?
A. It definitely will coexist for the foreseeable future, there is no compelling economic argument to replace the uncounted billions of dollars worth of existing systems that use existing standards and do what they do perfectly well with them. The change in technology is such that you probably couldn't retrofit most of those systems with FHIR.

But what will happen, I think, is that FHIR will serve as a translation layer, as is the case with the InterSystems health informatics platform, which has now become enabled so data can come in in existing standards like V2 or CDA documents, and can be transformed into FHIR and take advantage of the technology FHIR is based on to do things with that data. And then can be exported from that platform as any one of those standards, including FHIR, back to systems that may only understand some of the existing standards.

Q. Practically speaking, what should IT teams at hospitals and other providers be thinking about in the years ahead, as FHIR continues to evolve?
A. Vendors, and the organizations that use health IT systems, need to think about a strategy to live in this hybrid environment. You're certainly not going to replace or abandon your existing system – the average hospital today has in excess of 80 systems within their walls – so many of those systems may operate very well with older standards, but you want to be able to get that data and aggregate it with data that comes in other forms and from other systems – some of it in FHIR, some of it in existing standards – and aggregate that data.

I think FHIR is the ideal standard to create a representation of that data as FHIR resources, and then you can operate on that data with the technology that FHIR represents and do a lot with it that you couldn't previously.

Q. Do you see a time where FHIR will win out as a standard and be the only game in town? And if so, how far off would that be and what would have to happen between now and then?
A. I think before that happens there would be something new after FHIR. Because of all the systems that exist, the economic argument just can't be made for replacing all of them. And many of them have quite a long lifecycle. So by the time they are replaced, there will be something better than FHIR. But I think that day is probably 20 years off. Some people think longer.

That said, I think FHIR will be essential in the next few years as it evolves. I would compare the way FHIR is now to an early version of a smartphone: We have the iPhone 3G, and it can do things phones could never do, and we're excited about it. But it doesn't do nearly what the iPhone 7 will do. But it's still useful even in its current form. And it sort of confounds the concept of a draft standard because people are actually using it. So I think it's more the concept I suggest: It's a new reality of maturity where standards evolve, and you use the current version because it's useful and the F in FHIR stands for fast, and it is fast to develop applications with FHIR, and implement them, and they operate in this technology world that the older standards can't take advantage of.

Q. What are some areas where FHIR is being deployed that you're particularly excited about?
A. I'm really excited in general that there are so many people who have developed something with FHIR. I heard there were more than 60 FHIR presentations at HIMSS17, where at the previous annual conference there were fewer than 10. That reflects how fast it's growing.

I think some of the most exciting aspects of FHIR are when it's used in areas that don't have existing standards, like genomics. There's no older genomics standard because genomics hasn't been around that long. So that was an ideal place for FHIR to become the standard from the beginning. And truthfully it's the only standard that could meet the needs of that domain, because when someone has their whole genome sequenced it creates terabytes of data, and you're not going to be able to move that data around easily. You need to be able to access it, get the important pieces of that data – genomic variant or the tumor mutation – that's reflected in that huge amount of data, and that's what FHIR is ideal for doing.

The other thing that's great about FHIR is it's ideal for mobile devices and mobile applications, because it's the type of technology that most of those apps were already built on. FHIR is just the healthcare version of that, so a lot of the uses of it we're seeing are those mobile applications, web apps that leverage the technology FHIR is made from along with its healthcare structure to do things you couldn't do before.

Q. In the meantime, as it runs alongside existing standards in clinical settings, what are some of the technical challenges of managing that?
A. You do need a strategy. Connecting to each of those many systems individually with some sort of FHIR translation interface probably isn't practical. Having a platform that can connect to those systems, or maybe is already connected to those systems and can take in data in different formats and standards and transform it into FHIR is, I think, the only workable strategy. Retrofitting systems with FHIR or connecting them with some sort of individual translator probably isn't a good long-term strategy. It's going to be exciting to see what happens with FHIR even within the next year. We're about a month away, probably from the publication of the next version of FHIR STU3 – it stands for standard for trial use three – which will be another quantum leap for FHIR, and will enable a broader range of applications to use it. Because of how fast the applications can develop – even recreating an app for the new version of FHIR shouldn't be much of an obstacle, so organizations can go along and take their existing applications and start to build new ones that leverage the increased capability of this next version of FHIR.

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

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Nuance Communications and Epic are partnering to integrate the artificial intelligence capabilities of Nuance's computer-assisted physician documentation tool into the Epic NoteReader module for clinical documentation improvement.

By embedding that CAPD tool within Epic, the companies said physicians can get feedback at the point of care as provider organizations work to improve severity-adjusted quality scores and better understand reimbursement and risk adjustment factors to improve care management.

"We’ve worked with Nuance for years to embed voice innovations into clinical workflows," Epic President Carl Dvorak said in a statement. "This new AI twist provides another level of wow." 

[Also: Nuance, Epic partner to help veterans with disabilities]

By analyzing relevant patient notes using deep learning and natural language processing technologies, the Nuance CAPD tool can spotlight certain clinical indicators in an electronic medical record and alert doctors when there's data that is missing or needs clarification.

The NoteReader CDI module works leverages that AI technology more accurately show the quality of care, officials say, better reflecting patient acuity and reducing the need for retrospective coding queries.

Whether Dvorak's claim about a new "level of wow" reasonates with customers remains to be seen, of course. But Cincinnati-based TriHealth said Nuance CDI tools have helped it achieve a 14 percent improvement in case mix index and a 98 precent spike in physician repsonse rate to queries – as well as a $12.8 million increase in appropriate reimbursments during the first year, according to Sharon Krug, clinical documentation system manager at TriHealth. 

Krug added in a statement provided by Nuance that the new CAPD approach will help TriHealth "build on those successes by offering CDI intelligence at the point of care to help physicians complete their notes faster, with less disruption and greater clinical context."

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

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