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Why mHealth and Patient Engagement are Critical to the Future of Healthcare

Why mHealth and Patient Engagement are Critical to the Future of Healthcare | Healthcare and Technology news | Scoop.it

In the health IT industry, a lot of the focus on mobile health (mHealth) lies on the provider side—specifically how digital health tools are helping clinicians be more “mobile” within their workflows. In fact, this was precisely what HCI Senior Contributing Editor David Raths wrote about in this year’s Top Ten Tech Trends. This perspective is undoubtedly exciting and fascinating, and worth a read if you haven’t seen it already. But there’s another angle to mobile computing that has perked my interest lately—that being the care management side to mobile health tools, and how patients, in addition to providers, are using these technologies to improve their care.


Indeed, for the May/June issue of Healthcare Informatics, I wrote a fairly lengthy feature (now online!) on how mHealth tools are paving the way for better chronic care management. While doing my research for the story, I quickly noticed three important trends: First, the level of significance that provider organizations are putting on patient engagement shows how they are increasingly willing to adapt to the way healthcare is changing; Second, much of this engagement is starting to be done via mobile technologies; and Third, while the era of patient-generated health data (PGHD) is upon us, plenty of work is still needed for this type of data to be integrated into electronic health records (EHRs).


Regarding the first point,  as I wrote in the feature, according to findings of the 26th Annual HIMSS Leadership Survey, sponsored by the Chicago-based Healthcare Information and Management Systems Society (HIMSS) and released at the annual HIMSS conference this past April, “patient satisfaction, patient engagement, and quality of care improvement have raced to the top of healthcare CIOs’ and senior IT executives’ agendas in the past year, a stark change from previous years which found that health IT leaders were more focused on business and financial goals. Nonetheless, it’s been a struggle for physicians to truly engage their patients, especially the 45 percent of U.S. adults with at least one chronic condition, and particularly in underserved populations.”…As such, “another recent survey from HIMSS found that more than 90 percent of survey respondents are utilizing mobile devices within their organizations to engage patients in their care.”


Certainly, healthcare delivery is no longer limited to face-to-face encounters between patients and providers, a concept that has been pushed by the federal government when you consider their recent meaningful use Stage 3 proposals. In practice, there is clear evidence that mHealth tools can be effective for chronic disease management—a HIMSScase study gives an example of how this can happen in the real word. In Sacramento, Calif., a mother posts the results of her son’s latest round of treatment for neuroblastoma on a protected social network website. More than 2,500 miles away in North Carolina, a man who has been struggling to control his diabetes receives a text message from a health coach about a recent spike in his blood sugar level and asks what he ate for breakfast. Every day, from every corner of the United States, people are turning to mobile technologies to help them understand, manage and cope with chronic illness. According to the Pew Research Internet Project, 72 percent of Internet users look online for health information and one in three cell phone owners have used their phone to access health information.


Leading provider organizations such as Duke Medicine and Stanford Health Care are following this trend, using mobile tools to improve care, both of which I wrote about in the feature. Another innovative patient care organization, the New York City-based Mount Sinai Hospital and LifeMap Solutions, also in New York, recently announced the launch of a large-scale medical research study that uses Apple’s  ResearchKit to help individuals who suffer from asthma to participate in studies right from their iPhone.  The Asthma Health app is designed to facilitate asthma patient education and self-monitoring, promote positive behavioral changes, and reinforce adherence to treatment plans according to current asthma guidelines. The study tracks symptom patterns in an individual and potential triggers for these exacerbations so that researchers can learn new ways to personalize asthma treatment, officials say.


While Duke and Stanford have been slowly progressing with integrating this data into EHRs, in a recent interview, Yvonne Chan, M.D., Ph.D., director of personalized medicine and digital health at the Icahn Institute for Genomics and Multiscale Biology at Mount Sinai, told me that the Asthma Health app is in the research phase now and that when it comes to care management, it’s important to take baby steps. “This is the very first step. We are essentially collecting information, developing algorithms, and the next phase is further validated before you can start providing actual medical management feedback,” she said. “Integrating this into the EHR is something we definitely want to do down the road.”


Even the organizations that are incorporating patient-generated data into EHRs are doing it slowly, with plenty of challenges. Still, the market for wearable technologies continues to grow with a seemingly limitless future— market researcher Visiongain recently assessed that the value of the global wearables technology market will reach $16.1 billion by the end of this year. Other analysts predict that the wearables market will grow tenfold to $50 billion over the next three to five years.

And for certain healthcare organizations, the opportunities to leverage the wearable data go beyond just tracking. Nick Reddy, senior vice president of information system investments at the Dallas-based Baylor Scott & White Health, touches on this point in an interview featured in this year’s Top Ten Tech Trends on consumer-generated data. “The prevention side of healthcare is where the clinically-relevant things are happening, compared to just the 10 steps that are tracked by a wearable device. “We want to spin business intelligence and analytics on it,” Reddy said. “If you’re a diabetic and you haven’t been walking your steps or taking your [metmorfin], let’s flag you so your case manager can intervene. That’s where our roadmap is taking us,” Reddy said, referring to the Baylor Scott & White Quality Alliance (BSWQA), a 3,700 physician-strong network that is one of the largest accountable care organizations (ACOs) in the country.


At the core of all of this—patient engagement, mHealth tools, and EHR integration—is one very important factor: the patient, or as some now call us, the “consumer.” Are we ready for this type of engagement and activeness in our own care to be able to lower costs and improve health outcomes through the use of mobile tools? I think we’re certainly on the way there—and if you look at how the federal government wants to shape the healthcare industry—we better be.

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Engage Patients through Medication Education

Engage Patients through Medication Education | Healthcare and Technology news | Scoop.it

Patient engagement was one of the main buzzwords at HIMSS this year. It’s the kind of topic that can ignite a passionate game of tug-of-war. Some folks define patient engagement to patients accessing their health records or securely messaging their doctors. Others consider patient engagement as medication adherence, a reduction in readmissions, or even the use of mobile health apps.

From a patient’s perspective, a common place to “engage” is at the pharmacy, when they receive drug directions that are more than an arm’s length and include pages of side effects and warnings. Like many notoriously long Terms and Conditions agreements, a common response to these details is to just tune them out.

It’s a tough pill to swallow, but one in three Americans are considered low health literate and struggle to understand their often complex medication instructions. Medication mistakes are the most common form of medical errors in the U.S., resulting in 3.6 million office visits, 700,000 emergency room visits, and 117,000 hospitalizations each year, according to an Institute of Medicine report.

It should come as no surprise then that health literacy is strongly tied to patient engagement. When patients understands their condition as well as how to manage it, they are more empowered to make better health decisions.

One company is not satisfied with the status quo and is flipping the traditional model of disseminating drug directions on its head.
They’re turning this:

Meducation instructions are written at a 5-8th grade reading level, clearly identify drug, dose, time of day, explain what each drug is for, and even link to video tutorials for the more complicated directives, such as how to use an inhaler or give an insulin shot. Meducation is available in 22 languages and in larger fonts. It can be printed onto a single sheet and posted on the fridge or patients can enter the barcode number assigned to them on the website to access supplemental education materials.

Turns out that when patients have a better experience with their directives, they are safer, they have better outcomes, and their provider’s satisfaction scores go up. It’s a win-win.


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The fallacy of patient engagement

The fallacy of patient engagement | Healthcare and Technology news | Scoop.it

You may have noticed the absence of my usual posts to HealthBlog. Here’s why. I was preparing for an out of town business trip on Monday of last week when I learned that my adult daughter needed an emergency appendectomy. As coincidence would have it, my business trip just happened to be to a city very close to where my daughter lives. I was able to keep my business meeting in the morning and still arrive at my daughter’s apartment soon after she was discharged from the hospital. I spent the rest of the week helping her get in and out of bed, doing some cooking, walking her dog, and making sure that she was well enough to be on her own before I headed home.


It’s at times like this that one is very grateful for access to good healthcare. After all, there was a time before modern surgery and the availability of antibiotics that appendicitis was often a death sentence. Today, that rarely happens if the patient receives timely care.


There’s no question that when we are in pain, injured or very sick that we are “engaged” patients. Not only is the patient engaged, but often his or her entire family. The problem is that when we are well again, we tend to disengage and fall back into our usual routines. The fact of the matter is that most people really don’t spend all that much time with doctors and hospitals. Most care happens in the home, and most of the contributors to good health are determined more by our genetic makeup, diet, socioeconomic status, education, exercise and other environmental factors than by the things that doctors and hospitals do in our lives. For most people, encounters with doctors and hospitals are  episodic and infrequent. So, when hospitals and health systems speak of the need for greater “patient engagement”, what does that really mean and how can it be accomplished?


As a physician I know from the get-go that patient engagement is hard to achieve. First of all, we need to understand that healthcare is something most people view as a kind of “grudge buy”. Just as I dread going to see my dentist, I also don’t particularly enjoy anything about visits with my doctor. While both my dentist and doctor are very nice human beings, the reasons I go so see them aren’t on my list of fun things to do. I imagine most people feel the same way. Likewise, I suspect most people hate paying medical bills. Who wants to pay for something they don’t enjoy? One person I recently met likened buying healthcare services to purchasing tires for her car—necessary but definitely not satisfying.


Engagement is made even worse by the fact that medical billing is such a nightmare and paying for, and dealing with, health insurance companies is absolutely no fun at all. The insurance industry long ago trained most of us to expect someone else (government or insurance) to pay for a lot of the healthcare services we received. Now the tables have turned. More and more of our healthcare costs are not covered by insurance until we reach a yearly high deductible. This has consumers feeling even more disgruntled about doctors and hospitals and high healthcare costs. Is it any wonder that people are not “engaged”!


I think the way to engage patients or consumers is to really help them understand the things they can do to avoid any more “engagements” with doctors and hospitals than are absolutely necessary. Show them the connection between the unhealthy choices they make and the chronic diseases and health encounters they would much rather avoid. Create financial incentives to help people stay healthy. Develop technologies that ease the pain of engaging and interacting with the health system when one must do so, and help consumers avoid as many unnecessary medical visits and costs as possible. I’d like to see doctors and hospitals acknowledge that they totally understand they are not on our list of the people we like to see and places we like to go, and that they are doing everything possible to help us take better care of ourselves so we can avoid doing business with them as much as possible. Now that is a cause that just might get me “engaged”.


How about you?


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Patient Monitoring Market To Exceed 5 Billion By 2020

Patient Monitoring Market To Exceed 5 Billion By 2020 | Healthcare and Technology news | Scoop.it

An iData Research survey has projected the patient monitoring market will exceed $5 billion by 2020 as a result of double-digit growth over the next five years in the telehealth market. The study also predicts that telehealth for disease conditions management will comprise more than 50 percent of the total telehealth market, driven by increased chronic illness in an aging population, increasing demand for customized healthcare solutions, and financial pressures due to overburdened healthcare budgets.

“The goal of telehealth is to prevent hospital readmission, reduce in-office visits, better manage health of individuals with long term conditions and reduce costs for more remote and isolated health care providers,” Dr. Zamanian, CEO of iData explained.

Market growth is anticipated to be “further bolstered as awareness and implementation of standards for reimbursement and adoption of this type of care management increase,” according to iData, as public and private organizations each are expected to increase funding for telehealth expenditures as a fiscally responsible and efficient solution.

As Health IT Outcomes reported, there are three major hurdles for telehealth adoption including reimbursement, federal standards, and licensure. A policy report from ML Strategies explains, “Current federal law is extremely restrictive on how telehealth is paid for – resulting in a disincentive to provider adoption.” Restrictions only allow reimbursements for patients who receive virtual care at rural clinics and not in metropolitan areas.

However, some progress is being made in the area of telehealth reimbursement. For example, Governor Andrew Cuomo recently signed into law legislation that would require Medicaid to reimburse for telehealth service costs in New York. And in November, CMS issued a final rule updating physician fee schedules and boosting payments for telehealth services. This trend indicates there is growing recognition of the cost effectiveness and success of telehealth services in overall patient care and outcomes.

Other barriers still remain, including the fact that no federal telehealth standards are in place with each state having its own regulations. As ML Strategies explains, “Currently, there is no federal standard of clinical guidelines for telehealth,” creating a “patchwork of state laws that inhibit the proliferation of telehealth solutions in both the public and private sectors.” As telehealth grows in popularity, however, federal regulations will become necessary in order to guarantee consistency.

The final barrier to telehealth growth, according to the ML Strategies report, is licensure, as it raises issues of flexibility if a patient wishes to consult a telehealth provider across state lines. “With the advent of telehealth, licensing of health providers must be updated to reflect the flexibility provided by telehealth – allowing healthcare experts to bring their expertise virtually to where it is needed, even across state borders,” notes the report.

Nevertheless, despite the obstacles, the telehealth industry is set for unprecedented growth by 2020 as iData Research has asserted. According to a survey of senior healthcare executives released by law firm Foley & Lardner, “The reimbursement landscape is already changing, and there are many viable options for getting compensated for practicing telemedicine,” said Larry Vernaglia, chair of Foley’s Health Care Practice. “The smartest thing organizations can do now is to continue developing programs, and be ready for the law to catch up – because it will.”


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Patient Monitoring Market To Exceed 5 Billion By 2020 
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Patients have changed. How do we manage them?

Patients have changed. How do we manage them? | Healthcare and Technology news | Scoop.it

In the past half century or so, medicine has changed the complexity of the human population as it has never been seen in the past. Think about it, there are people walking around today that fifty years ago, wouldn’t even be alive.   This evolution in medicine has not only brought about transformation in the human population, but it is also changing the approach of how clinicians need to treat these complex patients.


Traditional medicine has always focused on a single cause for a particular disease, without any consideration towards multiple risk factors and co-morbidities (a concomitant but unrelated pathologic or disease process). For this reason, clinical practice guidelines may not be able to address a particular patient’s needs if the patient has more than one medical issue that they are dealing with simultaneously.

My concern is that clinical outcome studies may not give a true representation of the type of patient many of us are seeing in our practices. This is because patients with multiple co-morbidities or multi-morbidities are on the rise, as diseases that were once considered death sentences are now seen as manageable. However, in many clinical trials, patients with other illnesses are usually excluded from these trials. Unfortunately, those of us in clinical practice do not have the luxury of excluding patients with multi-morbidities making these clinical trials/guidelines inadequate to manage patients.

Interestingly enough, the United States has been, for decades, in the forefront of dealing with multiple co-morbidities as opposed to the rest of the world, and is probably the leading cause of increased healthcare costs here in the United States, as opposed to other countries. However, the rest of the world is catching up to us at a rapid rate as medical technology and poor dietary habits become more available throughout the world.

For instance, it is predicted that by 2030, over fifty percent of the obese patients in the world will be from China and India combined. Also, right now, the rapidest growth in obesity is not here in the U.S. but is occurring in Europe and Asia, mostly due to the rapid expansion of fast food markets in those areas.

The question now becomes: How do we manage this new type of patient?

The first thing is for clinicians to have a better understanding of how multi-morbidities can affect a patient simultaneously. This is going to require better history taking and a better understanding of how disease processes work. In addition, the clinician is going to have to be aware of poly-pharmacy and drug-drug interactions.  This can be accomplished by listening and establishing a dialog with the patient. Unfortunately, many clinic guidelines do not allow for this, but it must change if we are to be successful.

Second, it is my belief that there should be more emphasis on case studies where complex patients are described and how the clinician or clinicians successfully treated that patient. I believe this because in my thirty years of practice, no two patients have ever presented the same way or responded exactly the same way.

Thirdly, there needs to be a change in the medical education system with a better understanding of how all these multi-morbidities will impact a patient. This will not be easy to test considering that testing has always been driving towards a more traditional single-disease approach. Regardless, it must be done if we are to succeed.

As I have said before, the human race is evolving, and medical technology has been a major factor in this evolution. The old model of medical management is no longer able to help many patients, so it is now time for medicine to evolve to meet this new challenge.


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8 Ways to Improve Patient Satisfaction, Patient Experience And (By The Way) HCAHPS Scores

8 Ways to Improve Patient Satisfaction, Patient Experience And (By The Way) HCAHPS Scores | Healthcare and Technology news | Scoop.it

In light of Medicaid’s announcement that it may expand the use of Child HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) results, let’s do a roundup of what actually increases patient satisfaction and improves the patient experience, for hospital systems, primary care providers, and ambulatory care centers alic.

Although I feel that these CAHPS assessments are a largely positive development, it’s also true that patient satisfaction and the patient experience can suffer if your institution takes the wrongheaded approach of trying to “game” the assessment process, of aiming too narrowly for success on the specific questions asked in the assessment.

The power of the halo effect

A better approach is to look at the survey questions only as they fit within your broader attempt to create an overall experience of caring that will in turn translate into better responses on the individual assessment questions due to a positive “halo effect.”  The halo effect I’m referring to is the tendency of humans–including patients and their loved ones–to cut you slack when they have a generally positive impression of you, how a positive experience with you will spread in their minds (and in their survey responses) to areas where, literally speaking, your institution may not have been entirely up to snuff.

“Always” is impossible–but if patients love you, they’ll cut you some slack

Consider an assessment question where your goal is to have an answer of “always” (for example: “During this hospital stay, how often were your room and bathroom kept clean?”). Always kept clean” is, strictly speaking, an impossibility. Not even a five star hotel can achieve that level of housekeeping; they may tidy your room three times a day, but that’s plenty of time to trash it in between. Yet it is possible to get an “always” response from a patient. Because the way patients remember is more holistic than you think it is.  An overall extraordinary experience with your facility and organization will subliminally inspire a patient to cut you slack while a generally poorly treated patient is going to grade you literally on your survey. And a literal reading of/response to the HCAHPS survey questions isn’t going to turn out all that well for anyone.

Here, therefore, is a roundup of my suggestions for how to improve patient satisfaction and the patient experience–and, as an aside, improve your HCAHPS scores. 

1. If you want to stem patient dissatisfaction, stop giving off cues of indifference and uncaring.   Such as: Healthcare professionals avoiding eye contact with “civilians.” Med students hurrying self-importantly down the halls, nearly running down the slow-moving patients who won’t get with the program.  Patients ignored by nurses who haven’t yet clocked in and therefore don’t realize they are already (poorly) representing their institution. Doctors in the hallway loudly carrying on about the relative benefits of different Canyon Ranch vacations they’ve taken. Two radios playing at once from two administrative areas (with the waiting area for patients and their families located equidistant to both). Vending machines that are left out of service indefinitely. Vending machines that require exact change, but there’s no change machine.

2.  Strive actively to experience your care the way that your patients do.  Park where the patients do.  See how easy it is/isn’t to get to the front door on crutches.   Take a tour of your hospital with someone who hasn’t been there before, and let them show you whether they can really find where they’re going.  You’ll be amazed how many mis-aligned, out of date, confusing signs you have. It all makes intuitive sense to you, of course, because you have been in your building enough times that you know your way around in your sleep (Literally, I suspect.)  And, once a year, do a “full bladder exercise”: Everyone who works with patients should drink two or three liters of water–it is incredible how your perception of a “reasonable delay” between call button and response changes when you have a full bladder.

3.  Get every employee thinking about purpose, not just functions. A particularly crucial aspect of great patient service is ensuring that every employee—from orientation onward –understands her particular underlying purpose in your organization and appreciates its importance. An employee has both a function—his day-to-day job responsibilities—and a purpose—the reason why the job exists. (For example, ‘‘To create successful medical outcomes and hospitable human experiences for our patients” is a purpose.   “To change linens” is a function. A properly trained and managed employee will know to—and will be empowered to—stop changing linens if creating successful medical outcomes or being hospitable require a different action at the moment. And afterward, she will be celebrated for doing so, not scolded for being a few short in the number of linens changed.

4. “Sorry” may be the hardest word, but it’s a word that everyone on your team needs to learn.  Resolving patient issues means knowing how to apologize for service lapses pointed out by a patient. It means getting rid of the defensiveness (or, at best: apathy) that tends to mar the healthcare industry when confronted by a patient upset with what she perceives to be a service gaffe. Instead, take your patient’s side in these situations, immediately and with empathy, regardless of what you think the “rational” allocation of “blame” should be. And spread this approach throughout your staff through role-playing and other training devices, so it will serve you fully every time a patient hits the fan.

5. Teach your employees – every single one – how to handle a patient or family member’s complaint or concern.   Even if handling the concern means “I’m finding you someone right now who can address this” it’s far better than “I can’t help you, I’m the wrong person.”

6. If you want to improve, strive to create a blame-free environment. As the founder of the Ritz-Carlton is fond of saying, “If a mistake happens once it may be fault of employee. If it happens twice, it is most likely the fault of the system.”  So, they get to work fixing the system. This blame-free system has worked to help The Ritz-Carlton build a great culture, and it can do the same for your hospital.

7. Understand that improving patient satisfaction is about systems just as much as it is about smiles.  When we discuss improving patient satisfaction and the patient experience, physicians often think we are going to focus on making them “smile harder.” While genuine warmth and smiles are of value here, so are systems. For example, when Mayo Clinic overhauled their scheduling system they employed (according to the great Leonard L Berry) industrial engineers using stopwatches to time wheelchairs between appointment locations in order to ensure that correct scheduling algorithms were created.

8. Benchmark outside healthcare. One of the biggest obstacles to improving the patient experience in healthcare is the industry’s insular nature and the way this makes its problems self-reinforcing. In other words, healthcare providers and institutions compare themselves to each other – to the hospital in the next town, the surgeon in the next O.R. – and benchmark their customer service accordingly. And to do so is to set the bar too low.  It’s not as if patients stop being consumers – customers – when they put on a hospital gown. And it’s not as if their loved ones surrender their identities as businesspeople, twitterers, Facebook users, either, when they enter your institution. So, it’s time to benchmark healthcare customer service against the best in service-intensive industries, because that’s what your patients and their loved ones will do. Every patient’s interaction with healthcare is judged based on expectations set by the best players in hospitality industry, the financial services industry, and other areas where expert players have made a science of customer service.


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Doctor Who? When Men Skimp on Physicals

Doctor Who? When Men Skimp on Physicals | Healthcare and Technology news | Scoop.it

If you're like a lot of guys, you probably haven't had a physical in a while. Men are 24% less likely than women to have seen a doctor in the past year. Yet men are more likely to check into the hospital for congestive heart failure, diabetes -- related problems -- and pneumonia. These are all issues that you might prevent with checkups.

Now, you don't have to go every year, but if it's been more than 2 years since you've seen your primary care doc, it's probably time to make that appointment.

What happens at a physical and how often you need one depend on your health and your age. The physical itself is a head-to-toe exam, and men over 50 can expect a rectal exam to check for prostate problems, intestinal bleeding, and early signs of prostate and colorectal cancers.

A typical visit also includes a blood pressure check, which you should have at least every 2 years, and giving blood samples. Doctors use blood tests to check for diabetes and cholesterol level. Adults older than 20 who don't have risk factors for heart disease should have their cholesterol checked every 4 to 6 years. Adults who are overweight or have high blood pressure should get a diabetes screening test.

Chronic diseases and cancers may not show any symptoms at first, but you stand the best chance of curing or managing them when your doctor catches them early.

"Somebody may have severe diabetes and not have any symptoms, so certainly there's opportunity to turn some of those things around if they're detected early," says Clark T. Eddy, DO, of ProPartnersMD. That's a medical group in the Kansas City area that specializes in men's health.

During your checkup, you'll answer questions that can help your doctor see signs of depression or habits that might be a risk to your health. Depending on your lifestyle and personal and family history, your doctor might suggest more tests. The doctor will also recommend vaccines based on your age and lifestyle.

"Even if you haven't been to a doctor in 20 years," Eddy says, "coming in for a physical is the first step to being a more active participant in your health."

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Patient Engagement May Reduce Healthcare Reform Anxiety | EHRintelligence.com

Patient Engagement May Reduce Healthcare Reform Anxiety | EHRintelligence.com | Healthcare and Technology news | Scoop.it
How can greater adoption of patient engagement tools help to alleviate uncertainty about the future of healthcare reform?

Adopting more robust patient engagement technologies may help providers and patients alike find their way out of pervasive anxieties about the future of the healthcare industry – if physicians can lead the way.  According to a survey performed by Booz Allen Hamilton and Ipsos Public Affairs, few industry stakeholders are satisfied with the way healthcare is headed, but believe that preventative care, backed by patient engagement technologies, mobile apps, and care coordination, may help them find the way forward through a complicated maze of financial and administrative changes.

“Physicians, especially the older ones and the specialists, have to move into a whole new world, and they are concerned that it’s making their life a lot more complicated than it used to be,” said Nicolas Boyon, Senior Vice President at Ipsos Public Affairs, in an interview with HealthITAnalytics.  “It is partly generational.  The average age of practicing physicians in the US is actually slightly over 50, and specialists tend to be even older.  A lot of physicians started practicing when the world was very different.  They view their role, first and foremost, as caring for patients, and technology was not necessarily what they specialized in or learned a lot about in medical school.”

“It’s curious to see the level of anxiety out there,” added Grant McLaughlin, Vice President at Booz Allen.  “When you look at behavior change, anxiety is often lessened when there is a path.  We’re in a time of uncertainty as Affordable Care Act is being rolled out and new care models are being tested.  We may not necessarily have an endpoint clearly in view, and I think that causes anxiety.”

While physicians do not generally believe that current mobile apps and other patient engagement products are up to the challenge of providing valuable and medically sound information and tools to the patient population, there is a widespread interest in such technologies among consumers.  Patients are seeking a higher degree of convenience, more control over their own health, and more efficient ways to stay connected with their providers, conduct administrative tasks, and review their own health data, the survey revealed.

“Once you actually find an app that you can use, and you use it every day to help you do something, and you find the value in it, then it has become invaluable to you.  You absolutely cannot live without it,” McLaughlin said.  “That’s what we’re struggling with.  We’re seeing lots of technological inventions, but how do we add value in the context between the consumer and the provider?  If we can get to the crux of how to make the conversation between consumers and providers more valuable, and if technology can enable that, then I think we’ve struck gold.”

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Only 1.4% Of Physicians Are Ready To E-Prescribe Controlled Substances, Report Finds

Only 1.4% Of Physicians Are Ready To E-Prescribe Controlled Substances, Report Finds | Healthcare and Technology news | Scoop.it

As deaths involving prescription opioids increase, prescribers look toward other ways to curb patient overdoses. One fairly new solution in the medical community is to prescribe controlled substances electronically, but just how far along is this revolutionary approach, and will it help combat the ever-growing opioid epidemic in the country?

Health information network provider Surescripts on Tuesday released the results of research focusing on health data transactions in 2014. The report, titled the “2014 National Progress Report,” reviewed how prescribing controlled substances electronically could potentially diminish prescription fraud and abuse in the country.


The Centers for Disease Control (CDC) found that there were 16,235 deaths involving prescription opioids in 2013, an increase of 1% from 2012. In response, the CDC launched several initiatives. One of them included a campaign, titled “When the Prescription Becomes the Problem,” last month at the fourth annual National RX Drug Abuse Summit. The social media activity, designed to raise awareness of prescription painkiller abuse and overdose, ended on May 15 of this year. President Obama’s drug control priorities for the upcoming fiscal year included reducing prescription drug and heroin abuse by allocating additional funding to states with prescription drug monitoring programs (PDMPs), expanding and improving treatment for addicts, and spearheading efforts to make naloxone more readily available to first responders.


Dr. Sean Kelly, chief medical officer at Imprivata and emergency physician at Beth Israel Deaconess Medical Center in Boston,said in an interview that electronic prescribing of controlled substances (EPCS) has the potential to improve care, reduce fraud and identify potential evidences of abuse by “creating a secure, auditable electronic transmission directly from the prescriber to the pharmacy.”


“With EPCS, a paper prescription and a physician’s DEA number are never in the hands of the patient, which minimizes the risk of fraud or theft,” he said. “EPCS also improves care for patients with legitimate needs by reducing both wait times at pharmacies and the number of trips they need to make to the doctor’s office.”


He added: “EPCS also improves care by reducing prescription errors and inaccuracies.”


Prescribing controlled substances electronically can only effectively combat opioid abuse, misuse and overdose if both prescribers and pharmacies are willing to hold up their part of the deal — but that doesn’t seem to be the case. Nearly 75% of pharmacies across the country are ready to receive electronic prescriptions for controlled substances, the report found. Their counterparts are not: Only 1.4% of controlled substance prescribers are set up for EPCS.


EPCS for controlled substances is still in the early stages of development, and this is one of the main reasons why prescribers are slow to embrace this new kind of technology, Kelly said. This, however, shouldn’t worry early adopters.

“This is similar to the early days of e-prescribing for non-controlled substances,” he said. “Initially, it was a new technology that providers were unfamiliar with, but because it significantly improved efficiency and the delivery of care, it has gained rapid adoption.”


Even though physicians seem hesitant, the practice of prescribing controlled substances electronically is growing. The study reported a 400% increase in controlled substance e-prescriptions in 2014, totaling 1.67 million nationwide.


Every state in the country handles combatting the opioid epidemic in its own way. Despite only 53% of primary care physicians using prescription monitoring programs (PMPs), the majority of state governments have continued to support them. Structural differences hinder EPCS adoption. To rank states on their readiness to prescribe controlled substances electronically, Surescripts looked at several factors: the percent of enabled pharmacies, the percent of enabled prescribers and the percent of controlled substances prescribed electronically. The study found that Nebraska, California and Michigan are best equipped to handle e-prescribing of controlled substances.

“Total EPCS transaction volume is still so low across the board, so it’s difficult to say why some states are doing better or worse than others,” said Paul Uhrig, chief administrative and legal officer, and chief privacy officer at Surescripts. “But it seems to mostly hinge on whether or not a state government makes it a priority. The elimination of regulatory barriers and the implementation of legislative mandates have been the primary drivers of the adoption of EPCS.”


He added: “This means we need to work collectively, across the industry, to educate and inform all stakeholders in order to drive utilization of the technology.”


As investments in technology to improve delivery and patient care continue to grow, prescribers will become more selective. “This means that it must enable, not impede, the delivery of care,” Kelly said. “If the technology is developed and implemented in such a way that it fits easily into providers’ existing workflows, EPCS can gain widespread adoption as a formidable weapon in the fight against prescription drug abuse."


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Patient Satisfaction and Patient Engagement Race to the Top of CIOs’ Agendas: HIMSS Leadership Survey

Patient Satisfaction and Patient Engagement Race to the Top of CIOs’ Agendas: HIMSS Leadership Survey | Healthcare and Technology news | Scoop.it

Patient satisfaction, patient engagement, and quality of care improvement have raced to the top of healthcare CIOs’ and senior IT executives’ agendas in the past year, according to the industry’s leading executive survey. Those were among the findings of the 26th Annual HIMSS Leadership Survey, sponsored by the Chicago-based Healthcare Information and Management Systems Society, and released at a press briefing held Monday morning, April 13, at the vast McCormick Place Convention Center in Chicago.


At that same press briefing, HIMSS senior leaders announced that attendance at the HIMSS Conference this year had reached an all-time high, at 41,044, versus the 35,509 at HIMSS14 in Orlando, or an increase of 15.5 percent, based on Sunday evening registration numbers. What’s more, 1,326 vendors are exhibiting this year, versus 1,211 last year. And the entirety of the space that the annual conference is taking up, HIMSS senior executives announced, was more than 541,000 net square feet at McCormick Place. The gross square footage of the conference, or 1.3 million square feet, said Carla Smith, executive vice president-HIMSS North America, is actually larger this year than the Willis Tower, Chicago’s tallest building, is tall.

With regard to the HIMSS Leadership Survey, most dramatically, respondents ranked “improve patient satisfaction” and “improve patient care/quality of care” as their top business objectives, both at 87 percent, and above “sustain financial viability,” at 85 percent; “improve care coordination,” at 76 percent; “improve operational efficiency,” at 72 percent; “improve physician satisfaction,” at 68 percent; “achieve meaningful use,” at 68 percent; and “increase market share,” at 66 percent. Jennifer Horowitz, HIMSS’ senior director of research, in response to a question from Healthcare Informatics regarding the unprecedented nature of this survey result, noted that the methodology of the survey has changed in this year’s survey, compared to last year’s.


This year, Horowitz noted, survey respondents were asked to rate on a scale of 1 to 7 (7 being the highest), various items on a list; whereas last year, respondents were asked to rank items. Still, the contrast with the results of the 2014 survey is noteworthy, despite the methodological difference in question-asking. Respondents to the 2014 survey ranked the following as their top business objectives: “sustaining financial viability” (25 percent); “improving operational efficiency” (16 percent) “improving the quality of care” (14 percent); “achieving meaningful use” (14 percent); and “increasing market share”(10 percent).


Among a panel of four senior healthcare IT leaders, Paul Kleeberg, M.D., CMIO of the Bloomington, Minn.-based Stratis Health and clinical director for the Regional Extension Assistance Center for HIT (REACH), a REC serving Minnesota and North Dakota, commented that “I think what’s really driving that [survey result] is the Stage 2 requirements to get patients engaged and achieve 5 percent patient engagement according to that meaningful use measure, which I think is a good thing. It’s raising awareness,” he added.


William W. Feaster, M.D., CMIO at CHOC Children’s Hospital, Orange, Calif., added, with regard to the connection between patient engagement and population health, that his organization is involved in a concerted push around both. “Our focus right now is really what this survey is saying,” he said, adding that there are four keys to achieving success in those broad areas. “The first is how you communicate data about care. The second one that we’re really starting to engage in, more than just standing up a portal, is patient engagement. We’re not going to improve the health of populations unless we can engage patients. It’s a bit easier as a children’s hospital, because what parent isn’t engaged in the health of their child?” The third and fourth keys involve organizing data and information about patients via such mechanisms as patient registries; and engaging in concerted care management.


This year, for the first time, survey respondents were asked the degree to which they could credit the ability of IT with helping them to achieve success in a variety of areas. Seventy-four percent of responded said IT was helping their organizations achieve success in care coordination; 73 percent said it was helping them with mandated quality metrics improvement; 69 percent said it was helping them to achieve primary care provider efficiency; and 58 percent said it was helping them to be successful with patient experience management.

When asked what IT strategies they were pursuing for engaging patients, 87 percent reported that they were providing a patient portal to their patients; 82 percent were using an organizational website; and 57 percent were leveraging social media.


With regard to staffing and budgets, 49 percent of respondents said their staffs were growing; 35 percent said their staffs were neither growing nor shrinking; and 11 percent said their staffs were shrinking. Meanwhile, 62 percent reported that their IT operating budgets were increasing; 21 percent were seeing no change; and 11 percent had budgets that were decreasing.


In addition to the broad survey findings, HIMSS’ Smith noted that more than 50 percent of U.S. hospitals are now in Stages 5, 6, or 7 according to the HIMSS Analytics EMRAM schematic.


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Myriad Resources Devoted to Patient Engagement Improvements

Myriad Resources Devoted to Patient Engagement Improvements | Healthcare and Technology news | Scoop.it

The healthcare sector and world at large is moving farther away from paper-based sources of information to digital communication. More and more patients are now using portals to access their own medical records. Patient engagement is a key endeavor for the healthcare industry.


The Wall Street Journal reports that patient portals enable patients to securely message their physicians, schedule appointments, view laboratory test results, and even refill their prescribed medications. Additionally, the OpenNotes pilot programs are assisting about five million patients throughout the US by enabling them to read their doctors’ notes through their portals.


Author Dr. Robert M. Wachter explains that, while many were concerned that patient portals would lead to confusion or even depression among patients, early results show that the opposite may be true.


The OpenNotes pilots, for example, allow patients to catch any data errors and creates a greater self-care environment. Doctors’ fears of the program causing time delays and conflicts with patients were also unfounded. As more technology companies enter the market, patient portals are expected to become more user-friendly and refined.

The healthcare sector is only steps away from ensuring that medical records from a variety of hospitals and providers are seamlessly integrated into patient portals. Wachter goes on to predict that telemedicine tools will also be incorporated into these portals.

Patients will more often visit their doctors virtually and a copy of the recorded video will be stored privately and securely on their portal system. Both doctors and patients will be able to review this video at any point in time. The portals will also include educational resources, reminders, and other wellness-based encouragement tools, Wachter explains.


Additionally, there’s hope that patient portals will be able to provide information on billing including how much a certain test or treatment costs and how much a health insurance plan will cover it.

Patient engagement efforts are being pursued in healthcare organizations across the country. For example, the Robert Wood Johnson Foundation bestowed a grant to Partners HealthCare in order to develop and promote an ‘Engagement Engine.’


This technology would enable the use of health and activity trackers, which promote engagement with physical fitness. Essentially, the ‘Engagement Engine’ will promote better patient health outcomes in the overall population. Encouraging consumers to integrate mobile health and wellness technologies could help improve population health standards.


“Better understanding of preventative care is extremely important,” Kamal Jethwani, MD, MPH, Senior Director of Connected Health Innovation at Partners HealthCare, said in a public statement. “Our patients are also consumers, and this engagement tool will allow us to interact with them in a new way, helping prevent the onset of chronic disease by enabling them to adopt healthy lifestyles.”


Big data analytic tools will be integrated into the ‘Engagement Engine’ to provide customized feedback among users. These type of developments are going to play a major role in expanding patient engagement among the healthcare sector over the coming years.


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Searching for Creative Patient Portal Solutions

Searching for Creative Patient Portal Solutions | Healthcare and Technology news | Scoop.it

This year, as you may already know, both hospitals and physician practices participating in Meaningful Use must offer patients a way to access their health records electronically. The patient electronic access objective specifically calls for providing patients the ability to view online, download, and transmit their health information. Those familiar with this objective often call it VDT for short.

Although having a patient portal is a requirement of Meaningful Use, it’s not required to be helpful, relevant, responsive, attractive, or even usable. It’s just got to be “there.”

From a patient’s perspective, there are plenty of reasons to delay logging on, even beyond the well-documented reasons of not having an email address or access to the internet. Many patients have no idea what to look for on the portal and if they don’t understand the benefits of having access to their medical records, why should they care? Frankly, a bad online experience could seriously hurt a practice’s chances of meeting their VDT goals.

So What Works?

Everyone’s trying something. Here are some strategies practices are implementing:

  • Offer more amenities on the portal: the ability to see statements, pay bills, schedule visits, or access educational materials specific to the patient’s conditions.
  • Instead of listening to smooth jazz while on hold,  patients are given instructions on how to access the portal and told about what information they will find there.
  • A TV monitor on the wall of the waiting room cycles through testimonials about how convenient it is for patients to schedule, access their records, or email their doctor.
  • Signage is in place throughout the facility including hallways, triage rooms, exam rooms, bathrooms, elevators, stairwells.
  • Staff members are trained to talk articulately about the portal starting at check-in and at each point along the visit – because face it – if staff don’t buy-in to the benefits of the portal, then patients certainly won’t.
  • Offer tablets or other hand-held devices for patients to log in to the portal before they leave the office. Make sure staff are ready to help if patients have questions.
  • Do some investigative work – start taking notes about what patients call into the practice about most. Then find out if you can address these issues in the portal. This could automates a task for your staff while simultaneously addressing a need for your patients.

There are lots of challenges to getting patients to engage online, no doubt. But that means there’s a lot of opportunities for creative solutions.


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The key to medicine is to love our patients

The key to medicine is to love our patients | Healthcare and Technology news | Scoop.it

I have issues with the customer satisfaction paradigm, but it’s not generally hard to make patients happy. Sometimes, though, it can be nearly impossible. It all depends on our own inner life as physicians and human beings. The key to medicine, to being a beloved physician, is to love our patients.


This can be a tall order. Human beings are remarkably difficult to love. They are often angry, uncommunicative, cruel, manipulative, and dishonest. (And that’s just the doctors!) Humans resist love almost as fiercely as they desire it. They push one another away with profanity. They anger each other with attitude. They pick until someone lashes out. They remind us of our own human frailty.

So how do we do it? How do we love these people, especially when they come to us in the chaos of our work in the ED? How do we love them when we are weary and they have strange complaints at 2 a.m.? How do we love them when, despite our suggestions on all of their previous visits, they continue to ignore our advice, not take their prescriptions, and not change their lifestyles? Can we love them at all?

It depends. Do you think that loving them means having warm emotions for them? Do you think it means feeling good about them? Or is it having a satisfying relationship with them? If so, loving will be difficult. Because we in the modern West have excised and biopsied, reconstructed and deconstructed the word love until it is nearly unrecognizable.

We want love to be a feeling we have, when in fact, love must be an action we show. When our children are loud and disobedient, when they scream and throw tantrums, it’s often difficult to feel good about them. But we still feed them, bathe them, sing to them, and put them to bed with kisses in hope of a better day or after the terrible twos or threatening threes or whichever phase has passed. (Lately it’s the sarcastic seventeens, but I digress.)

Whatever we feel about the angry drunk, the manipulative attorney, the entitled college student, the addicted gang-banger, when we behave with competence, when we do what is right, and seek their best, we show love for them. A love borne of action, not emotion. A love that is in some ways more steady and true.

I’ve learned that a cycle is born. When I act toward them with competence, I show them love. And when I do that, I learn in time to see them less as numbers (or annoyances) and more as people. A crazy thing then happens; they love me back. And then the magic happens.

I talk to them, and they talk to me. And we come together. I ask about their family, and they ask about mine. I inquire about why they are sad, and they tell me things that shake me to the core and remind me of how I have nothing to complain about when held up to their life story of abuse and addiction, neglect and loss. And because I listen (and sometimes hug them or pray for them), they know I’m human, too. And they come to love me.

In time, you’ll find new, wonderful ways to love. Over the years, I’ve learned that everyone wants to hear how beautiful her baby is. I tell her. Because every baby is, if only to her own parents. And they say thank you, and I tell them how blessed they are. And we joke about children. The children then look at me, smile, and reach for me to hold them, and I am the recipient of the blessing.

I’m less and less bothered by little things. I like to get warm blankets, and I like to get cups of water. Yes, I still get annoyed when I’m busy, but I’m a work in progress, you see. If I can order a snack for them, I will. We have a wonderful time when it’s slow and I can sit and hear a life story or tell a joke. And the love grows. By acting in love, love increases.

Love isn’t taught in the classroom, and the boards certainly don’t measure it. It is nigh impossible to apply evidence-based evaluations to love. But once you allow it to start and carry you forward, your heart will thaw like the Winter Warlock and grow like the Grinch.

And your satisfaction scores will probably go up, too.



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Does Restricting Physician Duty Hours Improve Patient Care? | The Health Care Blog

Does Restricting Physician Duty Hours Improve Patient Care? | The Health Care Blog | Healthcare and Technology news | Scoop.it

Do physicians in training take better care of patients or perform better on their exams when their work hours are restricted?  Two recent studies in the Journal of the American Medical Association suggest that the answer is no.  In one, patients of surgery residents showed no difference in morality or postoperative outcomes after duty hour restrictions were implemented.  Their test scores did not improve either.  In the other, hospitalized Medicare patients being cared for by physicians working shorter hours experienced no improvement in mortality or readmission rates.

US resident duty hour restrictions were born in 2003, when the ACGME, the organization that accredits medical residency programs, capped the work week at 80 hours.  It also mandated that residents have 10 hours off between duty periods and a 24 hour limit on continuous duty, with 1 day in 7 free from patient care.  In 2011, the organization revised its policy, further restricting the total number of continuous duty hours for physicians in the first year of training to 16.

How could well-intentioned attempts to ensure that hardworking young physicians get sufficient rest fail to benefit patients?  To begin with, simply restricting duty hours does not guarantee that residents will use their extra off-duty time to sleep.  They might, for example, use it to study, exercise, or socialize.  It is also possible that the outcomes being assessed by these studies are influenced by so many factors that merely changing duty hours is insufficient to cause a change.  Yet if such changes do not benefit patients, how strong is the case for their implementation?

Some educators worry that duty hours restrictions are undermining the quality of medical education.  For example, a survey of surgery program directors published last year showed that 21% believe that residency graduates are unprepared for the operating room, 30% believe they cannot independently remove a gallbladder, and 68% believe they cannot perform a major procedure unsupervised for more than 30 minutes.  Another survey showed that 38% of residents themselves lack confidence in their preparation even after 5 years of training.


Part of the problem may lie in the fact that the duty hours restrictions have reduced the number of cases such residents are able to learn from.  For example, one study of the caseloads of surgery residents found that the implementation of duty hour restrictions was associated with a 26% reduction in cases per resident.  Moreover, the complexity of operating room cases in which residents participated declined even more, 32%.  To compensate for such reductions, some critics have argued that if duty hours restrictions remain in place, the length of surgery residency will need to be increased from the current  5 to 6 or even 7 years.

But the problems with attempts to reduce duty hours go deeper still.  When residents spend less time in the hospital, the number of patient “handoffs” that need to occur between residents increases.   A resident who might once have cared for a patient for 24 consecutive hours now needs to hand the patient off to a colleague at 16 hours.  It is well documented that every time a patient’s care is transferred from one health professional to another, errors in communication tend to occur.  Studies suggest that such error rates can be reduced, but not eliminated.

An associated problem is the fact that residents operating under duty hours restrictions have less time to get to know their patients.  In addition to creating opportunities for error, this also has negative implications for the quality of relationships that young physicians develop with their patients.  Confidence and trust are built in part on familiarity, which the duty hours restrictions tend to reduce.  As a result, many young physicians may expect less from relationships with patients, and these diminished expectations may remain with them throughout their careers.

The intent behind duty hours restrictions is a noble one.  As sleeplessness increases, it takes a toll on mental performance, including reaction time and the ability to memorize new information.  But sleeplessness is but one factor in the performance equation, and it may be counterbalanced by other equally or even more important factors, such as the importance of the task at hand.  When a patient’s health or even life is on the line, it is possible that many young physicians are able to compensate for lack of rest.

Another drawback of the duty hours restrictions is psychological, perhaps even cultural.  A whole generation of physicians in training is being told, directly or indirectly, that their education is not as rigorous as their teachers’.  They do work as hard and are not being tested to the same degree as those who trained before them.  As a result, many complete their training questioning whether they have given less of themselves than they needed to.

Without doubt, the culture of hard work and sacrifice can be taken too far.  A colleague recently shared with me this story.  When he was an intern, he was taking call every third night, admitting at least 8 patients each call shift, and getting too little sleep.  One morning while on rounds with his chief resident he stopped and said, “I don’t think I can keep doing this.  It is dangerous for the patients.”  The chief showed absolutely no sympathy, instead responded dismissively, “Just suck it up and carry on.”

Duty hours restrictions represent an attempt to deal with a genuine problem, a dominant culture in medicine that says, “If you can’t do this, you are weak.”  Yet they are problematic because they represent a one-size-fits-all solution.  In many cases, a more tailor-made approach is called for.  It makes no more sense to treat all residents in all medical fields identically than it would to treat all patients as if they were cut from the same mold.

Before we impose blanket restrictions on duty hours for every training program and resident in the country, we should turn our attention to more pressing matters.  First, we should try to foster a culture in which young physicians can admit they need help without fear of reprisal.  Second, we should ensure that the work residents are being asked to do is truly educational and important.  And third, we should put more trust in the ability of program directors and their residents to discern for themselves the amount of work they are able to handle.


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Hospital Signs $100 Million Deal With Health Catalyst To Improve Patient Outcomes

Hospital Signs $100 Million Deal With Health Catalyst To Improve Patient Outcomes | Healthcare and Technology news | Scoop.it

Penny Wheeler, the CEO of Allina Health, calls it a conundrum. The $3.7 billion (revenue) Minnesota-based health system is part of a group of accountable care organizations (ACOs) or health care providers selected by the government to test the move from fee-for-service to payment based on patient outcomes. Allina has done so well keeping patients out of the hospital, that by some measures it is actually losing revenue. And while it scores way above other ACOs in areas such as diabetes management, it has yet to show savings from the Medicare program which rewards health care providers for lowering costs.

There’s no turning back. “We want to help drive that reform. We don’t want to be incentivized for things that don’t make sense; fee-for-service doesn’t result in best patient outcomes,” says Wheeler, an obstetrician-gynecologist. 

To ride the transition and hopefully make money, Allina is paying Health Catalyst, a seven-year-old data warehousing and analytics company $100 million over 10 years—20% of which will be tied to Health Catalyst delivering on its goal to ferret out gaps in care and reduce costs. In exchange for equity, Allina is also turning over intellectual property, namely predictive analytics software to reduce hospital readmissions. Wheeler declined to disclose Allina’s stake, but it makes the health system the biggest strategic investor in Health Catalyst. Other customers that have invested in the company include Indiana University Health, Kaiser Permanente and Partners HealthCare. The company has raised nearly $100 million.

Health Catalyst has developed data management tools that are uniquely suited for health care. Oracle ORCL +0.21%, for example, typically captures data and converts it into a specific format, whereas Health Catalyst allows for more flexible manipulation of data–which it aggregates from electronic health records, making its system faster to implement, and easier to query. One feat consisted of warehousing 14 billion rows of data within 90 days for Indiana University Health—a process that can take years. 

Steve Barlow and Thomas Burton founded the company in 2008, after developing the data warehouse at Intermountain Healthcare, along with Dale Sanders, now at Health Catalyst. CEO Dan Burton, Thomas’ brother, credits their work for helping Intermountain lower costs per patient and boosting outcomes. Dad David Burton, an internist and former Intermountain executive, also joined.

Allina was the first customer to sign on in 2008. Health Catalyst aggregates data from 42 databases which clinicians and informaticians query for population health management. As part of the deal, several Allina employees will join Health Catalyst. This year, projects include lowering the risk of sepsis, making sure children are up to date on vaccines, preventing complications from pregnancy, and managing blood sugar levels in diabetes patients.


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