Downtime events in hospitals that shut down the functionality of the electronic health record can result in serious patient safety risks, according to a recently published study in the Journal of the American Medical Informatics Association.

In fact, over the three-year analyzation period of a large health system in the Mid-Atlantic, 76 incidents were reported that were directly related to downtime. And that included scheduled downtime, as well.

Downtime hit the lab department the hardest -- accounting for about half of the reports. Medication administration was the second most-affected with 14.5 percent of all incidents. And about 13.2 percent of the reports stemmed from a general delay in care.

The biggest downtime issue was labeling and tracking of specimens from the lab and a lack of continuity of patient identification throughout the lab processes. Researchers found that downtime most often resulted in the need for specimens to be redrawn from patients and reporting delays.

The majority of medication incidents stemmed from administration issues that include the wrong dosage and medication.

“Across the clinical domains and categories, patient identification and tracking of patient information were common areas for concern,” the authors said. “EHRs are the primary platform for tracking patients and their associated clinical information, and without these capabilities, clinicians face difficulties.”

What’s worse is that the researchers are “unaware of rigorous and validated solutions to this challenge.”

The researchers observed clinicians adapting to the situation and creating their own methods to track patients, including an offline computer and printer to manually create labels for patient identification. However, “it’s unclear how safe and effective these methods are.”

Researchers also discovered that in nearly half of the patient safety events, downtime procedures we’re either not in place or not followed. The finding “further highlights the need to ensure effective downtime procedures are developed, implemented and practiced by all hospital staff.”

“Few provider organizations practice their downtime procedures or assess their ability to safely and effectively deliver care during EHR downtime,” the authors said. “Without downtime procedure practice, gap analysis and iterative development of more robust downtime procedures, major safety hazards will persist.”

While the Office of the National Coordinator of Health Information Technology has established SAFER guides and other programs that highlight the importance of downtime procedures, the researchers found these may not always be in place for all clinical processes.

To prepare for downtime -- likely inevitable with the insurgence of cyberattacks -- researchers said hospitals must implement and practice downtime procedures, refine basic paper processes and remove redundancies, tailor paper processes to unique downtime events, determine how to address challenges of laboratory volumes, establish communication processes and focus on patient identification.

In a collaboration meant to develop genomics-based protocols for precision medicine, Mayo Clinic is collaborating with Pittsburgh-based 2bPrecise, licensing its cloud-based platform to bring individualized clinical decision support to the point of care.

The platform combines clinical and genomic information, extracting patient-specific and presenting them to clinicians, within the EHR workflow, overlaying other sources of data help enable clinical genomics at point of care, said 2bPrecise officials.

The technology will help to make the most of Mayo Clinic's deep knowledge of electronic phenotyping algorithms, enabling them to more easily be incorporated into clinical protocols, and applied to outcomes research.

[Also: Intermountain preps precision medicine tool for commercialization]

"Mayo Clinic has a very robust genomics research discipline," said Assaf Halevy, founder and CEO of 2bPrecise, in a statement. "The wealth of both genetic research and clinical data within the clinic is staggering."

Initial work will focus on genetic cardiovascular disease, specifically familial hypercholesterolemia. 2bPrecise will integrate Mayo's FH algorithm into the platform, offering researchers with the ability to test and validate new protocols based on its insights, ultimately aiming for genomics-based CDS at the point of care.

Eventually, the plan is to share algorithms with with the larger medical community. As a nonprofit organization, Mayo will channel any revenue it receives from licensing the technology back into its healthcare research.

This is the second such announcement from a world-class U.S. health system this week. On Monday, Intermountain Healthcare said it would invest $15 million more into its Navican Genomics spin-off, getting it closer to bringing its TheraMap precision medicine technology to market.
 

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Another group joined the battle for the budget of the Office of the National Coordinator for Health IT Thursday morning.

Pew Charitable Trust manager of health information technology Ben Moscovitch urged lawmakers to push back on the cuts to the Office of the National Coordinator for Health IT that President Trump put into his budget proposal.  

[Also: Population health: 'Let's leave CMS out of this,' experts say]

“The President’s budget includes cuts despite outlining many of the same priorities as Congress — specifically advancing usability and interoperability,” Moscovitch wrote in the Thursday letter addressed to members of the Subcommittee on Labor, Health and Human Services, Education and Related Agencies. “If the proposed budget cuts are enacted, ONC may not have the necessary resources to carry out the entirety of Congress’ priorities for health information technology.”

Whereas Trump’s proposal would slash nearly 37 percent, or $22 million, from ONC’s annual operating budget, Moscovitch and other several industry trade groups have publicly said ONC needs more funding to achieve Congress’ vision of improving health data interoperability, EHR usability and patient safety.  

AHIMA, AMIA and HIMSS all expressed disappointment about the cuts and called on members of Congress to ensure ONC has enough funding to succeed.

The coalition Health IT Now, however, took the opposite stance and pushed Health and Human Services Secretary Tom Price, MD, to curb ONC’s burdensome regulatory authority and accusing the office of mission creep.

ONC chief Donald Rucker, MD, meanwhile, has said the office will focus on interoperability standards, health information exchange policies, support for the Cures Act and MACRA by working to convene government and private industry stakeholders.

“The success of these congressional priorities relies on the agency having adequate resources and prioritizing efforts to enhance patient safety and care quality,” Pew’s Moscovitch wrote in the letter. “We urge you to underscore to ONC the need to focus on how EHRs can enhance quality and safety — including as it implements the congressional priorities put forth in the 21st Century Cures Act.”  
 

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When U.S. Secretary of Veterans Affairs David J. Shulkin, MD, made the decision to transition the VA away from its self-developed VistA electronic health record system and onto the same one being rolled out by the Department of Defense, he said he had a big reason for simply picking Cerner instead putting the contract out for bid.

"VA’s adoption of the same EHR system as DoD will ultimately result in all patient data residing in one common system and enable seamless care between the Departments without the manual and electronic exchange and reconciliation of data between two separate systems," said Shulkin.

[Also: VA secretary: Cerner EHR choice brings big clinical gains]

Cerner has the same expectation, and said implementing the VA system in tandem with DoD's MHS Genesis "will lead to ongoing innovation, improved interoperability and the creation of a single longitudinal health record that can facilitate the efficient exchange of data among military care facilities."

Other interoperability leaders also cheered the news. David C. Kibbe, MD, president and CEO of DirectTrust, said the choice represented a "banner day" for data exchange, since "Cerner has been a champion of Direct as a national standard for ubiquitous, easy, secure, interoperable health records exchange via Direct."

[Also: Expert to VA: Pick any vendor but Cerner to ignite EHR interoperability]

VA's Cerner pick makes it "that much more convenient and economical for Direct exchange and messaging to become a major source of interoperable health information exchange between the federal agencies," he said, "particularly the Defense Department and the VA medical facilities, and hospitals and medical clinics in the private sector using Direct exchange through their own EHRs."

In fact, Cerner's reputation for embracing interoperability – not just its support of Direct but its founding membership in groups such as the CommonWell Health Alliance – was also one of the big selling points when the DoD chose it over its close competitors back in 2015.

The company has been "one of the more proactive EHR vendors on the interoperability front," said John Moore, founder of Chilmark Research. "Years ago they partnered with a third party HIE vendor, Certify Data Systems, to support interoperability between Cerner instances and those of other EHRs."

Based that history, Moore said Cerner will be "more than capable in supporting interoperability between its system at VA hospitals and the disparate EHRs among community healthcare providers outside the VA system."

The VA's choice of Cerner "will greatly simplify interoperability with the DoD, something that has long been a both a real problem and political headache for both the VA and DoD," said Moore.

But it may not always be quite as "seamless" as Shulkin seems to expect. Cerner has earned high marks from groups such as KLAS, especially when it comes to connection across complex interfaces, for instance. But it's also been dinged for challenges related to internal exchange.

In a 2015 report that ranked Cerner third for interoperability, KLAS noted that the company is nonetheless "rated lower by clients for higher integration costs and the lack of a simple switch to turn on sharing with other Cerner clients." It said that resonance – the ability to query and retrieve data between Cerner customers – is "not taking off."

Whether or not that's improved over the past two years will be up to the DoD and VA to see for themselves. But in the meantime, Moore thinks the Cerner choice may be something of a missed opportunity for interoperability more broadly speaking.

"While decision makes sense, if VA picked a different vendor, Interop may have advanced further," he tweeted when the Cerner selection was announced earlier this week.

It's a point Moore made earlier this spring, when he told Healthcare IT News that, given the VA's sheer size, it's in a unique position to push the needle on interoperability industry-wide.

"Choosing another vendor besides Cerner may actually force leading industry EHR vendors to truly address interoperability at a far deeper level than what has been done to date," he said.

That was certainly one of the hopes back when DoD embarked on its own EHR modernization project. At the time, Assistant Secretary of Defense for Health Affairs Jonathan Woodson, MD, said the move "allows us to pivot toward the future – but also forces others to pivot toward the future," and would hopefully help nudge "the private sector to be able to exchange information in a very efficient way, in a very timely way."

In announcing the choice of Cerner this week, Shulkin emphasized that the vendor was just one of many who would have to make this large-scale endeavor work.

Given that more than one-third of veterans get care at providers outside the VA system, the EHR overhaul "is going to require this integration with other vendors to create a system for veterans so that they can get care both in the community as well as in the Department of Defense," he said.

"That's going to take the active cooperation of many companies and thought leaders, and it will serve as a model not only for the federal government, of federal agencies working together, but for all of healthcare that is trying to seek this type of interoperability."

That would be ideal, of course. But some have raised concerns that the size of the combined DoD-VA deployment – in parallel with other vendor hegemonies in the private sector – may simply lead to more large-scale networks with easy interoperability within themselves, but not with each other.

After all, shortly after the Cerner choice was made its rival, Epic, released a statement touting its own work on the VA scheduling project – and reminding us that it is "the largest electronic health record vendor in the United States, covering two-thirds of the nation’s patients."

Epic and Cerner are called the "Coke and Pepsi" of EHRs for a reason. In a world of consolidation (now accelerated, arguably, by the fact that who-knows-how-many providers may soon be fleeing eClinicalWorks for other vendors), it will bear watching to see what deployments of this scale will mean for larger data exchange efforts.

(Healthcare IT News Associate Editor Jessica Davis contributed to this story.)

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We asked our readers if they were surprised the U.S. Department of Veterans Affairs chose Cerner as their EHR vendor. Out of the 727 respondents, 77.4 percent said this decision was expected. For many, it confirmed earlier speculation in favor of Cerner since the vendor was already working on modernizing the health record for the U.S. Department of Defense.

Readers had a variety of thoughts on the reasons why this was a good (or bad) move for the agency. 

“Choosing proven and established EHR system over ailing homegrown EHR is a good decision.”

A few readers were “shocked this is being awarded without competition.“ While others were hopeful it “will push interoperability… as many vets get care outside of VA facilities.”

We rounded up some comments from the poll below.

As for who responded to the survey, 42.1 percent were hospitals/health systems while 34.5 percent were vendors, 7.1 percent worked for government agencies. The final 16.3 percent were a diverse number of workplaces.  

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Westborough, Massachusetts-based EMR provider eClinicalWorks has added telehealth capabilities to its mobile app. The company’s device-agnostic platform also provides tools for practice management and patient engagement, and the addition of the TeleVisits feature aims to nudge eClinicalWorks into that one-stop-shop territory. 

Using eClinicalWorks’ health and online wellness (Healow) app, physicians can carry out virtual visits without going through a third party, and all information shared or submitted through the visits can be imported right back into the EHR. It’s been more than four years since eClinicalWorks first launched the Healow app, which they did alongside a $25 million investment in patient engagement strategies. The latest offering is a way of keeping up with the growing demand for telemedicine, and their tack is different than those of telemedicine industry giants like American Well or Teladoc.

“Healow TeleVisits for the smartphone is taking telehealth to a whole new level by making healthcare more accessible,” eClinicalWorks CEO and co-founder Girish Navani said in a statement. “In today’s digital health age, patients are interested in care solutions that offer quicker delivery and flexibility. Additionally, providers are seeing benefits with increased patient engagement and streamlined workflow.”

Founded in 1999, eClinicalWorks has been a long-standing EMR provider, and now counts some 125,000 doctors and nurse practitioners and 850,000 medical professionals using their software. However, things haven’t been all rosy: the company was recently slapped with allegations from the U.S. Department of Justice that it had caused customers to submit false claims for Medicare and Medicaid meaningful use payment, which is a violation of the False Claims Act. The company later agreed to pay $155 million and enter into a five-year Corporate Integrity Agreement to resolve the matter.

Cloud-based EHR company athenahealth will buy Silicon Valley company Praxify Technologies in $63 million deal, athenahealth announced Thursday.

Praxify comes with a number of applications, including a personal assistant program integrated with EHRs and artificial intelligence aimed at patient engagement.

[Also: Epocrates seen as boon for athenahealth]

Palo Alto-based Praxify was founded in 2010 with the aim of reinventing how doctors work. Watertown, Mass.-based athenahealth was founded in 1997 with a similar idea: To take the burden of paperwork, or digital documentation off the doctors’ docket, the better for them to practice medicine.

The acquisition of Praxify will advance athenahealth's platform strategy and mobile capabilities. Praxify has invested in developing machine learning and natural language processing technology over the years.

[Also: Cisco and IBM team up, will leverage AI to take on cyberthreats]

“In combination with our cloud platform and services, Praxify's team and technology will help us further reduce the many inefficiencies of healthcare's clinical and operational workflows," Prakash Khot, athenahealth’s chief technology officer, said in a statement,

The underlying technology on which Praxify is built will be integrated into athenahealth's cloud platform. Knot noted, it would create new opportunities for both internal and third-party developers to rapidly build and launch applications. positioning athenahealth to speed development and delivery of innovation at scale for the healthcare industry.

The last time athenahealth acquired another company was in 2013 when it purchased San Mateo, California-based Epocrates for about $293 million. Epocrates had a popular clinical content app used by more than 300,000 physicians at the time.

Completion of the Praxify transaction is subject to customary closing conditions.

Whether and what effect the acquisition might have on investment firm Elliott Asscociates’ plans regarding athenahealth is hard to peg. The firm, led by activist investor Paul Singer, purchased a 9.2 percent stake in athenahealth last month. Singer is reputed to buy enough stock to force change, often leading to a sale of the company.

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The Department of Justice just last week slammed EHR vendor eClinicalWorks with a $155 million settlement for falsely obtaining meaningful use certification but that has not stopped hospitals from picking eClinicalWorks.

Ezras Choilim, a federally qualified health center in Monroe, New York, in fact, announced on Thursday that it picked eClinicalWorks cloud-based EHR and population health services.

Ezras Choilim CEO Joel Mittleman said the FQHC chose eCLinicalWorks 10e to advance patient and community outcomes.

[Also: DOJ demands eClinicalWorks transfer data to rival EHRs]

The eClinicalWorks platform, the organizations said, will both streamline operations and give Ezras Choilim’s 36 providers access to patients’ medical history, while the population health and care planning for behavioral health services will enable the FQHC to improve care transitions across various settings and deliver preventative care to certain patients.

While health IT pros might be surprised that eClinicalWorks announced a customer win so soon after the DOJ settlement -- part of which mandates that eClinicalWorks transfer a client’s data to a rival EHR vendor for the asking -- it’s too early to tell whether customers start will start moving away from eClinicalWorks or if everything involved in migrating to a new EHR will mean most customers stick with the vendor.

[Also: DOJ will probe more EHR vendors for false claims, sources say]

In the meantime, John Halamka, MD, CIO of Beth Israel Deaconess Medical Center, which uses eClinicalWorks and athenahealth, offered advice for other eClinicalWorks clients.

“Remain agile, mitigate risk by supplementing vendor services with internal and third-party resources,” Halamka said. “And assume that these are just bumps in the road.”

Legal experts and industry insiders, meanwhile, are anticipating that the Department of Justice will probe other EHR vendors business practices in the future. 
 

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Novant Health is using Epic’s Healthy Planet module to give healthcare providers access to key health trends for patients.

“Healthy Planet Link is an analytical tool that gives healthcare providers information about our patients, such as historical prescription trends, frequency of hospitalizations or preventive care measures,” Novant CIO Dave Garrett said in a statement. 

[Also: Epic CEO Judy Faulkner reveals two new EHR versions are in development]

“Over their lifetime, most people will see multiple providers undergo a variety of screenings and experience health emergencies,” Garrett said. “It is important that healthcare providers within the Novant Health system and those practicing outside of our system have access to this valuable patient information so they can provide appropriate preventive care.”

Healthy Planet is Epic’s accountable care and population management system module.

Headquartered in Winston-Salem, North Carolina, Novant Health, is an integrated network of physician clinics, outpatient facilities and hospitals that operate 470 locations across Virginia, North Carolina, South Carolina and Georgia.

[Also: Novant Health becomes first to revalidate HIMSS Stage 7 Award for EHR use]

Epic’s Healthy Planet, with its dashboard, gives healthcare systems and providers information that can help coordinate care delivery, monitor quality and cost, reduce financial risk and engage patients through a centralized data warehouse.

It also makes it possible for providers to track the performance of several care quality metrics, which can help improve population health.

Novant Health has identified 15 trackable measures. Among them are screening for future falls, controlling A1C -- blood glucose, high blood pressure, colorectal screening and statin therapy for the prevention and treatment of cardiovascular disease.

With Healthy Planet, says Garrett, Novant Health can provide care providers with retrospective, real-time and predictive analytics; risk scoring tools; chronic disease and wellness registries; operational reports with clinical drill-down; and quality measurement.

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BOSTON – Hospitals, networks and the federal government can use precision medicine to drive expenses out of the system, better understand disease and prevent people from getting sick in the first place.

“We have a broken healthcare systems and we’re hoping precision health can help reduce costs,” said Megan Mahoney, MD, chief of general primary care in the Division of Primary Care and Population Health at Stanford University, said Monday at the Precision Medicine Summit.

[Also: Widespread precision medicine is still years away, experts say]

Penn Medicine Associate Vice President Brian Wells agreed. “We think we can reduce costs,” Wells said. “At Penn we can shorten the time to a good outcome for the patients.”

Mahoney pointed, for example, to the ability to identify predictors of disease and move that upstream to advance disease prevention as just one example.

That is an enormous opportunity right now, according to Nephi Walton, a biomedical informaticist and genetics fellow at the Washington University School of Medicine.

[Also: Eric Dishman wants precision medicine to move from personal to universal]

“Every single day without exception we are discovering a new genetic disease,” Walton said. “Beyond knowing the diseases, how to manage them is a huge task, a huge amount of information gathering.”

And today’s crop of electronic health records are not ready for that, Walton said.

“In order to do precision medicine you need all the patient’s data in a common repository,” said Beth Israel Deaconess Medical Center CIO John Halamka, MD.

Beth Israel, for instance, has 26 different EHRs across 450 sites of care, so Halamka said that it uses a common data repository for precision medicine work instead of the electronic health record. 

Stanford, for its part, undertook a primary care transformation initiative as part of its precision medicine work to move away from a traditional, transactional, catastrophe-based model toward a team-based approach where responsibility is distributed across a physician, an advanced practice provider and four care coordinators, Mahoney said.

“The biggest issue we see in primary care is burnout – 50 percent of employees experience it,” Mahoney said.  “Precision health can help shift away from the in-person visit to what is more patient-centered and, I’d argue, more provider-centered. This has really freed up the providers and given the joy of practice back to doctors.” 

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BOSTON – Precision medicine holds big promise, but it's also posing big challenges for hospital labs trying to manage a huge increase in requests for genetic tests.

At the HIMSS Precision Medicine Summit on Tuesday, Patrick Mathias, associate director of laboratory medicine informatics at University of Washington, spotlighted just how complex the genetic testing boom has become for clinical technology.

Hospital laboratories are "feeling the first wave of precision medicine," said Mathias, as they're "on the front lines of coordinating high-complexity testing."

[Also: How Penn Medicine primed its IT infrastructure for precision medicine]

Many hospitals rely on having to send out tests to reference laboratory when testing is unavailable at primary lab. But that leads to IT challenges for hospitals. Most distinct tests aren't integrated into EHRs and there's a big potential for order entry errors from tests not defined in clinical information systems.

As genetic testing has evolved in complexity beyond the single-gene paradigm, the genetic testing market has become similarly complex and dynamic, he said – with more than 69,100 genetic testing products on the market and as many as 10 new ones every day.

[Also: EHRs and health IT infrastructure not ready for precision medicine]

To improve the management of tests and better integrate their genetic information into workflow,  Seattle Children’s Hospital – which spends more than $1,000,000 annually on genetic sendout testing – helped launched the Pediatric Laboratory Utilization Guidance Services, or PLUGS, a nationwide network with more 60 other hospitals and health systems, with the aim of improving ordering, retrieval, interpretation and reimbursement for genetic tests.

Along the way, within its own walls, coordination between clinical and IT staff was key, said Mathias, and demanded a nuanced approach to process improvement from both sides of the equation.

The initiative required staff at Seattle Children's to embrace workflow standardization improve the efficiency of manual sendout processes through. The hospital had to bolster lab staff expertise to improve ordering process, streamlining test comparison and get better test result management.

It also made used lab genetic counselors to improve quality and reduce costs – they help spot and correct errors that could impacting patient safety, said Mathias, leading to cost savings that in turn justify the addition of more resources.

Having achieved those successes, "the challenge was how can we do that so we can scale across all health systems," said Mathias.

PLUGS enables hospital labs across to decrease testing costs and errors. Seattle Children's says network members that have implemented smart utilization management have achieved savings of 10 percent or more on their sendout testing.

Within his hospital, Mathias said clinicians and IT staff are still grappling with certain aspects of  precision medicine – especially making better use of testing results in clinical workflow.

"There's this foundational question of, if you want data in the workflow, there has to be some EHR integration," he said. "I don't think we've really solved that question yet.

HL7 and FHIR standards are helping, he said, but "this is the tip of the iceberg – we need to lower the barrier to move usable genetic data."

But while integrating genomic data remains "an ongoing challenge," said Mathias, "we are creating actionable results today."

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A military budget bill passed by the U.S. House Appropriations Committee on Monday would provide $65 million for the U.S. Department of Veterans Affairs to move its VistA IT system to Cerner. 

However, those funds come with strings.

According to the budget, the VA must provide Congress with a detail explanation of its solicitation with Cerner for its development of the agency’s EHR. Further, the VA must detail how the new EHR would be interoperable with the DoD and private sector systems.

[Also: VA secretary: Cerner EHR choice brings big clinical gains]

The agency must share with Congress how it plans to maintain the functionality of VistA during the transition, while explaining how it will manage the transition process -- including pilot programs and user training.

The 2018 Military Construction and Veterans Affairs Appropriations bill allocates $182.3 billion to the VA.

VA Secretary David Shulkin, MD announced last week that it would make the shift from its outdated VistA system to Cerner -- the same platform as the U.S. Department of Defense.

[Also: VA picks Cerner to replace VistA; Trump says EHR will fix agency's data sharing 'once and for all']

The funding will “ensure the swift implementation of the plan for the VA to use an identical electronic record system as the DoD,” officials said in a statement. “This will also ensure our veterans get proper care, with timely and accurate medical data transferred between the VA, DoD and the private sector.”

Under terms of the bill, The VA must also create and share a detailed plan on how it will develop and implement the EHR, including timelines, performance milestones, a master schedule and both annual and lifecycle cost estimates.

DoD’s entire Defense Healthcare Management Systems Modernization is projected to cost $4.3 billion. The VA is significantly larger than DoD, so it’s likely the overhaul will cost significantly more.

Shulkin has yet to provide an estimate on cost or when the VA will begin the process. However, at a May House Committee on Veterans Affairs, Shulkin said he planned to return to Congress to ask for more funding if the agency chose to go with a commercial-off-the-shelf EHR.

“We’ve charted a course for modernization: We need help to improve growth and make healthcare a reality for all veterans,” Shulkin said in his opening statement.

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Boston Children’s collaborated with Duke Health System to develop the new Caremap app using Apple CareKit.

The software is designed especially for the approximately 500,000 children with complex medical needs and any doctors, nurses or clinicians can download or recommend Caremap, which is available in Apple’s App Store. 

The first version enables family members and caregivers to track and store medical information and health metrics and then share that data with doctors and clinicians to inform pediatric patient care, the hospitals said.

Development teams at Boston Children’s and Duke intend to add more functions to the app moving forward. The first is connecting Caremap to Cerner and Epic EHRs via the FHIR interoperability interface and, in a subsequent iteration, adding secure cloud connectivity.

“We wanted to harness the patient voice and family perspective,” said Michael Docktor, MD, a gastroenterologist and clinical director of innovation at Boston Children’s Innovation & Digital Health Accelerator. “The ability to track custom parameters provides an important window into patients’ lives that is not captured in the electronic health record, but is important to families.”

Boston Children’s and Duke said the app is particularly geared for the approximately 500,000 children with complex medical needs.

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In his first Capitol Hill appearance since the VA announced it would replace its electronic health record with a Cerner system, U.S. Department of Veterans Affairs Secretary David Shulkin, MD, shed some light on just what the move would mean.

In a brief mention of the department's IT needs during testimony before the Senate VA Committee on Wednesday, Shulkin clarified that the VA would not be scrapping VistA completely, and the agency would obviously be maintaining the 30-year-old record system.

However, Cerner would be specifically tasked with the EHR component of the IT system.

"While it's a decision to move forward with the same vendor as the DoD, it won't be an identical platform … we're different organizations," said Shulkin.

Shulkin also mentioned that the VA needs a program designed to work on interoperability with all of the VA's partners.

"We have to be interoperable with our community partners, as well," said Shulkin, explaining that about 80 percent of the community partners aren't running on the Cerner platform.

[Also: Will Cerner rollout at VA advance interoperability? Maybe]

Sen. Joseph Manchin, D-West Virginia, pressed Shulkin on the speed of this decision: "Are you concerned about having one vendor manage all of these records?"

"The U.S. Department of Defense went through a strong due diligence in choosing Cerner, and the VA will benefit from their due diligence," said Shulkin. "There's always a risk when making a decision of this magnitude. … The greater risk was doing nothing."

When it comes to the cost, and how the VA will know it's getting the best price for the system, Shulkin referenced what the DoD paid – and compared it with the price the VA is already paying to maintain its current system.

Further, he stressed the agency's lack of ability to maintain software developers.

"Most of the cost of the switch with an EHR is in cost management," said Shulkin. "We'll be seeking the best way to do this for taxpayers."

Shulkin said the VA will work with appropriators to make sure the agency is making the right decision.

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John Halamka, MD, was just the second human being to be sequenced in the landmark Personal Genome Project in 2008, one of the initial group of volunteers known as the PGP-10.

Back then, it cost about $350,000 for a company to do such a sequencing. Now the price tag is less than $1,000. Clearly, many advancements have been made in precision medicine over the past 10 years – and that includes information technologies just not necessarily in tandem with the bold vision of genomics.

[Also: Get social data into EHRs to bring precision medicine to population health]

"We aren't as good as we need to be," Halamka said this week at the Precision Medicine Summit. "Our EHRs are not exactly friendly for clinicians and they haven't done a good job of taking things like biomarkers, genomic interpretations and decision support and turning them into action."

How is precision medicine data relayed in the EHR, for instance?

"We use a very highly interoperable standard for such material called 'PDF,'" said Halamka.

[Also: Promise of precision medicine depends on overcoming big obstacles]

Washington University bioinformaticist and genetics fellow Nephi Walton said that in one project with Epic Systems it took them 9 months to get genetic data into the EHR and that, too, was via PDF.

Healthcare has to overcome several obstacles, in fact, to harness genomic advancement in a big way. While providers can send basic clinical summaries around, those are relatively simple data points like problem lists, meds, allergies and lab results rather than the genomic data that holds promise for personalized care.  

[Also: Is precision medicine a matter of national security?]

“What we need are systems that allow physicians quick and accurate knowledge of genetic conditions,” Walton added. “The informatics is crucial. This information can’t just come from what’s in the literature.”

Halamka said that interoperability has to make some evolutionary leaps if healthcare is going to capitalize on the ideals of precision medicine research.The good news? He’s starting to see upstarts and innovators enable more than just provider-to-provider exchange.

"I am meeting with more and more entrepreneurial 26-year-olds who are creating modules of functionality that are layering on top of electronic health records and will fundamentally provide more agility and more innovation than the EHR vendors themselves,” Halamka said.

The hope, he added, is that these companies will bring to market functions that live outside the EHR and enable bidirectional data exchange through FHIR and other standards.

Walton said that genomics and artificial intelligence, for instance, are advancing so fast right now that hospitals, payers, academic medical centers and government health entities need a framework to put those emerging technologies into practice quickly to manage to maintain and deliver precision medicine information.

"The future is bright," Halamka said. “And it’s happening quickly.”

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A woman’s medical records are at the center of a defamation suit being filed against the ride-sharing service Uber. The company is being charged with obtaining her records without authorization and using them to defend itself against charges that she was raped by an Uber driver.

The woman’s identity has not been disclosed but the Uber driver was convicted of rape in 2015 and is serving a life sentence in India. Her lawyers claim in the suit filed today in California federal court that Uber’s representatives obtained the records in an attempt to deny an assault took place.

The lawsuit alleges that Eric Alexander, president of Uber Asia-Pacific, was able to obtain the medical records “generated by physicians who examined her after her brutal rape.”

The complaint maintains that Alexander then discussed the records with Uber CEO Travis Kalanick and other company executives, “speculating that Plaintiff had made up the brutal rape in collusion with a rival of Uber in India in order to undermine Uber’s business” and that Uber continues to have the records in its possession.

The complaint, prepared by Wigdor LLP, does not indicate how Alexander allegedly obtained the medical records.

Uber’s management has been subject to public scrutiny over a series of misconduct allegations, which have resulted in Kalanick taking a leave of absence. The lawsuit claims the company has perpetuated a rape culture and is violating customer privacy.

This is the second suit filed by the woman who is living in the United States. In 2015 she sued Uber over failing to provide a safe environment; that case was settled.

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With Apple’s Wednesday revelation of healthcare and medical records plans for the iPhone, analysts said Thursday that the tech titan should snap up athenahealth – and one reported that athenahealth CEO Jonathan Bush is “warm to the idea.”

“Wait, I thought it was that I am interested in buying Apple?!?” Bush responded when asked about the news. “I am you know. Love that company. Not sure I could afford it just yet.” 

Bush also struck a more serious tone: “I know of utterly no basis for this rumor. Not sure who got the ball rolling but it must be a really slow news day.”

That's hardly ever the case in health IT, but that’s another matter.

[Also: Is a takeover of athenahealth inevitable?]

The ball started moving when Citigroup analyst Garen Sarafian wrote in a note to clients that the acquisition would give Apple some 83 million patient records, the cloud vendor’s Epocrates mobile app for doctors and the company’s physician network, CNBC reported.

The website Seeking Alpha, meanwhile, suggested that athenahealth would cost Apple in the ballpark of $7 billion. And it cited Bloomberg in saying that “Athena chief Jonathan Bush is reportedly warm to the idea.”

CNBC’s report, however, had a curious line: “Apple is looking at startups in the cloud hosting space about potential acquisitions that might fit into this plan.”

Whether that was an indirect reference to athenahealth – well beyond the startup phase at this point – or any number of smaller companies, questions have arisen lately about whether athenahealth is ripe for acquisition.

Bloomberg, for instance, called the company an attractive target after activist investor Paul Singer’s Elliott Associates firm bought nearly 10 percent of athenahealth’s stock.

Athenahealth public relations and social media director Holly Spring said that the current speculation is just rumors.

“Our focus remains on building a national information and innovation network, one that drives clinical and financial results to healthcare organizations of all sizes,” she said.

Twitter: SullyHIT
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Apple has been in talks with hospitals and other healthcare organizations to explore the possibility of bringing health records together via iPhones, media outlets reported. 

The effort to make all personal health information available via its devices would be a first for Apple, which until now has focused it healthcare work on fitness and wellness with its Apple HealthKit. Apple has been typically mum on the developments and CNBC, which first reported Apple’s latest intentions for healthcare, said the works has thus far been “secretive.” 

[Also: Will Apple buy athenahealth? Jonathan Bush calls rumor baseless]

Unnamed sources told CNBC Apple is looking at startups in the cloud-hosting space to give it a foothold in healthcare. 

The company has already acquired personal health data startup Gliimpse, which has a secure platform for consumers to manage and share their own medical records.

The entrepreneur Anil Sethi, who built Gliimpse and sold it to Apple three years later, is now working at Apple. His title, according to his LinkedIn page, is Director, Apple Health.

More recently, Apple recruited Sumbul Desai, MD, from Stanford, where she has been involved in several successful digital projects. Apple executives have not released what role Desai will play, whether she might join the team working on ResearchKit, HealthKit and CareKit, or work on another project altogether. 

Also, Apple insiders reportedly talked with people at The Argonaut Project, which is promoting the adoption of open standards for health information, and to "The Carin Alliance," an organization that advocates for giving patients a central role in controlling their own medical data.

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Precision medicine is more hype than reality right now — but, at the same time, the incredible potential it holds for the future is even greater than all the buzz teases today.

That’s what I came away with from the Precision Medicine Summit in Boston this week.

Let’s look into the distant future: A patient walks into a hospital to meet with clinicians who run tests and pinpoint a biomarker for, say, Alzheimer’s. Then a gene surgeon does some on-the-spot genome editing. The patient walks out with that Alzheimer’s-free-for-life feeling.

“Primary care and genome sequencing will come to the forefront to identify which patients can benefit in a future where genome editing is widespread,” said Ross Wilson, principal investigator at the University of California Berkeley’s Institute for Quantitative Biosciences. 

Just how widespread can precision medicine get? Well, Eric Dishman, who spearheads the NIH’s All of Us program said the program is starting off with the goal of attracting 1 million American participants but is already thinking about how to scale that into the billions globally.

Getting genomic data into an EHR
The grand vision is to democratize research and apply more brainpower per problem to the most vexing medical issues.

Before we can get there, though, a lot has to happen to hammer out data gathering and sharing capabilities, retool the healthcare system so it’s much more adaptable to change and ultimately modernize IT infrastructure to support precision medicine and all the data that entails.

Robert Green, MD, a medical geneticist and physician-scientist at Brigham and Women’s Hospital and Harvard Medical School predicted skirmishes, if not all-out war, over genetic and genomic screening practices: with clinicians and patients on one side, calling for as much information as they can possibly get, versus public health officials and others, warning about the unforeseeable consequences of over-screening.

Among the reasons that people are refusing to participate in genetic testing is fear of discrimination by life, disability or long-term care insurance companies, according to Mayo Clinic Department of Laboratory Medicine and Pathology attorney Sharon Zehe. She added that the whole scenario puts providers in an awkward position because even among patients who are willing to undergo screening, many don’t want that data to live in their medical records.

Not that getting genetic data into a medical record is exactly easy. One of the fascinating accounts at the conference was Washington University genetics fellow and bioinformaticist Nephi Walton explaining how it took nine months working with Epic to include genetic results into the EHR. “You can make a human in that time,” Walton said to laughter from the audience as he turned to a slide with a baby picture.

Precision medicine architecture emerging
While it’s true that today’s EHRs and IT infrastructure are not ready for the big data needs of precision medicine — and I saw that the same thing is true about population health last month — at least one architecture is emerging.

Indeed, the strategy of harnessing FHIR standards, with mobile phones as middleware and a common data repository outside the EHR, is an apt way to manage the demands of precision medicine, said John Halamka, MD, CIO of Beth Israel Deaconess Medical Center. The idea is to maximize what patients already have in their homes.

That approach also gives patients more control over who can and cannot share their data, including researchers, which India Hook-Barnard, director of strategy and associate director of precision medicine at University of California, San Francisco, said it is both the right thing to do and sound science.

But even the architecture Halamka described and giving patients more control over data sharing will not conquer all precision medicine challenges, of course. Michael Dulin, MD, director of the academy for population health innovation at the University of North Carolina Charlotte said simply dumping a whole heap of genomic data on top of the already broken healthcare system, replete with huge variances and medical errors, may actually yield worse outcomes than we have today.

“We have to use technology, we need AI,” Dulin said. “We cannot do this without it.”

Walton noted that first we need simple artificial intelligence and machine learning algorithms just to clean up healthcare’s messy data so it’s suitable for more sophisticated AI tools.

Becoming 'precision health'
What was perhaps the boldest prediction to emerge from the conference came from Bryce Olsen, global strategist for Intel’s Health and Life Sciences unit: Patients will start asking for precision medicine in the second half of 2017 – though many of them will not even realize what they’re requesting.

“Patients are going to demand that doctors get a better understanding of underlying drivers of disease and defects in their tumor. We’re going to see this for cancer first,” Olsen said. “Doctors that don’t have good answers will see patients bounce.”

I’ll add one more to the mix: Precision medicine, in both term and concept, will be supplanted by the phrase precision health – and, yes, this is distinct from how I’m seeing digital health become digital medicine.

“Precision health,” said Megan Mahoney, chief of primary care in Stanford’s population health division, “is a fundamental shift to a more proactive and personalized approach that empowers people to live healthy lives.”

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