The thorny matter of interoperability in healthcare, as it is or has historically been in other industries, is almost all-consuming among technology vendors and their clients. 

Indeed, a big part of the problem is exactly how many EHR companies are out there and, more specifically, the average number of platforms hospitals are running today.

It’s 16. That’s right: 16 distinct electronic health records platforms, according to statistics HIMSS Analytics pulled from its Logic database looking at 571,045 providers affiliated with 4,023 hospitals.

Wait, there’s more. Most hospitals have at least 10 EHRs in place and only two percent are down to just a pair of platforms.

HIMSS Analytics Chief Revenue Officer Mitchell Icenhower explained that the number currently in place doesn’t come up quite that high if you take out specialty EHRs — but doing so is no simple matter.

“The bottom line is there are a lot of different technologies at play here and many of these may be specialty EMRs that won’t be displaced by core vendors, such as behavioral health or oncology products,” added HIMSS Analytics Executive Vice President Blain Newton. 

The plot twists even more when considering both inpatient and outpatient settings.

The average health system, in fact, has 18 different EMR vendors when looking all the way across affiliated providers.

It’s not just the reality that implementing, running and maintaining all the different products have created something of mess, either. Healthcare as an industry needs interoperability to be able move forward now that the system is digital. 

“This is the reason ONC shifted meaningful use to promoting interoperability,” Icenhower said. “This is the environment health systems work in today — this is the challenge they have, so many data sources, trying to provide a total view of the patient.” 

Achieving interoperability among different EHR platforms is so difficult, in fact, that the Office of the National Coordinator for Health IT, the federal agency charged with leading public and private healthcare organizations toward interoperability, essentially retooled its meaningful use EHR incentive program to focus on enabling a more unified view of patient data. Health IT shops across America, meet “promoting interoperability.”

“There were three steps originally. Get as many hospitals and medical groups to purchase a viable EHR, then to meaningfully use that EHR, and the direction for the third step was to focus on qualitative value and quality measures,” Icenhower added. “Now they’re saying instead of that, ‘we skipped the step where the patient is the center of the universe and their data is spread across different systems,’ so ONC shifted to focusing on the patient.”  

Now, about those vendors. In the inpatient setting there’s a whole heap.

The above data points to the healthcare industry’s need for ONC and the Centers for Medicare and Medicaid Services to lead the drive toward interoperability.

“There needs to be a regulatory push here to play referee and determine what standards will be necessary,” Newton added. “But the vendors are going to have to do it because of consumer demand as things like Apple Health Records gain traction.”

Here’s the enormous upside, though: True interoperability will spark innovation and not just between EHR makers competing for best of breed but, more important, among innovators that don’t even sell EHRs as health data starts to flow.

“Even though there may be fewer vendors each feels the need to open up and enable innovation,” Icenhower said, and rattled off Epic, Cerner, Allscripts and athenahealth among those that now need to figure this out. Newton added: “You’re going to see consumer health apps that have been playing on the fringes now be able to plug into the mothership and pull data from it, add to it.”

That’s the scope of the interoperability problem: When tech vendors and hospitals enable data to flow more effectively, the real innovation can begin. 

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

Activist investment firm Elliott Associates criticized the executives and board of directors at athenahealth for not responding to the firm’s $6.5 billion offer to acquire the company a week after it was sent. 

Athenahealth initially said it would review the offer. 

“Last week, we made public our interest in acquiring athenahealth at a price of $160 per share in cash,” Jesse Cohn, partner and senior portfolio manager at Elliott Management, wrote in a letter to the athenahealth board of directors. “Additionally, we made clear that we may be able to raise our offer substantially if given access to diligence.” 

The takeover attempt began in August 2017 when activist investor Paul Singer’s Elliott Associates acquired 9 percent of athenahealth stock. At the time, Singer noted the company could do better for its shareholders.

“We find this lack of communication concerning because, unfortunately, this is the same pattern of behavior we experienced when we tried to get the company to engage in November,” Cohn wrote. “We have received no direct communication despite our emails and messages to athenahealth offering to discuss next steps or to answer any questions regarding our proposal. None of the Company’s advisors has contacted us.”

Athenahealth is in the midst of remaking itself after cutting costs, closing offices and retooling. In August 2017, it pledged to reduce expenses by $100 million. Last October, it cut 9 percent of its workforce, closed offices and sold the company jet.

In its letter to athenahealth, Elliott Management characterizes athenahealth’s response as cursory and akin to a boilerplate press release. 

“For the benefit of shareholders and the company, this pattern of behavior needs to stop,” Cohn wrote. “Our proposal to acquire athenahealth represents an attractive proposition, and numerous shareholders, research analysts and media sources have agreed that athenahealth should engage with us to explore whether a value-maximizing transaction is achievable.”

Cohn noted that Elliott has “a full team ready to engage in confirmatory diligence with the objective of reaching a definitive deal.” 

Responding to a Healthcare IT News request for comment, the company said, “Right now, the board is reviewing the offer from Elliot and in due course will make a decision with the best interest of the company in mind.”

This story was updated to include a comment form athenahealth.

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

Sutter Health faced more than a day of downtime of its Epic EHR and an outage of internal communications this week after the activation of a fire suppression system in one of its data centers, officials said.

All systems currently are back online.

The outage began late Monday night and impacted all 24 hospitals in the California-based health system, according to an internal memo obtained by the Press Democrat. The outage affected certain information systems, the service desk and some of its phone systems.

“Our top priority is patient care and safety,” according to the notice. “Services are open, although some services may need to be delayed or rescheduled. Patients are asked to arrive at their appointments as scheduled unless they have been contacted with specific instructions otherwise.”

“All Sutter Health data remains secure,” the notice continued. “Standardized downtime procedures have been activated and are designed to support high-quality, safe patient care.”

Sutter Health’s emergency management system was activated as a result of the outage, which is programmed to be triggered in the event of a catastrophe. The idea is to allow staff to maintain patient care during an emergency.

The provider began operating under standard downtime procedures early Tuesday morning while it worked to restore its systems, officials said. Some sites were forced back to pencil and paper to record patient information while the computer systems were down.

Those records will be entered into the computers once the system is back online, a spokesperson told the news outlet.

The outage continued through Tuesday night, and officials kept all services open throughout the outage. While some sites were able to maintain all surgeries during the outage, other Sutter facilities were forced to cancel some procedures and reschedule.

While the outage slightly interrupted patient care, Sutter’s emergency planning likely curtailed what could have been a serious event. Allscripts customers faced up to a week without their EHRs after the EHR vendor was hit by a ransomware attack in January.

And just last year, the U.K. National Health Servicewas crippled after WannaCry infected 47 of its trusts. Proper emergency planning can allow hospitals to maintain patient care in the event of a network outage.

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

A group of House and Senate Democrats are calling on the Department of Veterans Affairs to remove its Acting CIO over controversies that stem from his role on the Trump campaign, while expressing concerns about some in the President’s inner circle who may be “inappropriately influencing EHR modernization.”

The letter, sent by 11 lawmakers include Sens. Richard Blumenthal, D-New York, and Tim Walz, D-Nebraska, blasts the VA for its “malign neglect” for failing to obtain qualified leadership and “reports of political interference hindering EHR implementation.”

After Acting CIO Scott Blackburn resigned in April, Trump named Camilo Sandoval to the position. Sandoval, a former Trump campaign staffer, is surrounded by a growing list of controversies.

Among the concerns addressed in the letter is Sandoval’s previous position as Director of Data Operations in 2016. During that time, the Trump campaign contracted with Cambridge Analytica, the company currently under fire for mining Facebook user data.

“Cambridge Analytica’s misuse of personal information from tens of millions of Americans, including veterans, was an incredible breach of trust,” the letter authors wrote. “As such, Sandoval’s role in these activities must be thoroughly examined.”

“He should be put nowhere near veterans’ health and benefits data,” they added.

The letter also noted Sandoval is currently the subject of a $25 million lawsuit that claims he slandered, harassed and sexually discriminated against a campaign colleague. All of these items “raise serious red flags and indicate a history of interpersonal conflicts with coworkers.”

As a result, the VA should remove him from the position, the Congressional members wrote.

Sandoval is just one of many senior staffing issues concerning the Congressional members. There are more than 33,000 vacancies within the agency, including 553 in the Office of Information Technology. And about 40 senior staffers have stepped down in the last four months alone.

These vacancies are adding to concerns about the EHR modernization project.

“Current VA employees…are forced to shoulder the work of former colleagues -- contributing to low morale among the VA workforce,” the letter authors wrote. “The historic overhaul of the VA’s outdated [EHR] requires adequate staffing levels to ensure this project succeeds.”

Given that the Department of Defense’s project is facing its own serious challenges, the need for a VA leader who understands the “risks and requirements” of the project is crucial, they continued. “The need for VA’s EHR modernization cannot be overstated.”

Also notable is that the letter is addressed to Deputy Secretary Thomas Bowman instead of Acting Secretary Robert Wilkie. Some have called into question Wilkie’s authority in that role, given Trump sidestepped appointing Bowman as secretary after ousting VA Secretary David Shulkin, MD. In fact, two veterans’ groups have sued to have Wilkie removed.

Despite this opposition, Wilkie has continued to forge ahead with plans to decide on the EHR modernization by May 28.

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

Crisp Regional Health picked healthcare IT tech giant Cerner for a cloud-based integrated EHR and revenue cycle management system for its acute, ambulatory and post-acute care facilities.

This is just one of several contracts Cerner has closed recently, a boon for the EHR giant in Indiana, Missouri and Maine. The company has taken a hit as it waits for Veterans Affairs to decide on May 28 whether or not to go forward with a Cerner to replace its VistA EHR.

On the EHR front, Cerner has double the EHR global market share of closest rival Epic, according to Kalorama.

Crisp Regional executives expect the new tech platform will streamline operations and improve patient care.

“Cerner provides us with one integrated health record across all venues of care, supporting our goal of clinical and financial optimization throughout our system,” Jessica Carter, vice president and chief financial officer at Crisp Regional, said in a statement.

[Also: Indiana psychiatric facilities to roll out Cerner EHR, revenue cycle software]

"We are committed to providing the highest quality of care possible to Crisp County and surrounding communities," added Lynn Lyons, chief of staff-elect at the hospital. The hospital is employing measurable goals of increased physician visibility and strong patient outcomes.

Crisp Regional will transition to Cerner Millennium. Through the new online patient portal, patients and their families will be able to securely message doctors, schedule appointments, view and settle balances, and access their health history.

Cerner’s Revenue Cycle Management System provides Crisp Regional clinicians a view of clinical and financial data in one patient record.

Also, executives expect the hospital will benefit from the documentation that can improve reimbursement and limit claims errors.

With Cerner CommunityWorks cloud technology the hospital will have help with managing, operating and upgrading the EHR. It also will have access to its application management services, meaningful use and regulatory services and evidence-based recommended workflows and content.

“Cerner CommunityWorks will bring Crisp Regional a sophisticated, single integrated health record across the continuum of care for all our patients, regardless of where they receive care in our system,” IT Director Mitch Hiers said in a statement. “While that's a welcome improvement for patients, physicians and clinicians, we also look forward to the many technological advancements it brings with it – especially in terms of interoperability, decision support, population health and data analytics.”

Crisp Regional’s network of health and social service facilities includes a home health program, two nursing homes totaling 243 beds, a retirement home, a hospice and home care program, a dialysis facility, and rural health clinics in bordering areas.

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

Nearly a year after the initial announcement, Cerner can officially add another government contract to its belt: The U.S. Department of Veterans Affairs will officially contract with the EHR-giant to overhaul its legacy VistA EHR.

The pair made the announcement Thursday night, after a year of speculation over whether the contract would be signed. Former VA Secretary David Shulkin, MD, said he planned to transition the VA to Cerner last June, but interoperability concerns and staffing shake-ups have left the contract in limbo.

According to the announcement -- and a budget forecast -- the Cerner EHR at the VA will be identical to the one currently in the pilot phase at the Department of Defense. Currently, officials at both agencies are working together to impart lessons learned into the VA project.

The agency will also add its own capabilities to support the special needs of veterans, such as mental health. If successful, the EHR will allow for seamless data sharing between the agency and community providers.

The project is slated to cost $10 billion over the next 10 years and currently has a starting budget of $782 million for Fiscal Year 2018.

This week is not only significant for @Cerner, but it's personal for me. As the son of a veteran, I want to thank the @DeptVetAffairs for taking the necessary steps to provide vital care for the millions of individuals who have served our country. https://t.co/QHoKZZfId1

— Brent Shafer (@BrentShaferCEO) May 17, 2018

We are humbled and honored by the responsibility that comes with serving our nation's active duty military personnel, and now, its veterans. This is a historic day for @Cerner and the @DeptVetAffairs. https://t.co/oCQLUH4TNk

— Zane Burke (@zanemburke) May 17, 2018

“This is one of the largest IT contracts in the federal government,” said Acting VA Secretary Robert Wilkie in a statement. “And with a contract of that size, you can understand why Shulkin and I took some extra time to do our due diligence and make sure the contract does what the President wanted.”

“We expect this program to be a positive catalyst for interoperability across the public and private healthcare sectors,” said Cerner President Zane Burke in a statement. “We look forward to moving quickly with organizations across the industry to deliver on the promise of this Mission.”

Neither the announcement or officials have said when the project will kick-off, but Cerner officials said that the VA will roll-out its project in waves to match the DoD implementations. At the moment, the DoD project is facing serious challenges with usability and patient safety concerns, which it has been addressing for more than two months.

DoD officials remain firm that the agency will still complete implementation timelines.

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

This week Athenahealth is amid a takeover bid of at least $6.5 billion.  Elliott Associates offered $160 per share in cash to take athenahealth private, and the investment firm appears willing to up the ante.  While athenahealth has not publicly responded, here’s a look back at some of the moves by the company and outside forces that preceded the offer.

May 16, 2018

After one week of silence from athenahealth regarding the proposed acquisition of the cloud-based public company for $6.5 billion or even more, Elliott Management sends a scathing letter to the board of directors scolding the group for its failure to engage.

May 7, 2018

Activist investing firm Elliott Management makes an offer to buy athenahealth. Co-founder and CEO Jonathan Bush, who is in the midst of retooling the cloud-based company, states thatthe board of directors would "carefully review the proposal to determine the course of action that it believes is in the best interest of the company and shareholders.”

April 5, 2018

Athenahealth CEO Jonathan Bush said he expects that in the next 12 to 24 months, athenahealth will be completely deconstructed into a set of standalone micro-services. The change, he said, would result in having many more products than the company offers today. The shift will also allow many other people to make products, he said.

March 12, 2018

Healthcare IT News caught up with Bush at HIMSS18 in Las Vegas. He told us something we had never heard before. The company he founded with Todd Park launched with bad software. “We literally built a company proudly on the fact that we had bad software,” Bush said, “Little by little by little as we got bigger and bigger and bigger that bad software made it harder for even us who knew it so well to use.” 

Feb 7, 2018

Athenahealth appointed former GE CEO Jeff Immelt as chairman of its board of directors. The move was one of several strategic initiatives the company had started in 2017, as it planned to build a more focused and efficient company and, of course to drive growth, the better to boost shareholder value.

May 18, 2017

Since Elliott Associates scooped up a nearly 10 percent share in athenahealth, rumors have been rampant that its founder and well-known activist investor Paul Singer may be eyeing the cloud-based healthcare technology vendor as its next big deal. And that likely means a sale or merger.

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

President Donald Trump plans to nominate acting U.S. Department of Veterans Affairs Secretary Robert Wilkie to permanently lead the agency, the President announced on Friday at the White House summit on prison reform.

The news will come as a surprise to Wilkie, as the President hadn’t even told him before the announcement.

“Wilkie, who, by the way, has done an incredible job at the VA” said Trump. “I’ll be informing him in a little while — he doesn’t know this yet — that we’re going to be putting his name up for nomination to be Secretary of the Veterans Administration. Fantastic. I’m sorry that I ruined the surprise.”

The President also applauded the agency’s moves to expand the VA Choice and accountability programs.

The nomination comes just three weeks after Trump’s first nominee former White House physician Ronny Jackson withdrew his nomination amid the emergence of workplace controversies.

Currently, Wilkie is the Department of Defense Undersecretary for personnel and readiness. Trump pulled him into the role after the President fired former VA Secretary David Shulkin, MD. The move came as a surprise, as Trump sidestepped Deputy Secretary Thomas Bowman -- next in line to the position.

In fact, two veterans groups sued the VA over what they argue was Trump’s ‘unlawful’ choice. While that lawsuit is still pending, it remains to be seen how those groups will view the most recent nomination.

While another large veterans group AMVETS initially urged Trump to reconsider his choice, they’ve since changed their tune.

“Wilkie has clearly been working hard to learn the many extremely complicated and most pressing issues facing veterans right now,” AMVETS Executive Director Joe Chenelly said in a statement. “His early work has earned him the confidence of AMVETS, and we’re looking forward to a thorough but hopefully speedy confirmation process.”

The VA just announced it will officially sign a $10 billion EHR modernization contract with Cerner, nearly a year after Shulkin said the agency planned to build an EHR to match DoD.

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

The Cancer Informatics for Cancer Centers represents chief information officers and other informatics leaders from 70 National Cancer Institute-designated cancer centers nationwide. At the HIMSS Precision Medicine Summit on May 18, the two co-founders of CI4CC offered their thoughts on how the vast promise of precision oncology can be realized more quickly at NCI and beyond.

Warren Kibbe, chief for translational biomedical informatics and chief data officer at Duke University, and Sorena Nadaf, chief informatics officer and director of data science at City of Hope, founded CI4CC to offer a forum for the sharing of ideas among cancer center informatics and IT leaders, and other stakeholders from across healthcare.

Most recently, they have been intently focused on helping the ideals of genomic research gain traction in healthcare settings of all shapes and sizes Despite the "tremendous hype" around precision medicine, its promise is real and potentially transformative, said Kibbe.

[Also: Community hospitals can do precision medicine too - here's how]

The advent of gene sequencing and improved biological understanding more generally has "changed our view of cancer as a disease in last 20 years," he said, and that "has helped us target and develop new therapies."

And sequencing continues to improve and get less expensive by the day. That means technology and informatics professionals have a hugely important role to play as the huge data generated by those techniques keeps proliferating.

"I worry as an informatician about where we're going to put all that data and make it accessible," said Kibbe.

Despite those concerns, he's even more excited about the huge leaps in evolution made for imaging, nanotechnology and more. Still, there's work to be done to capitalize on those advances, and it involves developing sound techniques for data science and process improvement at healthcare organizations large and small.

"We really need to build a learning health system for precision medicine to be real," said Kibbe.

[Also: AI is key to precision medicine, but hospitals must have strategies for data integrity]

Making the most of precision medicine's achievements means "building a different environment for how we think about sharing data," he explained.

In part, he pointed to some reluctance from organizations such as his own when it comes to opening the spigot of their own health information: "Academic Medical Centers are too focused on the perceived value of their own data to let it flow," he said.

But community care settings account for 85 percent of cancer treatments, Kibbe pointed out. That means they have 85 percent of the data. "We need to not be afraid to share it so we all learn from it."

From there, healthcare needs to get better at integrating genomic information into EHRs, and commingling it with labs numbers and frictionless patient-generated data.

Easy, right? But the benefits of getting the technology infrastructure and data management squared away will be immense, said CI4CC's Sorena Nadaf.

The advent of precision medicine has already "changed the way we're looking at every patient," he said.

Still as "our understanding of disease has grown," the way healthcare manages and treats its patients has largely remained the same for the past several decades, he said. "That gap is where translational science lives."

We're "closer and closer to closing this gap," said Nadaf. But doing so will demand sound data science ("we're all still making methodological errors when we do deep learning," Kibbe notes) and robust technology infrastructure.

But not only technology, of course. Nadaf noted that "despite all the hype about AI, it's is much more challenging than many believed it would be." (Need evidence? Just look at the abandoned $62 million rollout of IBM's Watson at University of Texas M.D. Anderson Cancer Center.)

But "it's not technology that's going to drive the changes," said Nadaf. "It's the way we apply and learn from it that will allow us to grow.

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

The electronic health record is the lynchpin of healthcare information technology. And it has been evolving at a consistently quick pace in recent years.

Healthcare CIOs seeking to ensure they are making the best EHR investments today for the years ahead would do well to listen to experts in the field offering an insightful look ahead at the future of EHRs.

We checked in with Epic Systems President Carl Dvorak, Allscripts CEO Paul Black, an Accenture consultant and drchrono founder Daniel Kivatinos to get a sense of where big and smaller EHR vendors are headed.

Epic’s Dvorak singled out automation analytics, genomics-informed medicine, telemedicine and next-generation analytics as areas that will impact the EHR.

“Automation analytics: Akin to a flight data recorder, collecting information about how providers are using automation in the care and administrative processes will be a significant leap forward in reducing costs, increasing efficiencies and reducing harmful variation,” Dvorak said. “This holds the key to unlocking some of the secrets to physician well-being. For example, we can avoid work being unnecessarily diverted to physicians when it could be better managed by others.”

The advent of genomics-informed medicine also will be key to the future, he said. As part of an effort to incorporate social determinants into patient care, genomics-informed medicine allows caregivers to tailor healthcare precisely to the needs of the individual, as they best understand them today, he added.

“On a deeper level, it also helps us form a more detailed understanding about how disease forms and what clinicians and patients can do to influence outcomes,” he said. “Genomics-informed medicine gives us insight into our personal futures – which may help guide, direct and motivate our preventive healthcare behaviors. It can also be considered our ability to see into the future on a few dimensions.”

On another note, the evolution of telemedicine will affect how EHRs are viewed and used, Dvorak predicted. Delivering care virtually allows healthcare organizations to reengineer care processes and care delivery at a much lower cost, while maintaining high effectiveness and improving outcomes, he said.

“More specifically, there are significant opportunities to leverage remote patient monitoring with consumer- and medical-grade devices that can stream information to a clinical process via an algorithm or human, where appropriate,” he said. “In addition, there’s great promise in consumer diagnostics that allow a patient to reliably test for conditions in the home, while transmitting the results of those tests back to their medical institution, which may also be transmitting back to an algorithm or human.”

The ability to maintain a personal connection with a provider through video and other technologies has proven to benefit patient experience and convenience, while at the same time allowing health systems to reduce the total cost of delivering care, he added.

And the next generation of analytics will have an impact on EHRs and what they are used for, Dvorak said. At first, the next generation of analytics will seem more magical than the reality behind the scenes, he said. However, fairly soon, this functionality will turn out to be even more magical than healthcare executives could have imagined, he added.

“In particular, machine learning and predictive models allow us yet another way to see into the future and even help prevent adverse outcomes in real time – such as sepsis and other forms of deterioration or complications,” he said. “At the same time, analytics will help us maintain our health and well-being by providing guidance on what we can do to prevent adverse outcomes that would otherwise be inevitable without intervention.”

When it comes to next-generation EHR features, it is becoming more challenging to retrofit EHRs to take full advantage of new innovations – such as the cloud, machine learning and mobility. These three areas are top of mind for Paul Black, CEO of Allscripts.

One of the biggest concerns in the industry today is physician fatigue and issues around how they are spending an increasingly large amount of time with the computer versus the patient.

“We believe using human-centered design will transform the way physicians experience and interact with technology, as well as improve provider wellness,” Black said. “The industry needs an entirely new approach to the EHR. We’re seeing a huge need for the EHR to be mobile, cloud-based and comprehensive to streamline workflow and get smarter with every use.”

"The industry needs an entirely new approach to the EHR. We’re seeing a huge need for the EHR to be mobile, cloud-based and comprehensive to streamline workflow and get smarter with every use."

Paul Black, Allscripts

In general, the cloud can reduce the total cost of ownership of IT while improving scalability and security. The cloud offers many advantages to users, Black insisted.

“For example, with cloud solutions they don’t have to deal with maintenance, equipment, upgrades and security,” he said. “Public cloud-based EHRs offer advantages over traditional private cloud-based EHRs, which are often a software as a service model.”

With machine learning, the IT learns what works best for a healthcare organization for maximum efficiency.

“We’re incorporating machine learning capabilities to learn our clients’ treatment patterns,” Black said. “It can pre-populate information based on these patterns and deliver preference reminders. It’s constantly surveilling trends by user, organization and region to create opportunities for more efficiency.”

Plus, the power of machine learning surfaces information relevant to the encounter in real time – which helps improve quality and immediate interaction with the patient, he said. Ultimately, this reduces the amount of time spent on documentation, helping address the problems of EHR fatigue and physician burnout, he added.

And mobility gives the user what he or she needs, when and where he or she needs it, Black said. Many EHR companies have released companion mobile apps that offer a subset of the functionality in the EHR. Because the experience is limited, users have begun to dismiss mobile solutions over time, Black contended.

“By offering a new approach to mobility, with 100 percent of the EHR workflow in a user-friendly environment, the full power of the EHR will be at physicians’ fingertips, which means they are better informed and better able to engage directly with patients,” he said.

While several EHR vendors are developing cloud-based inpatient and outpatient electronic health record systems, these products are a few years away from meeting the needs of a full-service medical center, said Kip Webb, MD, consulting giant Accenture’s provider practice lead.

“Look for the vendors to implement EHRs in smaller hospitals and critical access facilities first, and work upstream from there,” he said. “In the meantime, I expect to see Epic and Cerner grow their footprint in the small to mid-size hospital market.”

There are two important product lines currently in development among the major EHR vendors, Webb added.

“The first product line is in the field of population health,” he said. “Currently, these products are displacing niche registry vendors primarily using EHR and claims data. Over time, these products will consume more data, including data related to the social determinants of health, thus enabling true population health management.”

The second product line is increasing analytic capability, including artificial intelligence. As was true with population health, this product line will be an incredibly important arrow in the quiver, he said. Not only will it enable healthcare executives to better understand the most vulnerable patients and the care they require, but it also has the promise of moving some work off the busy clinicians’ plate, he said.

Daniel Kivatinos, founder of EHR, practice management and revenue cycle systems vendor drchrono, said the next generation of EHR features and functions will be very interesting, and there will be a lot of attention on the cloud and APIs.

“Many EHR vendors are locked to data centers in the basements of medical facilities,” he said. “Is having an expensive IT staff and having a huge server farm infrastructure worth it? This way of operating for decades has been impeding on innovation. Do you recall the days of having all of our banking in just one bank location when nothing was digital and you would go to your local bank to get paper cash? Do you recall when ATMs started popping up?”

The currencies industry went digital in a big way. It allowed innovation from companies like Square to build ways to take payments from a phone to companies like Apple to create Apple Pay and Apple Pay Cash. Now it is all in the cloud.

“Moving forward, healthcare CIOs should understand that the industry is moving to the cloud,” Kivatinos said. “Looking to the future will benefit innovative healthcare institutions in many ways in the long term. Perhaps one of the biggest ways having a fully cloud-based EHR will change the way we as an industry operate will be enabled API access.”

APIs are powerful. Brilliant developers inside and outside the healthcare industry can join forces with a healthcare organization in a very fast way.

“As a CIO, you will be able to test apps without having to have massive timelines, long setup times, and adding to costs within the organization,” he said. “With APIs and testing apps at a fast rate, you will see what is working and what isn’t working quickly. You will be able to add other partners into the mix that just weren’t available before when you have a local EHR install only.”

Enabling a cloud EHR, he concluded, will ensure the long-term success of a medical institution getting access to additional components and partner apps through modern cloud APIs.

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

Just one day after signing a $10 billion EHR contract with the U.S. Department of Veterans Affairs, Cerner President Zane Burke told investors that the company’s other major government project with the Defense Department has taught him a lot about ‘fake news’ and that one of Cerner’s competitors may have been involved.

“I have learned the term fake news a little bit,” Burke said on a call with investors. “If you followed the one side of this, there’s been concern about some of the delivery on the DoD side. So, if you had an axe to grind with us and wanted to perhaps keep us from getting to a veterans contract – and you’re one of our competitors – you might want to use some information negatively.” 

Burke was likely referring to multiple media reports that came to light early this year that pointed to serious user issues with four of the DoD pilot test sites. Members of Congress caught wind of these and let DoD officials know they were concerned.

But a DoD Initial Operational Test and Evaluation report released on May 11 echoed a lot of those reports and found that issues with usability, cybersecurity, user training and the help desk rendered the platform “not operationally suitable.”

DoD officials agreed with recommendations made in the report, but refuted the negative reports and said the EHR rollout will continue as scheduled.

Burke echoed those sentiments.

“I tell you that’s gone incredibly well, overall,” Burke said. “There were some known elements upfront as we rolled through the first three sites. The plan was always to come back and do a remediation of those three sites and do an evaluation and make things better.”

Burke said the good news in all this is that Cerner’s client, the DoD, understands the value of what the software company is delivering. 

To Burke, the VA contract provides a real opportunity to “provide seamless care across the continuum” and ensure that men and women in the service can keep their records with them as they move into the VA. Not only that, but the $10 billion contract is half of the projected cost to support VistA for the next 20 years if VA kept that proprietary EHR and its modernization in-house. 

Former VA Secretary David Shulkin, MD, announced his plan to give the EHR modernization contract to Cerner through a no-bid process to expedite the project and to match the platform currently in a pilot phase. Not all EHR vendors were pleased with this decision, and CliniComp actually sued to stop the process. The judge later dismissed that case.

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

HIMSS released its Environmental Scan of Interoperability Initiatives to collect in one place the health information exchange options that currently exist for hospitals.  

The free tool comes as health IT shops grapple with more than a dozen EHRs running in-house, the Office of the National Coordinator for Health has retooled its efforts to focus on enabling interoperability and health information exchange, and more and more hospitals are turning to Carequality, CommonWell and others to share patient data outside their four walls.

[Also: Why EHR data interoperability is such a mess in 3 charts]

“We now have a better understanding of who exists, how they differ, how they’re similar and how they’re collaborating,” said Katie Crenshaw, Manager of Informatics at HIMSS. “The whole point is to make it easier for hospitals to gather information people keep hearing about.” 

Participating organizations include Epic Care Everywhere, Carequality, CommonWell Health Alliance, DirectTrust, Sequoia Project’s eHealth Exchange,  Surescripts, Community HIE, National Association for Trusted Exchange, CARIN Alliance, and SHIEC, which stands for Strategic Health Information Exchange Collaborative.

“They’re not approaching it in the same way. Some are providing networks, others are creating a governance structure with policies that need to be in place for interoperability to occur,” Crenshaw said. “There’s a lot of collaboration across them as well — the direct result for users is they don’t have to be members of each of these.”

The interoperability environmental scan is open to the public and includes 20 categories for each entry, such as certification requirements, costs, which standards the entity leverages, its mission, future plans, partners, and directory details, among others.

“It’s open for comment and continuous feedback,” Crenshaw said. “Now we want to make sure it stays up to date.”

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

The Office of the National Coordinator for Health IT announced a new developer contest focusing on EHR safety. 

ONC has a history of looking to private sector app developers for innovations that bolster the use of health data, such as Blue Button mashups, reducing medical errors, apps for children’s health, data aggregators, secure APIs, just to name a few examples.

Backed by $80,000 in prizes and dubbed the new Easy EHR Issue Reporting Challenge, ONC said the program aims to help clinicians report EHR safety issues when they happen and right in the workflow.

[Also: Next-gen EHRs: Epic, Allscripts and others reveal future of electronic health records]

That’s a big contrast to the way safety reporting happens right now.

“The vast majority of EHRs currently require the end user to either log out of the EHR system entirely or leave the current workflow process to report a problem,” ONC Chief Medical Officer Andrew Gettinger, MD, wrote on the HealthIT Buzz blog Tuesday. “These workflow disruptions place a large enough burden on many users that they just avoid reporting altogether.”  

ONC is looking for innovators to develop an EHR-agnostic application that integrates into clinician workflow to enable them to more easily create reports and choose who they want to share those with.

Gettinger explained that all submissions must involve user testing by physicians, clinicians and include that feedback in the application process.

“Stakeholder feedback – and our own experiences – show that there is a need for more efficient and user-friendly mechanisms that allow EHR end users to report concerns quickly and easily, with little or no disruption to their workflow,” Gettinger added.

The deadline is Oct. 15.

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

After Integris Health failed several security audits, the Oklahoma health system concluded it was time to implement an identity governance program.

Previously, employees and contractors were accessing the organization's Epic electronic health record and other clinical applications without any type of access management policy in place. Integris needed visibility into each user and their access to sensitive patient information.

"We had increased our investments in IT security to address compliance pressures around protecting healthcare data," said James Landers, identity access management security engineer at Integris Health. "We also put measures in place to proactively protect ourselves from a potential data breach. Failure to meet compliance needs or exposure of sensitive healthcare data could have serious consequences for the organization if not properly addressed."

Despite these investments, Integris still had a limited view of the applications and healthcare information systems employees were accessing. This "identity" information was housed in disparate repositories. One of the bigger issues was the lack of visibility for all employees with access to a Cerner EHR which was the largest clinical application at the time. (Integris later switched from Cerner to Epic.)

"We could track what our full-time employees had requested access to, but we lacked a view of what access had been granted," Landers said. "We also had zero visibility into what our contract employees were accessing. Moreover, we used PeopleSoft to track full-time employee access to applications and information, but not contractors, who were managed in an ad hoc way."

So Integris turned to an identity governance program, with help from vendor SailPoint. An IG program helps an organization understand which users have access to what and, more importantly, ensures users have the right access to information. It also confirms that the contents of account repositories are properly controlled.

In addition to SailPoint, there are many vendors in the identity governance and identity access management market. These vendors include AlertEnterprise, Datum, Edgile, Janrain, OpenText and Oracle.

"Identity governance allows us to align our policies and establish consistent, centralized access controls across the enterprise," Landers explained. "For example, we have contract nurses and therapists who are constantly coming and going and need access to systems and information to do their jobs. It's important for employees to have the proper access needed, in a safe and secure way, and it's also important for us to have visibility into user access across our applications."

For Integris, identity governance is a solution that protects its patient data and healthcare information systems in the event of a breach. Identity governance also integrates with its clinical applications and tracks who has access to what within the organization.

Integris kicked off its identity program by addressing access certifications head-on. For Integris, this was key.

"We kicked off our identity program with the access certification because it's a crucial component in proving compliance with healthcare regulations," Landers said. 

The technology helped "establish and enforce user access policies like separation-of-duty," he explained. "Once these policies were established, we were able to automate the process of reviewing, approving and revoking user access rights across the organization, saving us time and money by reducing the burden on both IT and business staff, while strengthening our security posture."

Landers said the initiative made an impact in three key areas. 

The first was to give the health system a complete view of the users accessing applications within the organization. Upon bringing Cerner users into SailPoint and prior to transitioning to Epic, Integris learned there were quite a few Cerner accounts not mapped to active directory accounts. SailPoint helped correctly map them, eliminating unnecessary Cerner accounts and establish a governance process for future provisioning.

"The second area is helping us manage our contract employees," he said. "We moved forward with putting contract employees in PeopleSoft to address this issue, giving us the holistic view of the organization we were looking for. It also became critical to put access certification and provisioning in place for all employees."

Third, Integris developed a termination process to de-provision major applications from users who leave the organization in a timely manner. Integris also recently transitioned from Cerner to Epic, Landers said. 

Ultimately, Integris' identity governance program created greater efficiencies and workflows for the entire organization. 

"Every non-employee worker is now mapped to a manager, creating a clear line of sight of who has access to applications and data," he explained. "Integris now runs bi-annual certifications with 90 percent completion rate for all users with application access. We also run a uniform process and audit trail for all applications access granted, especially to non-employee workers."

Managers are aware of access – especially access to the main clinical application, Epic – that employees have because they requested or approved it. When an employee leaves the company, within 30 minutes of leaving in PeopleSoft, a user's active directory account is disabled, prohibiting them from accessing the IT environment, and service desk tickets are created to terminate each of their application accounts.

"The uniform provisioning process for both employees and non-employees means that no one gets access to an application without their manager, who has ultimate responsibility, knowing about it," Landers said. 

Additionally, he said, a uniform termination process for both employees and non-employees means that no one retains access that slips through the cracks, he added. Since active directory and other accounts are deactivated, no bad actors can use those accounts after the user has left the organization.

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com

The Senate overwhelmingly approved the VA Mission Act on Wednesday, overhauling private sector care options for veterans.

Passing with a 92-5 vote, the bill cleared just one week after passing in the House with a 347-70 vote. Its passage meets the White House’s deadline to act on the issue before Congress leaves for a week-long recess and heads to the President’s desk where it is expected to be signed into law in the next few days.

The $52 billion reform legislation will overhaul the Department of Veterans Affairs, including how veterans can access healthcare in the private sector and is aimed to improve information sharing between community providers and VA doctors.

The bill clarifies that the “VA could share medical record information with non-department entities for the purpose of providing healthcare to patients or performing other healthcare-related activities.”

Its passage also will require the VA to create a process to make sure private sector providers are able to access relevant patient medical histories, including all prescribed medications. It’s aimed at curbing opioid abuse among veterans.

The bill requires all “contracted providers submit medical records of any care or services furnished, including records of any prescriptions for opioids, to VA in a timeframe and format specified by VA.” The VA also is required to record all prescriptions into the EHR.

Under the legislation, the VA also will be required to participate in a national network of prescription drug monitoring programs that give licensed providers to receive and submit PDMP data. Currently, all but four states participate in a PDMP data sharing collective.

According to the bill, “licensed healthcare providers or delegates would be required to query the network in accordance with applicable VA regulations and policies and no state would be authorized to restrict the access of licensed healthcare providers or delegates from accessing that state’s prescription drug monitoring programs.”

The bill also gives legislative authority to the VA’s Anywhere-to-Anywhere telemedicine program launched by former VA Secretary David Shulkin, MD, and President Donald Trump last summer.

The provision makes it clear that providers can treat patients across state lines with a telemedicine platform, and that care doesn’t need to be delivered in a federal medical facility.

The legislation also mandates a two-year pilot to increase the agency’s use of medical scribes in specialty care settings and emergency rooms at 10 VA medical centers.

The passage has been praised by numerous groups, including the American Medical Association, which said the bill will ensure veterans have “continuity of care external to the VA’s medical network.”

“For many years, we’ve seen veterans and their providers frustrated because veteran health records were not accessible to private sector providers due to an administrative issue,” said The Sequoia Project CEO Mariann Yeager in a statement. “[It] provides an important fix that will unlock veteran health records to enable the providers who care for veterans to make better informed decisions and coordinate care regardless of whether they are treated at a VA medical facility or in the private sector.”

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

Of the 216 hospitals that contracted for a new electronic health record system in 2017, a hefty 80 percent of them were smaller acute care sites with 200 or fewer beds, a new KLAS study shows. Those hospitals are making their mark on the EHR market, looking for specialized technology that meets their unique needs and tight budgets.

"These smaller hospitals are hungry for new technology but often resource poor; over half that signed a new contract in 2017 chose a less expensive or less resource-intensive platform – namely, athenahealth, MEDITECH, and the community deployment models from Cerner and Epic," said KLAS researchers.

As more sizable health systems increasingly consolidate around the broader offerings from Epic, Cerner and, to a lesser extent, Allscripts, small hospitals are forging their own path, looking for vendors whose products are best-suited to their own workflows.

Of course, that's not to say that giants like Cerner and Epic have not made inroads in that market, however. "In competitive decisions by large organizations, they are almost the only vendors considered," according to KLAS. But even with smaller hospitals, "Cerner's and Epic's alternative deployment models … both saw significant wins."

Across all sizes in 2017, Cerner saw gained the most new contracts of all vendors the report showed. Epic had fewer, but also didn't lose any clients, giving it highest net growth in market share. Cerner lost 25 hospitals clients, 15 of them due to customer standardization, according to KLAS. (It has added a fewmore smaller hospitals to its client base just this month.)

Allscripts, of course, almost doubled its hospital client base in 2017, thanks to its acquisition of McKesson's Paragon and Horizon platforms. But "both solutions have been losing customers for years, and 2017 was no different," according to researchers. That said, "many Horizon and Paragon customers who left in 2017 had already made decisions to switch to other vendors prior to being acquired by Allscripts."

But what KLAS found more notable were a couple big customer losses for Allscripts' Sunrise Clinical Manager, which is aimed at larger hospitals. That platform's market share "had been relatively stable for a number of years, but in 2017, two large multihospital organizations switched their SCM hospitals to Epic, looking to simplify their IT infrastructure and consolidate to an integrated solution," researchers said.

Meanwhile, athenahealth, which has been striving to find a foothold in the inpatient space, "continued to gain traction," in 2017. (That's perhaps just one reason Elliott Management sees it as a worthy $6.5 billion investment.) It notched more contract wins among smaller hospitals, specifically, than any other vendor, said KLAS, owing largely to the fact of its unique value-proposition.

"The cloud-based platform is particularly attractive to the smallest hospitals, who require minimal IT footprints and up-front costs," according to the report. "Indeed, athenahealth's 2017 wins occurred solely among hospitals with under 50 beds."

However, questions about the maturity of athena's inpatient offering were a concern. This past year 13 contracted customers "backed out before going live, returning to previous vendors, primarily CPSI."

Meditech has traditionally been a strong player among the smaller hospital market, of course, but 2017 was the first time in three years that the company saw a net increase in market share, according to KLAS. If athenahealth is finding favor in that space thanks to its cloud-based EHR, Meditech's renewed growth is also largely due its own newish SaaS platform, Expanse.

Beyond new signups, that offering has also led to "increased migration activity among Meditech's legacy customers – 58 percent of those who made a go-forward decision in 2017 chose Expanse, while 42 percent went with other vendors," researchers said. "Historically, Meditech's systems have not generated significant consideration outside of the existing Meditech base, but Expanse is changing that."

As for other systems, KLAS notes that hospitals using EHRs from Medhost, CPSI (both Healthland and Evident), Cerner's legacy Soarian system (a remnant of the company's 2014 Siemens acquisition) and others compose a highly diverse one-third of all contracts in the United States.

Medhost's customer base did stay mostly stable in 2017 thanks to "improved relationship efforts and the release of a new hosted option," but Evident, Healthland and Soarian all experienced varying degrees of attrition this past year.

Many of the more traditional small-hospital systems "are seeing high rates of replacement as provider organizations consolidate and as customers switch to more attractive deployment models," according to the report.

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

As Elliott Management Corp. impatiently taps its feet, waiting for athenahealth to come to a decision about its offer to take the company private in a potential $7 billion sale, the hedge fund is upping the pressure on the cloud-based IT vendor.

On May 24, Elliott sent a letter to the athenahealth board collecting hundreds of words of support for the deal – an "outpouring of positive reactions" – spread across dozens of approving quotes from Wall Street equity analysts, the financial media and athena's own shareholders.

The letter professes to show that "the investment community broadly agrees that athenahealth has struggled as a public company and should immediately explore a value-maximizing sale, including consideration of Elliott’s offer," according to the activist fund.

"The purpose of this note is to share with you the reactions to our offer that we’ve seen and heard, both privately and in the form of published research and commentary," wrote Elliott Management Partner and Senior Portfolio Manager Jesse Cohn. "As you consider the best path forward, we thought sharing some of this feedback would add value to your deliberations."

Read the letter here to peruse some of the many comments Elliott aggregated to try to press its case.

In addition, Cohn said the fund has "received feedback from athenahealth shareholders, both new and longstanding," that "has only intensified over the last few weeks. At this point, we have had dozens of conversations and have heard from a majority of athenahealth’s shareholder base."

While those conversations varied, he said, the general sentiment was that: "athenahealth should fully explore a sale process, including Elliott’s offer; athenahealth should attempt to solicit the highest price possible for the Company; shareholders are frustrated by historical execution and skeptical of the Company’s plan and ability to execute in the future; shareholders were profoundly upset to learn of the Company’s lack of engagement with Elliott’s prior efforts to start a discussion about a value-maximizing sale."

Response from athenahealth

For its part, the athenahealth board of directors released its own statement on Thursday in response to Elliott's exhortations.

The company "takes very seriously its obligation to protect shareholders and to take only those actions that are in the best interests of all shareholders," it said, "and will continue to take the time necessary to complete this review notwithstanding Elliott Management's attempts to publicly pressure the Board and management team."

The statement added that, "based on our discussions with shareholders, we do not believe the positions set forth in Elliott Management's letter are representative of the positions of all of our shareholders."

While reiterating that athenahealth would take the time it needed to get the best deal for its investors, the statement added: "We sit in the very early days of the digitization of healthcare and the company remains excited by its future."

Achieving Stage 7, the top stage, in the HIMSS Analytics Electronic Medical Record Adoption Model is quite a feat. It shows that a healthcare provider organization is playing at the top of its game in health IT.

Children's Mercy Kansas City has achieved HIMSS Stage 7 on the ambulatory side, joining an elite group of just 10.8 percent of health systems. The achievement comes with many benefits.

Achieving HIMSS Stage 7 required significant buy-in and collaboration from clinical and business leaders across the organization, said David Chou, chief information and data officer at Children's Mercy Kansas City.

"The stakeholders were required to unite around utilizing best practices in workflow and technology and renew the commitment to continuous process and technology improvements in order to pursue a safe, high-quality care for our patients and achieve this designation," he said.

"Physician, nursing, pharmacy, quality improvement, regulatory and compliance, radiology, HIM, decision support, and information systems and medical informatics leaders were a part of the core team that reviewed requirements, ensured risks were mitigated and that staff was prepared for the HIMSS Stage 7 discussions," Chou explained.

That common understanding of goals reinforced the health system's commitment to being united in its commitment to improve safety and quality of care for patients, he added.

EHR implementation continues to be a journey instead of a destination. Through projects such as the Stage 7 work, the hospital is able to reinforce the message in its organization that constantly improving process and technology leads to better patient care and operational efficiencies, Chou said.

"By building processes and a culture to support continuous optimization of our digital tools, we have streamlined workflows for staff, implemented tools that put our patients at the forefront and improved our quality of care, which has resulted in significant improvements of our outcomes and patient experience," he explained.

"Clinical leaders and business leaders see the value in continuous improvement after the project and are supporting additional improvements that will drive an improved patient experience," he added.

Children's Mercy Kansas City is ahead when it comes to leveraging analytics and dashboards to drive clinical decisions and to the adoption and integration of technology.

"As a result of implementing technology that allowed us to achieve HIMSS Level 7, we are well-positioned to adapt to the many demands of healthcare reform and coming changes in payment models," said Chou. "As a LEAN organization, we have been focused on True North success metrics for all areas of the hospital and building a culture of data-driven decision making."

With the technology implemented to support these initiatives, the distinction of achieving Stage 7 has been a benefit, he added.

Children's Mercy Kansas City is now working on achieving HIMSS Stage 7 for its inpatient side, said Laura Fitzmaurice, chief medical information officer. "We currently are evaluating our gaps with the newly released requirements," she said.

Whiteville, N.C.-based Columbus Regional Healthcare System announced it will deploy the cloud-based model of the Cerner Millennium EHR along with Cerner’s revenue cycle management technology and patient portal.

The announcement about signing up the 154-bed CRHS follows a spate of new hospitals Cerner landed recently, including Missouri Health, Menninger Clinic and Rankin County Hospital District -- not to mention the U.S. Department of Veterans Affairs officially signing its modernization contract on May 18. 

Kalorama Information reported earlier this month that Cerner has the largest EHR marketshare among leading vendors. KLAS Research also said this month that the electronic health record market is in flux, and pointed to smaller hospitals, many of which are “hungry for new technology,” among the reasons. 

CRHS, for its part, will deploy the technology across both its acute and ambulatory facilities to support clinicians as they work to streamline operations to improve patient care.

“With Cerner’s integrated EHR and commitment to interoperability, CRHS will provide patients with high-quality health services and a streamlined healthcare experience now and into the future,” CRHS interim CEO John Young said in a statement.

Cerner’s cloud-based platform will provide CRHS staff with a broader view of their patients’ health history that includes clinical and financial data. As part of the deal with Cerner, the hospital will also implement an online patient portal, giving patients access to their health records, the ability to contact their doctors and to schedule appointments.

Moving to Cerner Millennium is also expected to improve interoperability and communication between CRHS and its parent hospital network Atrium Health (formerly Carolinas HealthCare), as they will be on one integrated platform, the companies said.

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