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The Security Risks of Medical Devices

The Security Risks of Medical Devices | Healthcare and Technology news |
There are a large number of potential attack vectors on any network. Medical devices on a healthcare network is certainly one of them. While medical devices represent a potential threat, it is important to keep in mind that the threat level posed by any given medical device should be determined by a Security Risk Assessment (SRA) and dealt with appropriately.

So let’s assume the worst case and discuss the issues associated with medical devices. First off, it must be recognized that any device connected to a network represents a potential incursion point. Medical devices are regulated by the FDA, and that agency realized the security implications of medical devices as far back as November 2009, when it issued this advisory. In it, the FDA emphasized the following points:

Medical device manufacturers and user facilities should work together to ensure that cybersecurity threats are addressed in a timely manner.
The agency typically does not need to review or approve medical device software changes made for cybersecurity reasons.
All software changes that address cybersecurity threats should be validated before installation to ensure they do not affect the safety and effectiveness of the medical devices.

Software patches and updates are essential to the continued safe and effective performance of medical devices.

Many device manufacturers are way behind on cybersecurity issues. As an example, many devices are still running on Windows XP today, even though we are one year past the XP support deadline. They are often loathe to update their software for a new operating system. In other situations device manufacturers use the XP support issue as a way to force a client to purchase a new device at a very high price. All healthcare facilities would be well advised to review any purchase and support contracts for medical devices and make sure that things such as Windows upgrades do not force unwanted or unnecessary changes down the road. While there are options to remediate risks around obsolete operating systems, they are unnecessary and costly. Manufacturers should be supporting their products in a commercially reasonable manner.

Why would anyone be interested in hacking into a medical device? Of course there are those that would argue that anything that can be hacked will be hacked, “just because”. While it is possible that hacking could also occur to disrupt the operations of the device, the more likely reason is that getting onto a medical device represents a backdoor into a network with a treasure trove of PHI that can be sold for high prices on the black market. Medical devices are often accessible outside of normal network logon requirements. That is because manufacturers maintain separate, backdoor access for maintenance reasons.

Hackers armed with knowledge of default passwords and other default logon information can have great success targeting a medical device. For example, this article details examples of a blood gas analyzer, a PACS system and an X-Ray system that were hacked. Many times healthcare IT departments are unaware or unable to remediate backdoor access to these systems. These are perhaps more “valuable” as a hack because they are hard to detect and can go unnoticed for a long period of time. As a reminder, the Target data breach last year was initiated because the access that a third party had to the retailer’s network was compromised. A complete SRA should inventory all network connected medical devices and analyze the access/credentials that a device has, and any associated security threat. The best defense is a good offense – make sure that networked devices have proper security built in and implemented. Then your devices will no longer be “the weak link in the chain”.

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HHS, CVS Partner for Personalized Preventive Care

HHS, CVS Partner for Personalized Preventive Care | Healthcare and Technology news |

The U.S. Department of Health and Human Services (HHS) and CVS are collaborating to promote an online tool that provides recommendations for the personalized preventive services patients should receive based on their age and gender. 

Many of these preventive services are available to patients at MinuteClinic and CVS/pharmacy locations, as well as at their physician's office, and many are now covered by most insurance without additional co-pays or other cost sharing under the Affordable Care Act. The recommendations, officials say, come from government-recognized clinical experts.

Announced this week at Health Datapolooza 2015 in Washington, D.C., CVS Health says it is the first national partner to work with HHS to take advantage of the technology-based tools, developed within the Department by the Office of Disease Prevention and Health Promotion, which make it possible for the myhealthfinder tool to be available on and at

Commonly recommended preventive services available at MinuteClinic include blood pressure checks, cholesterol screenings, wellness counseling and routine vaccinations. In a blog post accompanying the announcement, Acting Assistant Secretary for Health (ASH) and National Coordinator for Health Information Technology (ONC) Karen DeSalvo, M.D. said, “Our collaboration with CVS Health was made possible by one of our projects that has been an example of innovation in the federal government since 1997. Nearly two decades ago, was the first government website designed to share health information with consumers and improve health literacy.

Since then, the Office of Disease Prevention and Health Promotion within HHS has developed the current website into a trusted, credible source for easy-to-understand prevention and wellness information. Through myhealthfinder, an interactive tool available on the website, you can enter your age, sex, and pregnancy status to receive customized wellness and prevention information along with steps you can take with your provider and at home to prevent illnesses and improve your health.”

What’s more, DeSalvo said, “To make myhealthfinder more readily available to more people, we recently developed a free, publically available application programming interface (API) to integrate the tool into any website. The API imports up-to-date information directly from This tool supports physicians and the care team, and is an easy way to help people understand the recommended preventive services that are often available to them at no out of pocket cost thanks to the Affordable Care Act,” DeSalvo said.

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New Medicare data available to increase transparency on hospital and physician utilization

New Medicare data available to increase transparency on hospital and physician utilization | Healthcare and Technology news |

As part of the Administration’s efforts to promote better care, smarter spending, and healthier people, today CMS is posting the third annual release of the Medicare hospital utilization and payment data (both inpatient andoutpatient) and the second annual release of the physician and other supplier utilization and payment data. The announcement was made at the annual Health Datapalooza conference in Washington, DC.

“These data releases will give patients, researchers, and providers continued access to information to transform the health care delivery system,” said acting CMS Administrator Andy Slavitt. “It’s important for consumers, their providers, researchers and other stakeholders to understand the delivery of care and spending under the Medicare program.”

The Medicare hospital utilization and payment data consists of information for 2013 about the average amount a hospital bills for services that may be provided in an inpatient stay or outpatient visit. The hospital data includes payment and utilization information for services that may be provided in connection with the 100 most common Medicare inpatient stays and 30 selected outpatient procedures at over 3,000 hospitals in all 50 states and the District of Columbia. The top 100 inpatient stays represented in the hospital inpatient data are associated with approximately $62 billion in Medicare payments and over 7 million hospital discharges.

The Medicare Part B physician, practitioner, and other supplier utilization and payment data consists of information on services and procedures provided to Medicare beneficiaries by physicians and other healthcare professionals. The data also shows payment and submitted charges, or bills, for those services and procedures by provider. It allows for comparisons by physician, specialty, location, types of medical services and procedures delivered, Medicare payment, and submitted charges. The new 2013 dataset has information for over 950,000 distinct health care providers who collectively received $90 billion in Medicare payments. Hospitals, physicians, and other health care providers determine what they will charge for services and procedures provided to patients and these “charges” are the amount the hospital or provider generally bills for the service or procedure, but the amount paid is determined by Medicare’s physician fee schedule or other payment methodologies. CMS protects beneficiaries’ personal information in all its data releases.

“Data transparency facilitates a vibrant health data ecosystem, promotes innovation, and leads to better informed and more engaged health care consumers,” said Niall Brennan, CMS chief data officer and director of the Office of Enterprise and Data Analytics. “CMS will continue to release the hospital and physician data on an annual basis so we can enable smarter decision making about care that is delivered in the health care system.”

The Administration has set measurable goals and a timeline to move Medicare toward paying providers based on the quality, rather than the quantity, of care they give patients. These data releases are part of a wide set of initiatives to achieve better care, smarter spending, and healthier people through our health care system. Open sharing of data securely, timely, and more broadly supports insight and innovation in health care delivery.

Today’s data release adds to the unprecedented information recently released on Medicare Part D prescription drugs prescribed by physicians and other health care providers.

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Son's ICD-10 Software Helps Save Dad's Solo Practice

Son's ICD-10 Software Helps Save Dad's Solo Practice | Healthcare and Technology news |

Nitin Desai has the kind of medical practice you don't see much anymore. Desai, an internist, is the only physician in the practice in Columbus, Ga. His patients are like family; they know the staff personally and even have the doctor's cell phone number. Desai's wife, Bhavna Desai, is the practice manager, and his sons, Parth and Koosh, grew up in and around the practice, cutting the grass, helping out in the office, and developing a love for the practice of medicine that would led them both to medical school.

Sadly, increasing regulations and requirements for health information technology are making it more and more difficult to keep this kind of practice afloat. "I was under a lot of pressure to sell out to a hospital or join a group of other doctors," said Desai. "It is seriously hard to maintain a solo practice these days." Coming so soon after installing an EHR, the requirement to switch to ICD-10 was the last straw for Desai. Running a medical practice as a family business just didn't seem possible any longer.

Parth Desai, a first-year student at Mercer University School of Medicine in Macon, Ga., learned early about the business side of medicine. When he was just 16, health problems forced his mother to take a break from her duties as office manager. Parth stepped in to help out. His computer skills came in very handy, since neither of his parents is very computer savvy. When Parth heard about the ICD-10 transition, he knew that he could help with that, too.

Parth and his best friend, Will Pattiz, a computer programmer with experience developing training platforms and e-learning courses, built software that creates ICD-chart templates and converts codes from ICD-9 to ICD-10. For the 70 percent of codes that have one-to-one matching, conversion requires little more than the click of a button. For the 30 percent that are more complex, "You can go through and edit, fill in the codes you use, and customize as you go," Parth explained.

The pair's "ICD-10 Charts" software is quite valuable, with many practices seeking an easy way to convert to the new coding system. But Parth isn't aiming to make money from his software; he just wants to help his dad. "Dad has always helped me," he says simply.

One lesson Parth did not miss growing up in the heart of a community-focused medical practice was the imperative to help others. Parth and Pattiz have made the software available free on the Web [at] for anyone who can use it. In addition, the Physicians Foundation, a nonprofit organization dedicated to advancing the work of physicians practices, has stepped in to fund the project. With the foundation's support, additional free resources, including free coding training, will be available soon. "The Physicians Foundation is also helping us spread ICD-10 Charts throughout the country so that the project can benefit as many struggling practices as possible," said Parth.

Meanwhile back home, Nitin Desai says his son's software has made a noticeable difference in his practice's bottom line. "We're okay for now." And in the long run? "The chances are very high," says Desai, "that the boys will come home and join the practice."

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The Mobile Patient: How mHealth Tools are Paving the Way for Better Care Management

The Mobile Patient: How mHealth Tools are Paving the Way for Better Care Management | Healthcare and Technology news |

In the new healthcare, one which emphasizes comprehensive, team-based and accessible care, provider organizations will need to make concerted efforts to become more patient-centered.  For many providers, patient engagement is no easy task, but it’s certainly at the top of mind for healthcare CIOs.

Indeed, 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.

Enter the world of mobile health (mHealth) to help with care management and patient engagement, a growing trend in healthcare. In fact, 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. The fourth annual HIMSS mobile survey, which included more than 200 healthcare provider employees, revealed that 73 percent of respondents believe the use of app-enabled patient portals has been the most effective tool in patient engagement to date.

Further, when asked about patient-generated health data (PGHD), 14 percent reported that all or most data generated by mobile devices is integrated into the electronic health record (EHR), while 52 percent reported that some data has been integrated into the medical record. “mHealth continues to evolve as a tool to drive healthcare efficiencies. The proposed meaningful use Stage 3 rule realizes this with the concept of application program interfaces (APIs) and patient-generated health data, and this year’s survey showed that the wide spread availability of mobile technology has had a positive impact on the coordination of patient care,” said David Collins, senior director of the HIMSS mHealth community.

Analysts do predict that the wearables market will grow tenfold to $50 billion over the next three to five years. So undoubtedly, putting personal devices in the hands of patients has begun to change the way patients and physicians communicate with each other. And for each of the major smartphone operating systems, there is now an app for almost every conceivable healthcare need.

What’s more, there are policy implications to consider as well. As HIMSS’ Collins mentioned, the recent meaningful use Stage 3 proposal that calls for more that 15 percent of patients to contribute PGHD or data from a non-clinical setting into the certified EHR technology during the EHR reporting period, will put the onus on providers to collect information from patients, often captured from exercise or fitness devices or recorded on mobile apps.

What does all this mean? For forward-thinking providers, it’s about getting patients to use mHealth tools for more effective care management. Mobile health tools have the potential to create a low-cost stream of highly actionable clinical data, using readily available cloud-connected sensors, ranging from glucose meters to heart monitors to asthma tools. To this end, all sorts of vendors in the market place are working on using mobile devices to get first get patients to track their own data, with the eventual goal to get said data into the EHR. For most vendors and provider organizations though, as noted in the HIMSS mHealth survey, this concept is a novel one.


According to Ken Kleinberg, director of health IT membership service at the Washington, D.C.-based The Advisory Board Company, mHealth vendors are now making it easier on patients to track and share their data than ever before. “These apps are now designed for a small device. You’re no longer trying to open a browser on a tiny screen, but instead you’re looking at an app designed just for that platform, so the data entry and reminders are pretty straight forward,” Kleinberg says. “You may get text message reminders, for example, and these are simple mechanisms that don’t require complex hardware,” he says. Kleinberg adds that there is also a trend involving smartphones with medical devices, where asthma patients, for instance, can have their inhaler with an attachment to it that keeps track of every time the inhaler is used. “This way you can sit down with your provider or look at the data yourself, and sit down and figure out trends,” he says.

To this end, at this year’s HIMSS conference, the Durham, N.C.-based Duke Medicine shared the experience it has had thus far with Apple’s HealthKit, a framework designed to house healthcare and fitness apps, allowing them to work together and gather their data under the Health app. Since HealthKit’s launch, many notable healthcare organizations, including Stanford Medicine, Cleveland Clinic, and EHR vendors like Epic, have all partnered with Apple to work in their own patient-generated data applications.

At Duke, Ricky Bloomfield, M.D., director, mobile technology strategy, has led the effort to integrate Apple’s HealthKit. For providers at Duke, the first step to getting the data integrated with their medical records involved asking patients if they want to share their information, says Bloomfield. Such data, which goes into the EHR via the patient portal, can be from activity trackers, blood pressure devices, glucose monitoring, and many other devices. But then there are limits, he adds. “Patients cannot unilaterally enter their data into the EHR, and that’s by design. There simply is no way for providers to handle that mass intake of data right now,” he says. As such, the provider enables Apple’s HealthKit for patients right now, and the provider has a flow sheet that keeps the patient-generated data separate from other data in the system, Bloomfield says. This way, you can still do analytics on it, but it’s separate from other clinical data, he says.

Across the country, providers are handling patient-generated data in the same manner. In Palo Alto Calif., Stanford Health Care recently released its MyHealth mobile app that will allow patients to review test results and medical bills, manage prescriptions, schedule appointments, and conduct video visits with a Stanford physician.  The app also connects directly with Epic’s EHR system and with Apple’s HealthKit. The idea behind this integration, according to Aditya Bhasin, executive director of software at Stanford Health Care and part of the team that built the app, was to get both doctors patients to be looking at exactly the same sources of truth.

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Is This Population Health’s Moment? Time for Data and Analytics

Is This Population Health’s Moment? Time for Data and Analytics | Healthcare and Technology news |

Every year, the annual HIMSS Conference, sponsored by the Chicago-based Healthcare Information and Management Systems Society, offers its attendees a kind of conference-based snapshot of where the U.S. healthcare industry is with regard to the forward evolution of healthcare information technology adoption, as well as a sense of the overall policy and operational landscape of healthcare. Attendees can get a sense of the healthcare IT Zeitgeist through attending keynote addresses, educational sessions, association meetings, and networking-focused gatherings, as well as by wandering the exhibit hall and simply by having meaningful conversations with fellow attendees.

HIMSS15, held at the vast McCormick Place Convention Center in Chicago the week of April 12, offered perhaps the clearest portrait of the current moment that has yet been offered to date. Session after session focused on the shift beginning to take place from volume-based healthcare reimbursement to value-based payment, across a very wide range of mechanisms, between providers and both the public and private purchasers and payers of healthcare, and the implications of that shift for healthcare IT leaders.

Further, as part of the keynote session on Thursday, April 16 in the Skyline Ballroom at McCormick Place, Andy Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services (CMS), made the intentions of federal authorities crystal clear, when, referencing the statement of Health and Human Services Secretary Sylvia Mathews Burwell in January that she wanted the bulk of Medicare fee-for-service payments to providers to shift as quickly as possible over to quality- and value-based payment, Slavitt said, “Our priority is simple: to drive a delivery system that provides better care, smarter spending, and keeps people healthier. The success in the first five years since the Affordable Care Act has been very encouraging… Our agenda now,” he said, “is to get busy strengthening these gains. That will mean that more providers in more communities will need to be able to transform the care they provide so that they will benefit from value-based reimbursement. And they will need technology to help them get there.”

What’s more, in his keynote address two days earlier, Humana CEO Bruce Broussard had told HIMSS attendees, “We have to change the conversation on what we are doing in healthcare from a supply-based system to a system around demand, a system where we put the customer first as opposed to the system. Over the years,” he added, “healthcare has been built by creating more and more supply. I hope I leave today by convincing you that we have to change the focus towards how we improve health for our customers, members, and patients.”

The good news on the solutions side of this landscape is that vendors are rushing forward to provide population health- and accountable care-driven analytics solutions, at a time when such solutions are most desperately needed. Certainly, the hype at HIMSS15 was all around population health, care management, and accountable care solutions. The only question now, as the U.S. healthcare industry hurtles forward into the near future, is, is this a breakthrough moment for population health efforts? And if so, are provider and health plan leaders ready to effectively leverage the tools to make pop health really happen?

The long journey ahead

Leaders from all sectors of healthcare understand that the journey to population health and value-driven care delivery and payment success is going to continue to be a long, challenging one. Donald W. Fisher, Ph.D., president and CEO of the Alexandria, Va.-based American Medical Group Association (AMGA), says he and his colleagues are putting the vast bulk of their efforts into helping prepare physician group leaders for the transition. “We’re not quite there yet, and as we change to a new reimbursement system, even the large, sophisticated medical groups are going to need a few years to make the transition,” Fisher says.  “You’ve got to put the infrastructure in place, and the large integrated health systems have been putting those elements in place—EHRs [electronic health records], alert systems, analytics systems, data warehouses—and some have teams of people mining the data to assess patient status.”

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How Virtual Reality May Change Medical Education And Save Lives

How Virtual Reality May Change Medical Education And Save Lives | Healthcare and Technology news |

The old adage applies to many aspects of our life in a variety of ways.

Practicing your backhand, learning a dance move, or rehearsing your speech.

But where it may matter the most is for medical professionals who perform lifesaving interventions or procedures for patients in emergency departments or in the operating room.

The reality is that there are some lifesaving procedures in emergency medicine that you rarely perform–but must always be ready to perform in a split second.

One such a procedure–known as cricothyrotomy–which involves making an incision into a specific area of patient’s neck and inserting a plastic tube through a thin membrane into the trachea—requires accuracy and speed, and can be lifesaving if performed correctly, but deadly if not completed in a timely or improper fashion. Other life-saving skills including intubation, central line and intraosseous catheter placement also require practice and repetition in order to save lives.

Over the past decade, there has been an explosion in the use of simulation medicine to help physicians gain preparation for performing lifesaving procedures as well as approaching delicate or difficult situations related to patient care.

Simulation has been embraced by residency programs as well as hospital training programs in orders to keep the skills of physicians sharp for rarely performed life saving procedures such as cricothyrotomy.

Yet one important lifesaving skill that all healthcare providers must stay current on is CPR or Cardiopulmonary Resuscitation.

CPR has generally been taught in large classes using mannequins, with instructors demonstrating technique and proper form. Students read and attempt to memorize algorithms in preparation for classes.

Newer electronic approaches involve online portals to view CPR or BLS and integrate online test taking. Whether this more modern approach is useful and sustainable is unclear at this time.

Now enter Virtual Reality or VR, which can open up an entirely new world of possibilities to experience the tense, real world clinical situations which require rapid thinking and quick analysis for management of critically ill patients undergoing CPR.

While VR initially gained a foothold in the world of gaming, more relevant and far-reaching possibilities are now envisioned by experts in the realm of education and learning.

According to Mary Spio, CEO of Next Galaxy, a developer of innovative content solutions and consumer virtual reality technology, VR is poised to be our new medium for education and dissemination of information.

Spio, a former aerospace engineer, and patent holder of digital technology that allowed transfer of Star Wars II: Attack of the Clones to theaters, sees our global educational future based on VR.

Next Galaxy’s flagship consumer product currently in development is referred to as CEEK, “a next-generation fully immersive entertainment and educational social virtual reality platform featuring a combination of live action and 3D experiences,” according to the company’s recent press release.

Spio’s hope is that Next Galaxy’s virtual reality model will better educate and prepare health care providers–as well as consumers–for learning CPR, based on a more realistic learning environment. She advocates a paradigm shift, away from the current approach–which relies upon passively watching videos and taking written exams–to a method for learning that involves the use of gestures, voice commands and eye gaze controls, thereby transforming how medical providers and laypersons experience such situations.

As a first step towards developing this new reality, Next Galaxy Corporation recently announced an agreement with Miami Children’s Hospital to engage Next Galaxy’s VR Model and develop immersive virtual reality medical instructional content to educate medical professionals as well as patients.

Next Galaxy and Miami Children’s Hospital will be jointly developing VR didactic modules on cardiopulmonary resuscitation (CPR) as well as other lifesaving procedures that will be available on smartphones and tablets.

According to Spio, participants using VR will be required to make clinical decisions regarding proper techniques, after they make assessments using specific medical VR scenarios. Metrics and real-time feedback from the virtual CPR instructional video will also allow participants the opportunity to accurately perform CPR techniques. VR modules will highlight errors and encourage users to repeat a task when errors occur.

Next Galaxy stated that the VR models will be viewable through smartphones and desktops as 3D, 
as well as using VR devices such as Google GOOGL -1.88% Cardboard, Oculus Rift, and VRONE.

“I think that it’s going to be instrumental in the training and education of not just health care workers and medical professionals, but also patient education,” proclaimed Spio.

A lot of times, Spio explains, patients don’t understand the procedures happening or being performed on them.

“By visualizing the situation, it sinks in a more visual way when they have actually experienced the procedure beforehand,” said Spio. “They become more responsible for their own healing and treatment by having a deeper understanding.”

It also helps medical professionals even further, by reducing risk for litigation in theory, Spio also believes.

Spio also explains that her company has developed an immersive voice-activated model of CPR for choking in infants or adults—for lay providers as well as medical professionals—allowing one to virtually manipulate patients, perform CPR, and remove a potential foreign body.

Spio also describes plans to use her VR library to educate women in countries such as Jamaica and Ethiopia about birthing, where access to basic education is often lacking. Spio envisions her platform (CEEK) and her library as way for mothers to develop a basic understanding about ways to prevent and control infection or even to stop bleeding.

Appealing to consumers, Spio explains that her content library is adaptable to a Google-inspired version of a VR headset (Google Cardboard), with a price point as low as $25.00.

Teaching lactation is another potential area where Spio believes that VR may have potential application. Teaching the “normal” ins and outs and potential expectations and pitfalls would be useful for reducing anxiety for mothers.

She also believes that training the next generation of surgeons using VR technology will be commonplace, with training programs requiring content  from such a platform and library built at Next Galaxy.

“Virtual Reality represents the highest form of learning, essentially because you are immersed in the task and actually doing it,” concluded Spio.

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Up to 1.1 Million Customers Could be Affected in Data Breach at Insurer CareFirst

Up to 1.1 Million Customers Could be Affected in Data Breach at Insurer CareFirst | Healthcare and Technology news |

CareFirst, a Blue Cross Blue Shield plan, on Wednesday became the third major health insurer in the United States to disclose this year that hackers had breached its computer systems and potentially compromised some customer information.

The attack could affect as many as 1.1 million of its customers, but CareFirst said that although the hackers gained access to customer names, email addresses and birthdates, they did not obtain sensitive financial or medical information like Social Security numbers, credit card information and medical claims. The company, which has headquarters in Maryland and serves the Washington area, said the attack occurred in June and described it as “sophisticated.”

Chet Burrell, CareFirst’s chief executive, said the company contacted the Federal Bureau of Investigation, which is investigating attacks against the insurers Anthem and Premera. “They are looking into it,” he said.

While it was not clear whether the attacks were related, he said the company was under constant assault by criminals seeking access to its systems.

Federal officials have yet to label the breaches at Anthem and Premera Blue Cross as state-sponsored hackings, but the F.B.I. is effectively treating them as such, and China is believed to be the main culprit, according to several people who were briefed on the investigations but spoke on the condition of anonymity. There are indications the attacks on Anthem, Premera and now CareFirst may have some common links.

Charles Carmakal, a managing director at Mandiant, a security firm retained by all three insurers, said in an emailed statement that the hacking at CareFirst “was orchestrated by a sophisticated threat actor that we have seen specifically target the health care industry over the past year.”

The Breaches at Anthem, which is one of the nation’s largest health insurers and operates Blue Cross Blue Shield plans, and Premera Blue Cross, based in Washington State, were much larger. The one at Anthem may have compromised the personal information of 79 million customers and the one at Premera up to 11 million customers.

Anthem has said the hackers may have stolen Social Security numbers but did not get access to any medical information. Premera said it was possible that some medical and bank account information may have been pilfered.

CareFirst said it was aware of one attack last year that it did not believe was successful. But after the attacks on other insurers, Mr. Burrell said he created a task force to scrutinize the company’s vulnerabilities and asked Mandiant, a division of FireEye, to perform a forensic review of its systems. Last month, Mandiant determined a breach had occurred in June 2014.

Health insurance firms are seen as prime targets for hackers because they maintain a wealth of personal information on consumers, including medical claims records and information about credit card and bank accounts.

In recent years, the attacks have escalated, said Dr. Larry Ponemon, the chairman of Ponemon Institute, which studies security breaches in health care. He said the health care industry was particularly vulnerable and that the information it had was attractive to criminals who use the data to steal the identity of consumers.

“A lot of health care organizations have been historically laggards for security,” he said.

Insurers say they are now on guard against these attacks. But Dr. Ponemon said they had taken only small steps, not “huge leaps,” in safeguarding their systems.

The motivation of the hackers in these cases, however, is unclear — whether they are traditional criminals or groups bent on intelligence-gathering for a foreign government.

In the retail and banking industries, the hackers have been determined to get access to customer credit card information or financial data to sell on the black market to other online criminals, who then can use it to make charges or create false identities.

So far, there is scant evidence that any of the customer information that might have been taken from Anthem and Premera has made its way onto the black market. The longer that remains the case, the less likely that profit was a motive for taking the information, consultants said. That suggests that the hackers targeting the health care industry may be more interested in gathering information.

“It’s such an attractive target and it’s a soft target and one not traditionally well protected,” said Austin Berglas, head of online investigations in the United States and incident response for K2 Intelligence and a former top agent with the F.B.I. in New York. “A nation state might be looking at pulling out medical information or simply looking to get a foothold, which they can use as a testing ground for tools to infiltrate other sectors,” he said.

Paul Luehr, a managing director at Stroz Friedberg, a security consulting firm, said the health care breaches could be an entry point into other systems. “It could serve as a conduit to valuable information in other sectors because everyone is connected to health information,” he said.

Or the breaches could simply be crimes of opportunity. The hackers could be making off with information and waiting to determine what to do with it.

“We want to jump to the conclusion that there is an organized chain and command,” said Laura Galante, threat intelligence manager for FireEye, who was not commenting specifically on any particular breach. “But what could be happening here is much more chaotic. It’s simply, ‘Get whatever data you can get and figure out what to do with it later.’ ”

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How health IT is a barrier to patient satisfaction

How health IT is a barrier to patient satisfaction | Healthcare and Technology news |

I was recently talking to a patient about having some extra help at home when she left the hospital with home nursing services. The elderly lady — highly intelligent and fiercely independent — politely declined with the reply: “No, I’m fine thanks Dr Dhand — all they’ve done before is just come in with their computers, barely talk to me, enter a few things on their keyboards and then leave.”

This reply really struck a chord with me (as someone who has written extensively on all that we need to do to improve the use of information technology at the frontlines of medicine). We then engaged in a brief conversation about all the changes she’s seen over the years and how medicine now seems so fragmented and impersonal. I finished with a strong feeling inside that I really couldn’t blame her for declining additional “robotic” services, and that she was talking absolute sense about her experiences.

Her reply is typical of dozens, if not hundreds, of similar complaints I’ve heard over the years about how doctors (and nurses) are simply too pre-occupied with their keyboards and screens and barely look at a patient nowadays. This problem particularly affects the more generalist medical specialties — including primary care — which should be the cornerstone of all health care. The last decade has seen the proliferation of information technology, mainly due to meaningful use and the government’s incentives for the computerization of the health care system.

Let me pause right here and say that I am far from advocating a return to the paper chart or the archaic days of yesteryear. Many of the aims and goals behind meaningful use are noble ones. We simply need to redesign the current systems so that they are fully optimized for frontline medicine, and design them to be as seamless and efficient as possible so that doctors and nurses can get back to where they belong: with their patients talking face to face. Likewise, doctors and nurses need additional training on how better to use the information technology so that it doesn’t come in-between them and their patients.

A study published not so long ago in the Journal of General Medicine showed that medical interns now spend only around 10 percent of their day engaging in direct patient care in hospital and almost half their time with computers. That’s a shocking statistic and an unfortunate imbalance. I’m sure if a comprehensive study was done on primary care doctors, and how long they spend looking at actual patients versus their screens, the results may be even more disappointing.

If it were expanded, the same study would probably also show that one of patients’ biggest let-downs would be when their doctor keeps glancing in between them and their screens. So if we are really serious about improving patient satisfaction and the health care experience, how can we let this situation go on?

I hope that in the not too distant future the world of frontline medicine, IT, and hospital administration, can all get together to solve this problem. I gave a presentation last year in Boston titled: “Healthcare IT: What the frontline of hospital medicine really needs.” The audience was a mixture of entrepreneurs, techies and clinicians. The biggest round of applause I got was from the clinicians when I opened with the provocative statement that health care IT has done more to destroy the doctor-patient relationship over the last five years than any other one single thing. I stand by that statement and hope that we can change things. Until that happens, we continue to massively let down our suffering patients.

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Apple Watch Changes the Health Wearables Game

Apple Watch Changes the Health Wearables Game | Healthcare and Technology news |

After months of speculation and hype, the Apple Watch has finally arrived. 

What are some first impressions? How does it compare with other watches, bands and wearables? How will it impact the digital health landscape? (By the way, if you are reading this review for information on how to deliver your one-way banner ads brand messages via Apple Watch, you're already missing the point.)

I have been an avid user of wearable fitness and health trackers for a few years. After losing several Nike FuelBands on the soccer field, I recently switched to the Microsoft Band. Although it's slightly bulky, I truly enjoy the simple interface for tracking my activities, instantly measuring my heart rate and even paying for my Starbucks coffee.

Then along comes the Apple Watch. Of course it's got a great design, but it's not going to be for everyone initially. The learning curve is steep, especially if you're like me and don't take advantage of the online or in-store training. It does have a limited battery life and seems to be missing some core health functions. It might not be ideal for people with poor vision, and it doesn't currently have independent GPS capability. I was particularly worried about whether I could wear it while playing soccer, but I simply placed a wristband over it. Voila! I didn't find a default sleep-measurement function, but I assume that there will be apps to do that. Maybe Apple would rather I charge my watch while I sleep.

It's been only a few days, but I can already say that the Apple Watch experience is a great improvement over my other fitness bands. In addition to tracking my heart rate and how much I'm moving or sitting, the Apple Watch lets me do everyday things like receive texts and email, take phone calls and use Apple Pay. But I'm most excited about how it and other wearables will help me modify my behavior for better health. There's something very motivating about receiving visual and sensory cues from a device attached to your body. For instance, the Apple Watch gives you a nudge every hour to get up and move for a minute. It's very subtle and it may be a minuscule benefit, but it can be a great tool to combat the 21st century “disease of sitting” that so many of us are facing. 

We have been talking about big data, value beyond the pill and behavioral economics for some time. 

These wearable devices provide a great opportunity to do more than simply be shiny objects for early adopters. Wearables aren't just for fitness—they can make a big impact on adherence, compliance and cessation of unhealthy behaviors. 

Two hospital systems are currently conducting digital medicine trials using the Apple Watch to help manage hypertension and to determine how nurses and physicians can benefit from incorporating the Apple Watch into a medical home program. There are already a number of industry-related apps available for Apple Watch, including those from Drchrono, Lark, Doximity, WebMD, HealthTap and others.

The uptake has been rapid: Consider the fact more Apple Watches were sold in one day than Android Wear devices in an entire year. As a digital marketer, don't expect every demographic to immediately adopt the Apple Watch or other wearables. But ignore the Apple Watch effect at your own risk. The impact of this new technology and interface will manifest over time, just like our mobile phones did. 

Remember when they said social media was only a fad?

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Health IT Holds the Promise to Help Improve Health

Health IT Holds the Promise to Help Improve Health | Healthcare and Technology news |

About 1 of 3 U.S. adults—67 million people—have high blood pressure, also called hypertension. High blood pressure increases the risk for a variety of diseases, including stroke, coronary artery disease, peripheral vascular disease, heart and kidney failure, and atrial fibrillation. High blood pressure is also called the “silent killer” because it often has no warning signs or symptoms, and many people do not know they have it.

The Department of Health and Human Services, through its national Million Hearts® initiative, has set a goal to prevent 1 million heart attacks and strokes by 2017. Million Hearts® is working with providers to reach clinical targets that could improve population health. For example, health care providers are encouraged to have 70 percent or more of their patients with hypertension control their blood pressure, which could be done by self-monitoring.

During National High Blood Pressure Education Month (May 2015), HHS’ Office of the National Coordinator for Health IT (ONC) and the Centers for Disease Control and Prevention (CDC) are emphasizing the important impact that electronic health records (EHRs) are having through the ability for patients and providers to interchangeably share blood pressure data.

New research about the Million Hearts® electronic clinical quality measures (eCQMs) included in the Medicare EHR Incentive Programs was published today in the Morbidity and Mortality Weekly Report (MMWR) in the article “Morbidity and Mortality Weekly Report: Using Meaningful Use Clinical Quality Measures for Million Hearts Surveillance.” The report shows that, for the first time, data reported as part of the incentive programs, or meaningful use, could improve the timeliness and possibly completeness of data used to track issues of public health concern.

Health IT is on the Quality Team

With a primary focus on the reporting of the Million Hearts® hypertension measures, the research published today shows that:

  • Among providers that started in 2011, the very first year of CMS’ EHR Incentive Program, the average proportion of patients with hypertension in control remained unchanged at 62-63 percent over 3 years.
  • About one-third (36 percent) of reporting providers met the Million Hearts® clinical target of 70 percent or more of their patients with hypertension under control.

The findings show that an EHR is a tool that should make providing better health care easier, but it cannot do so in isolation. Health IT is on the quality team, which means that patient-centered, team-based approaches to care, coupled with the use of certified health IT, can move the health system towards meeting the very important Million Hearts® targets. These strategies should also help clinicians guide patients to achieve safe blood pressures and avoid preventable death and disability.

Quality Reporting is a Powerful Tool for Population Health Surveillance

With the Health IT Dashboard: Office-based Physician Health IT Adoption, discrete blood pressure data, documented and captured electronically, are now available to help us understand hypertension trends and identify steps to accelerate progress. The first three years of the meaningful use program yielded electronic clinical quality measures data from 63,000 health care providers and about 17 million patients with hypertension, which represents large portions of health care provider and patient populations. The eCQM data reported as part of that program demonstrates that continuous quality improvement can be used to track national progress towards an important health goal – preventing 1 million heart attacks and strokes by 2017.

Health Information to Help Coordinate Patient Care

The eCQM data can also help individual physicians target appropriate interventions that can help to manage patients’ health in an effort to better coordinate care. To do that, clinicians make it a priority to be aware of their patient’s health status, and an interoperable health care system can help make this a reality, with reporting on eCQMs being just one part of the picture. Facilitating the flow and exchange of electronic information allows for improved coordination of care across the care continuum by making sure that a patient has the health information they need, when they need it. This is a challenge because health data comes from many different sources. Consider this scenario:

Julia, diagnosed and treated initially for hypertension by her primary care clinician, has noted that her readings are still not in the optimal range. She is referred to a hypertension specialist for further evaluation and management. She is pleased to see her blood pressure reach and stay in good control. Unfortunately, though this achievement is well-documented in her personal paper health diary and in the specialist’s EHR, her primary care clinician is left out of the loop.

This situation happens frequently, but is not a model for coordinated care. Ideally, Julia’s specialist would update her primary care provider on a regular basis. However, we know that sharing, receiving, and using electronic information is not always easy. To reach a level of care coordination necessary to promote better health – and in this case to help address a patient’s high blood pressure – the entire health system must move towards an interoperable, learning health system. The exchange and use of electronic information by all health care providers on the care team is necessary to improve health and health care while decreasing costs.

The optimal use of EHRs should accommodate a provider’s workflow and take advantage of patient-generated data when available. Health information comes from a variety of sources, and eCQMs may not maximize the available data. For example, the blood pressure control measure does not capture:

  • Patient-generated data, such as measurements from a home blood pressure cuff
  • Clinical notes stored as free text in the EHR.

mproving and enhancing eCQMs, and making sure that health IT can use health data from a variety of sources, are key components of the federal health IT strategic plan, and the draft interoperability roadmap.

We still have work to do. To continue to make progress to achieve this goal for more patients, we must work together to reach an interoperable health system that facilitates information exchange across the care continuum, and that enables care transformation.

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In The Grand Canyon State, Behavioral Health Data Exchange Gets Steeper

In The Grand Canyon State, Behavioral Health Data Exchange Gets Steeper | Healthcare and Technology news |

Last April, two health IT vendors—the Horsham, Pa.-based NextGen Healthcare Information Systems and its sister company, Mirth, based in Costa Mesa, Calif.—announced the launch of the Behavioral Health Information Network of Arizona (BHINAZ), publicized by its officials as the first statewide behavioral health information exchange (HIE) in the nation.

BHINAZ was the brainchild of a consortium of behavioral health providers who are customers of Topaz Information Solutions, an authorized NextGen reseller and outsource partner that specializes in behavioral health and social services. Topaz, in partnership with NextGen Healthcare, built specific content within the technology platform to meet specific needs of behavioral health and social services organizations.

Leveraging NextGen’s ambulatory electronic health record (EHR) and HIE, and Mirth Connect— an open source application used for healthcare data integrations—BHINAZ created the legal and operational framework necessary to protect confidentiality while helping to facilitate data exchange and streamline the process for behavioral health providers to obtain and manage patient consent, specifically as it relates to exchanging patient information, officials say. As a result, BHINAZ will provide clinicians throughout the state with a longitudinal patient history at the point of care, making information available when and where it's needed for medical care.

Shortly after the announcement, HCI Senior Contributing Editor David Raths interviewed Laura Young, the executive director of BHINAZ, about the network’s goals and progresses for HCI’s sister publication, Behavioral Healthcare. At that time, the organization was just getting off the ground, with some of the main challenges being around legal and privacy issues with patient consent, as well as connecting to the physical health HIE in Arizona, and of course, cost.

Operating under an “opt-in” consent management model, BHINAZ said that it will ensure that data protected under Federal Law 42 CFR Part 2 is not re-disclosed without proper consent. Within the NextGen EHR, customized behavioral health consent management templates were created by working collaboratively with BHINAZ to include required content management language and capture electronic signatures at the point of care. Using these templates, information is sent to the NextGen HIE, which then dictates specifically what data a given provider can access within the EHR. Patients and clients have the option to choose if they would like their data to be shared with the rest of the closed network at each BHINAZ location. Last year, Young told Raths that, “It really is all or nothing. We are treating all of the data within our HIE as protected 42 CFR Part 2 data. If the client isn’t comfortable sharing their Part 2 data, then we aren’t going to share anything else.”

A year later, HCI Associate Editor Rajiv Leventhal checked in with Young, and the challenges for BHINAZ remain similar to what they were in 2014. Below are excerpts of that recent interview.

Tell me about the logistics behind the creation of BHINAZ?

In Arizona and in other states, we have Regional Behavioral Health Authorities (RBHAs)and in Maricopa County, where I live, the RBHA contract of $7 billion over five years—for behavioral health services passed out from federal funds to the state and then out to designated behavioral health agencies— was up for bid. In the past, the challenge has been when those agencies lose those contracts, they pack up their data with them, so there are issues with continuity of care and being able to access information about patients and clients. There was a feeling that the way to go was start working on an HIE for behavioral health.

So the HIE is stakeholder-owned, comprised of seven nonprofit organizations.  It’s very much at the community level, driven by behavioral and community health providers. Our approach comes from the bottom up rather than top down, so we are able to be at provider level and insert the HIE directly into the practice and do workflow and training right at the organizational level.

How is it being funded?

Initially, the money didn’t come from the RHBAs, but that where it’s gone towards now. We do have a subscription model, and when we connect providers, there’s a connection fee with a sliding scale for monthly subscriptions. In working with the RHBAs, and there are now three of them in Arizona, their contracts obligate them to have some sort of HIE technology, and they’re also obligated to do integrated care, for both physical and behavioral health. So it’s turned into a critical thing for them to work with us. We’re contracting with them to connect providers, and they’re covering the cost of connection in exchange. We want providers to put some sort of money into it, otherwise they don’t own the technology and are less inclined to use it to be honest. We are also working on initiatives at the state level to get allocations that would go to our HIE and the physical health HIE in the state.

To what extent has your network grown, and how many organizations are exchanging data?

We have about eight providers, not necessarily the stakeholders which is ironic since it’s around the same number. We have also partnered with Quest Diagnostics, and now we have providers ordering in results and labs through the HIE. We’re right at that threshold where we'll connect more providers. There are about 200-300 behavioral health providers statewide, and of that, 40 or 50 of them touch 90 percent of the participants, so we are working on getting those providers on board first.

Has the lack of meaningful use incentive dollars hampered things at all?

One of the barriers is definitely lack of good EHR technology. In behavioral health, there are a lot of mom-and-pop applications. The other barrier is that a lot of these vendors charge a fortune for interfaces—thy either charge per interface or charge a lot at one time to give you an HL7 channel for instance. That makes it cost prohibitive for some of these providers, especially the smaller ones. The vendor cost for their EHR is sometimes the barrier to getting connected. The EHR companies are also trying to bite a piece off the HIE business, so they compete against HIEs, which I think slows everyone down. More collaboration is needed.

How has that experience been, connecting to the physical health HIE in the state?

We’re finishing up a connection from them so we will have all the hospital admits and discharges, and we can rout those in real time to our providers. A lot of the time these behavioral health patients get admitted in hospital or go to the ER, and they stay for 72 hours which is the requirement, but they don’t necessarily get a lot of treatment during that time. They might get discharged without addressing their concerns. Sometimes there are no follow-ups, and this way with alerts, intervention and coordination becomes critical.

Working with them has been a good partnership, I’d say. Our approaches are different, they have an opt-out model, we have an opt-in one. Their main focus has been around connections, getting big hospitals and payers on board and connected. They don’t spend much time at the community level doing workflow, so we do have different approaches. But we do also need each other, and we try to work together on things as the long-term goal is bi-directional exchange so the behavioral health data is getting back to the physical health providers. That will take some work.

How does your opt-in model work specifically with behavioral health patients?

We require explicit consent. For our model, the education piece is especially important. We spend time on educating the provider on educating the patient. We have about a 78 percent opt-in rate, but it does vary by type of provider, and when that consent is presented varies too. For example, if you’re coming into a detox center you won’t be presented with the consent right away. We have had good success with it though. If we convince the patients that the HIE is good for them, that they don’t have to repeat things every time they go to another provider, it will help them understand why it’s really best to opt-in. We want to improve that rate and do more education, but we are happy with our success so far.  

Consent has also taken up a big chunk of our time. We spent 18 months doing legal and technical work on consent. In fact, we have done so much work on it that we have become the de facto expert on it. We actually get calls on how we do it. A lot of groups see things that go into consent requirements for behavioral health and want to figure it out later. I mean it took us a year and a half, that’s all our organization was doing. Imagine if you had a lot of other priorities?  

Are there other HIEs in this space who you’re competing against?

We are the only standalone behavioral health HIE in the country. Other states are doing behavioral health as a component, but some of it is just using Direct exchange point-to-point, not a full blown repository. Colorado, Kansas, Rhode Island are states that do have behavioral health in their exchanges, but it’s hard for me to say what it looks like or what’s being exchanged. So there is no competition from that perspective.

Is behavioral health data exchange any different than physical health exchange?

One of the big areas of focus for us is crisis services. In a crisis, time is of the essence, so being able to have as much data as possible available about someone is critical. The type of data isn’t your standard data set, though. Rather than radiology and labs you’re looking for documents, assessments, and treatment plans. That’s where I see a bigger difference between physical health and behavioral health data exchange. And it’s not that they don’t exchange documents, but they are looking for diagnostic types of data versus these comprehensive documents. That’s where we insert ourselves and try to get people off paper. It’s such an old process, faxing and scanning compared to embedding right into the EHR.

What are some key goals for BHINAZ in the next year or so?

A lot of what we do is dictated by our participants; the RHBAs have a priority list, so we work that direction. We are also really focused on crisis services; it’s at the top of our list. We are working on a consolidated crisis viewer, which is different than what you’d see in a standard HIE, as there are very specific data elements that you need to see for crisis. Right now folks are looking in seven different systems, and in crisis, that’s not efficient as you can imagine.

Also around crisis, we are improving our call centers. It’s a very old-fashioned process right now, so we are building a connection from the call center to the HIE that would rout a crisis call to the mobile team as a direct referral, and they would be able to pull that directly into the EHR. An added benefit of that is if there happens to be patient match, and in crisis that’s not easy because patients don’t always give their real names, we can pick up any other HIE data that we might have that they didn’t relay on the phone call. The team can then document that back in the EHR, and close that loop back to the call center. 

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Report: ACOs Continue to Grow, Now Serve 16 Percent of U.S. Population

Report: ACOs Continue to Grow, Now Serve 16 Percent of U.S. Population | Healthcare and Technology news |

The number of accountable care organizations (ACOs) continued to rise in the past year, though at a slower pace than in 2013, according to new research from consulting firm Oliver Wyman.

Almost 70 percent of the U.S. population now lives in localities served by ACOs, and 44 percent live in areas served by two or more. The total number of ACOs participating in Medicare programs has increased to 426, up from 368 in January 2014 and 134 in January 2013. Oliver Wyman has identified an additional 159 ACOs, bringing the estimated total to 585, up from 520 in January 2014, and 260 in January 2013.

The figures from the firm are based on the Department of Health and Human Services’ (HHS) announcement of the latest class of ACOs approved to participate in Medicare’s ACO programs. The firm further found that about 5.6 million Medicare beneficiaries, or about 11 percent of total Medicare beneficiaries, now receive their healthcare from ACOs participating in Medicare’s ACO programs. These organizations also provide care to 35 million non-Medicare patients, about 6 percent more than last year. And ACOs collectively serve between 49 and 59 million U.S. residents, or between 15 and 17 percent of the population, according to the research.

“The slowdown we’re seeing in the growth of ACOs was almost inevitable, given the pace of change of the past two years,” said Niyum Gandhi, a partner in Oliver Wyman’s Health & Life Sciences practice. “The next big spurt will be more in effectiveness and sophistication than it will be in growth in numbers of ACOs.” Gandhi also cites that the changes to the rules that the Centers for Medicare & Medicaid Services (CMS) proposed this past winter, especially the Next Generation ACO model, could give ACOs the boost they need to compete more aggressively. “ACOs have reached an important point in their evolution. The best deliver care at 10 or more percent below average with excellent quality and patient satisfaction. But most have not progressed nearly that far,” Gandhi added.

These results come in spite of the well-publicized departures from Medicare’s Pioneer ACO Program. A recent study from Harvard Medical School on Medicare Pioneer ACOs found that while the program achieved a savings of $118 million in its first year, the program needs tweaking, citing the 13 ACOs that dropped out of the program after 2012, despite achieving savings that were similar to those that stayed in the program.

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HIMSS15 Provides Both Clarity Confusion

HIMSS15 Provides Both Clarity Confusion | Healthcare and Technology news |

For the first time since 2009, the HIMSS Annual Conference & Exhibition was back in its hometown of Chicago this year. And, with more than 43,000 attendees and 1,200 exhibiting vendors flocking to McCormick Place Convention Center, this proved to be the largest HIMSS conference on record. Many of the same pressing topics from HIMSS14 were prevalent again at this year’s event — namely interoperability and population health management.

A Step Forward For Interoperability

Interoperability continues to be one of the biggest challenges facing the health IT industry. And, thankfully, HIMSS15 actually seemed to provide some much needed direction in this area as opposed to just rhetoric.

For example, HIMSS15 provided one of the biggest venues for health IT industry leaders to sit down with members of the ONC to discuss the nationwide Interoperability Roadmap that was drafted earlier this year. This roadmap charts a path for the health IT industry to achieve interoperability progress in 3, 6, and 10 years using core critical building blocks identified by the ONC.

The ONC even organized several listening sessions dedicated to fostering industry collaboration on the Roadmap. One, titled Advancing Interoperability and Standards, was open to all HIMSS attendees and aimed to answer questions, provide clarity, and set realistic expectations surrounding the Roadmap. Another, titled ONC Interoperability Listening Session With Health IT Developers, was specifically designed for the software developer community to discuss the unique challenges and opportunities associated with developing an interoperable infrastructure for health IT. Yet another ONC interoperability listening session targeted clinicians in an effort to gain a better understanding of their interoperability demands.

The ONC’s take on interoperability was summed up well by the organization’s National Coordinator Karen DeSalvo, MD during her keynote on Thursday morning.  During her speech, DeSalvo referenced that she participated in dozens of similar interoperability listening sessions throughout the year and she believes the path to health IT interoperability hinges on three primary objectives:

  1. Creating standardized standards, including APIs;
  2. Improving clarity regarding the trust environment, particularly data security and privacy; and
  3. Establishing sustainable and durable incentives that promote interoperability and appropriate use of health information between systems.

Finally, HIMSS15 once again featured an Interoperability Showcase, where more than 50 sponsoring vendors offered first-hand demonstrations as to how their technologies could be leveraged to deliver health IT interoperability in a variety of care settings. This year’s Interoperability Showcase was the largest landmark on the exhibit floor and provided visitors with real-world insight into how interoperability can be achieved.

A Muddled Population Health Management Message

While HIMSS15 did an admirable job of attempting to clarify the interoperability dilemma facing health IT and the go-forward strategy, I believe it had the opposite effect in regards to Population Health Management (PHM). PHM was one of the biggest buzzwords at HIMSS15. Just about every other vendor on the exhibit floor promoted how its product or service was instrumental in the PHM equation. I can’t help but think that all of this noise was confusing to the providers in attendance searching for an effective PHM solution.

From my perspective, HIMSS15 clearly illustrated the clear need for a universally accepted definition for PHM in the health IT industry. I must have spoken to executives from more than a dozen self-proclaimed PHM vendors at HIMSS, and I never heard the term defined the same way twice.

Rather than simply complain about the lack of an agreed upon PHM definition, I thought I might take a crack at getting the ball rolling toward this end. Based on my conversations at HIMSS and my editorial coverage on PHM to date, a true PHM initiative must include the following key elements:

  1. It must incorporate data aggregation from multiple sources;
  2. It must include the analytics technology necessary to turn that aggregated data into actionable intelligence;
  3. It must provide workflow tools to facilitate/automate case management and care coordination; and
  4. It must deliver mechanisms for patient engagement and feedback.

In my opinion, if a vendor product or service doesn’t address all four of these areas, then it only solves part of the equation, and isn’t a true PHM solution. While I doubt the list of criteria outlined above is the universal PHM definition the industry needs, I believe these elements provide the building blocks upon which that definition can be based. What factors am I missing? How can we round out this rough skeleton to create an accurate PHM definition that clarifies the concept as opposed to leaving it up to multiple interpretations? I’d be interested in your thoughts and feedback.  

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More Patients, Not Fewer, Turn To Health Clinics After Obamacare

More Patients, Not Fewer, Turn To Health Clinics After Obamacare | Healthcare and Technology news |

Nurse practitioner Martha Brinsko helps a lot of patients manage their diabetes at the Charlotte Community Health Clinic in North Carolina.

“Most mornings when you check your sugar, what would you say kind of the average is?” Brinsko asked patient Diana Coble.

Coble hesitated before explaining she ran out of the supplies she needs to check her blood sugar levels, and she didn’t have the gas money to get back to the clinic sooner. Brinsko helped Coble stock up again.

“If you need to get more than one box, get more than one box,” Brinsko said. “But you need to check them every morning so that we can adjust things.”

Coble, who is unemployed, lives with her sister and can’t afford insurance even now that the health law is in place, relies on the clinic for health care.

“They do a great job with everything,” Coble said. “I couldn’t do without them.”

Nancy Hudson was the clinic’s director as Obamacare rolled out and now consults for the clinic. She expected the insurance exchange, or marketplace, established under the Affordable Care Act would reduce the number of uninsured patients the clinic sees. The opposite happened, she says.

“What we found within our patient population and within the community is that a lot of the advertisement and information about the marketplace brought people [in who] didn’t know anything about free clinics and did not qualify for any of the programs within the ACA marketplace,” Hudson says.

And now they get free or low-cost care at the clinic, which is designated by the government at an FQHC, or federally qualified health center.

The health law was designed to cover the poorest people by expanding Medicaid, the federal-state program for low-income people. But the Supreme Court made that optional. The result in states that didn’t expand Medicaid is a gap, where some people make too much money to qualify for Medicaid but not enough to qualify for insurance subsidies. In North Carolina, about 319,000 people, like Coble, fall into the Medicaid gap.

“Over half of the people that we see would’ve been eligible for Medicaid expansion had the state elected to exercise that option,” says Ben Money is president of the association that represents North Carolina’s community health centers.

North Carolina is among the 21 states, including many in the South, that are currently saying no to Medicaid expansion. Louisiana is another.

Dr. Gary Wiltz, the CEO of 10 community health centers in the southwestern part of Louisiana, says demand has surged. “We’ve gone from 10,000 patients to 20,000 in the last six or seven years, so we’ve doubled,” he says.

Wiltz says other things are at play, too. The economic recovery hasn’t reached many of the poorest people, and some who do qualify for Obamacare subsidies say their options are still too expensive.

“The need keeps increasing, and I think that’s reflected throughout all the states,” he says.

Wiltz, who also heads the board of directors for the National Association of Community Health Centers, says clinics are packed even in states that expanded Medicaid. After all, most of the clinics treat Medicaid patients too.

The Charlotte clinic’s Nancy Hudson says there’s another part of the health law helping fuel the growth: additional funding for community health centers.

Hudson found out last week her clinic is getting about $700,000 to expand in partnership with Goodwill.

“Many of their clients did not have any access to health care,” she says. “They can’t train and sustain a job if they don’t have the basic needs taken care of, and health care is one of them.”

Nationwide, the federal government estimates its latest round of funding will lead to about 650,000 people getting better access to health care.

This story is part of a reporting partnership with NPR, WFAE and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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Reflecting on the Clash of Incentives Around “Information-Blocking” in the Push Towards the New Healthcare

Reflecting on the Clash of Incentives Around “Information-Blocking” in the Push Towards the New Healthcare | Healthcare and Technology news |

As Healthcare Informatics reported last month, the Office of the National Coordinator for Health Information Technology (ONC) released a report in early April that highlighted what the federal healthcare IT agency referred to as “information-blocking.” As Senior Editor Gabriel Perna noted in his April 10 report immediately following the release of the ONC document, “The report’s authors and researchers detailed several examples of electronic health record (EHR) developers and health systems blocking health information sharing between each other. The act of information blocking occurs when an entity or person knowingly and unreasonably interferes with the exchange of electronic health information. Examples of this,” he noted, “are charging prices and fees for data exchange; creating terms of a contract that restrict individuals access to their health information; developing health IT in a non-standard way that dissuades information sharing; and developing health IT in a way that locks in information.”

The ONC cited examples in its report of anecdotal evidence suggesting that “EHR application developers are breaking several of the rules in this regard,” Perna’s report noted. “Using interviews with people at regional extension centers (RECs), the authors detailed complaints from industry sources on how developers are charging fees that make it cost-prohibitive to send, receive, or export electronic health information stored in EHRs. Some EHR developers even charge a substantial transaction fee any time a user sends, receives, or queries a patient’s electronic health information, the report says. The variation in prices reported to ONC suggests that some are taking advantage of the situation.”

In announcing the availability of the report, National Coordinator for Health IT Karen DeSalvo, M.D. noted in a blog on the agency’s website that it is difficult to pinpoint concrete evidence of information-blocking. “The full extent of the information blocking problem is difficult to assess, primarily because health IT developers impose contractual restrictions that prohibit customers from reporting or even discussing costs, restrictions, and other relevant details,” she noted. “Still, from the evidence available, it is readily apparent that some providers and developers are engaging in information blocking,” she said.

Given all this, I read with interest a May 20 blog in Health Affairs online by Julia Adler-Milstein on this subject, because of the clear way in which she frames the dynamic tension taking place right now in the industry between the forces that would restrict information for profit or proprietary gain, and those that would advance it for the common good. AsAdler-Milstein, who is an assistant professor of information in the School of Information and an assistant professor of health management and policy at the School of Public Health at the University of Michigan, states very bluntly in her blog, “When it comes to sharing electronic patient health information, public good should trump private gain. While it may seem like an obvious statement, it represents a tectonic shift in the narrative surrounding health information exchange,” or HIE.

As Adler-Milstein notes, “For more than a decade, our federal strategy has largely left HIE to the market under the assumption that, if there is benefit to be created (and estimates suggest that there is), we should see the emergence of ways to capture that benefit. In practice, this means that HIE efforts have sprung up in various health care markets across the country, and where public money has been spent on HIE (largely at state and community levels), it has come in the form of one-time start-up funding, not a commitment of ongoing support or regulatory mandates for HIE participation.”

Here’s where Adler-Milstein really scores a home run on this, in my view: “What has been substantially underappreciated, however,” she writes, “is the fact that, for the key actors needed to enable HIE to occur—provider organizations and vendors—there might be more benefit, or at least more certain benefit, from not doing so. And as a result, these actors may behave in ways that interfere with the free-flow of patient information that is needed to improve health and health care.”

Instead, she says, “With the release of the information blocking report, which was produced in response to a 2015 Omnibus bill request that introduced the term ‘information blocking,’ ONC makes plain that this behavior will no longer be tolerated. This enormously exciting development means we might see real progress after decades of investment that has failed to convert into sustainable approaches to robust HIE. The key to such progress, however,” she warns, “lies in how well we can identify when information blocking is occurring. This will not be easy.”

And in those short paragraphs, we can see some of the core opportunities and challenges moving forward in this critical area. In this arena as in so many others in healthcare, we see a dynamic tension based on conflicting incentives within the U.S. healthcare system. On the one hand, there is broad consensus that data- and information-sharing will be essential to accountable care organization (ACO) development, population health management, bundled payment-facilitated care delivery, patient-centered medical home work, and indeed, every iteration of the new healthcare. Yet at the same time, there are many elements embedded even in those concepts that speak to at least short-term—and certainly arguably, medium-term as well—market advantages that can be gained through data- and information-hoarding.

It is this clash of incentives that we are collectively burdened with at this early stage of the trajectory towards the new healthcare. The rhetoric around healthcare policy right now is all about sharing for common gain, and yet the incentives in the moment are far from purely conducive to—well, purity.

That’s why it’s good to be reminded at times like this by elegantly concise writings like those of Julia Adler-Milstein. Adler-Milsteiin’s blog reminds us what the ultimate prize is, on which we should at least theoretically all be setting our eyes. This is not to engage in the laying of blame on those working for specific market advantage, but rather to affirm the need to continue to push forward collectively as an industry and indeed as a society, towards a more mature healthcare system—one in which all the incentives really all will be aligned. In other words, keep watching this space.

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Is This Population Health’s Moment? Time for Data and Analytics

Is This Population Health’s Moment? Time for Data and Analytics | Healthcare and Technology news |

Every year, the annual HIMSS Conference, sponsored by the Chicago-based Healthcare Information and Management Systems Society, offers its attendees a kind of conference-based snapshot of where the U.S. healthcare industry is with regard to the forward evolution of healthcare information technology adoption, as well as a sense of the overall policy and operational landscape of healthcare. Attendees can get a sense of the healthcare IT Zeitgeist through attending keynote addresses, educational sessions, association meetings, and networking-focused gatherings, as well as by wandering the exhibit hall and simply by having meaningful conversations with fellow attendees.

HIMSS15, held at the vast McCormick Place Convention Center in Chicago the week of April 12, offered perhaps the clearest portrait of the current moment that has yet been offered to date. Session after session focused on the shift beginning to take place from volume-based healthcare reimbursement to value-based payment, across a very wide range of mechanisms, between providers and both the public and private purchasers and payers of healthcare, and the implications of that shift for healthcare IT leaders.

Further, as part of the keynote session on Thursday, April 16 in the Skyline Ballroom at McCormick Place, Andy Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services (CMS), made the intentions of federal authorities crystal clear, when, referencing the statement of Health and Human Services Secretary Sylvia Mathews Burwell in January that she wanted the bulk of Medicare fee-for-service payments to providers to shift as quickly as possible over to quality- and value-based payment, Slavitt said, “Our priority is simple: to drive a delivery system that provides better care, smarter spending, and keeps people healthier. The success in the first five years since the Affordable Care Act has been very encouraging… Our agenda now,” he said, “is to get busy strengthening these gains. That will mean that more providers in more communities will need to be able to transform the care they provide so that they will benefit from value-based reimbursement. And they will need technology to help them get there.”

What’s more, in his keynote address two days earlier, Humana CEO Bruce Broussard had told HIMSS attendees, “We have to change the conversation on what we are doing in healthcare from a supply-based system to a system around demand, a system where we put the customer first as opposed to the system. Over the years,” he added, “healthcare has been built by creating more and more supply. I hope I leave today by convincing you that we have to change the focus towards how we improve health for our customers, members, and patients.”

The good news on the solutions side of this landscape is that vendors are rushing forward to provide population health- and accountable care-driven analytics solutions, at a time when such solutions are most desperately needed. Certainly, the hype at HIMSS15 was all around population health, care management, and accountable care solutions. The only question now, as the U.S. healthcare industry hurtles forward into the near future, is, is this a breakthrough moment for population health efforts? And if so, are provider and health plan leaders ready to effectively leverage the tools to make pop health really happen?

The long journey ahead

Leaders from all sectors of healthcare understand that the journey to population health and value-driven care delivery and payment success is going to continue to be a long, challenging one. Donald W. Fisher, Ph.D., president and CEO of the Alexandria, Va.-based American Medical Group Association (AMGA), says he and his colleagues are putting the vast bulk of their efforts into helping prepare physician group leaders for the transition. “We’re not quite there yet, and as we change to a new reimbursement system, even the large, sophisticated medical groups are going to need a few years to make the transition,” Fisher says.  “You’ve got to put the infrastructure in place, and the large integrated health systems have been putting those elements in place—EHRs [electronic health records], alert systems, analytics systems, data warehouses—and some have teams of people mining the data to assess patient status.”

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Why We Need Design Thinking In Healthcare

Why We Need Design Thinking In Healthcare | Healthcare and Technology news |

The one given across all sectors of healthcare today is that change is coming, and not the gradual kind. This is multi-billion-dollar, build-up while tearing down kind of change. If that change is to lead to dramatic improvements in the effective and efficient care of patients, our systems must be redesigned, not re-engineered. Here's why: It's a matter of life and death.

On Sept. 25, 2014, Eric Duncan reported to the emergency department of the Texas Health Presbyterian Hospital Dallas with a low-grade fever, abdominal pain, dizziness, and headaches. When he returned to the hospital on Sept. 30 and was diagnosed with Ebola, the question asked by nearly everyone paying attention (and we all were) was, "How could the doctors and nurses have missed the telltale signs of Ebola presenting in a man just returned from west Africa?"

The hospital's first response was to blame a design flaw in its electronic health record (EHR) system that prevented travel history data entered by nurses from presenting itself to doctors. It later retracted that claim, stating, "There was no flaw in the EHR in the way the physician and nursing portions interacted related to this event." The system behaved exactly as it was intended to.

So was there a flaw? Absolutely. The system was built with the assumption that the people using it should conform the way they work to the way the EHR was built, rather than the other way around. In other words, like most healthcare systems, their EHR was engineered.

Design, on the other hand, begins by gaining an understanding of how a system is likely to be used within a given environment and creating that system accordingly.

For those on the delivery side of healthcare, it is not news that very few of our systems are created with consideration of how they'll actually be used.

Our methods of "handing off" patients from one clinician to another create deadly information black holes and miscommunications. The devices in our incredibly sophisticated Intensive Care Units emit a cacophony of competing sounds, causing nurses and doctors to ignore the occasional deadly warning. Clinicians cut and paste pages of text into the notes sections of electronic medical records, ensuring adequate documentation for billing, but burying potentially critical details. In fact, health services researchers have filled medical libraries with details of poorly designed systems that contribute to the accidental deaths of hundreds of thousands of patients globally each year.  

So why the urgent need for design in healthcare now? There are three macro-level developments that are combining to create a perfect storm of change in healthcare.  

  1. Payment reform. The shift from "fee for service" toward a "fee for value" reimbursement will affect nearly every aspect of care, from who pays, to where and how care is provided.
  2. Healthcare goes digital. Significant government investments, including up to $44,000 per adopting clinician, have driven electronic medical record adoption from 11% in 2007 to 78% in 2014. In turn, healthcare is increasingly awash in data that has yet to be widely employed to improve care.
  3. Affordable high throughput sequencing. The dropping cost of reading a human's DNA is leading to a fundamental rethinking of disease and biology, and  to new classes of drugs and diagnostics. The implications of what is sometimes called "personalized medicine" will affect everything from how clinicians will make sense of mountains of new data, to how IT departments will store it, and how payers will reimburse for it.

Each of these impending changes represents fundamental change to existing processes, systems, and structures. Success in transforming these systems will be dictated by good or bad design -- regardless of whether designers are involved (they are usually not) or even if it's recognized that "design" is actually what is taking place (it usually isn't).

What Exactly Is "Design?"

Most of the healthcare industry views designers as a luxury afforded to consumer product companies. They are the more-stylish-than-thou gurus who use words like "metaphor" and "user experience." Sure, one or two wander into healthcare now and then, adding a bit of contrast to our drab lab coats and beige walls.  

But the need for design is popping up in more industries these days. The notion of involving designers in improving healthcare pinged twice for me in a couple weeks -- once at a meeting and once during lunch with a colleague. That's enough of a sign that I had some homework to do in order to figure out what exactly they were talking about. I had heard one or two interesting talks from designers about their work in re-orienting the architecture of hospitals to "promote" health, and of wheelchairs designed to climb stairs. But what design had to do with the type of health-system-improvement work we do at Ariadne Labs wasn't obvious to me.

So, I started knocking on the doors of designers. I met with the founders of the design firm Invivia, the co-founder of the strategy firm Jump Associates, and spoke with the lead designer at the HELIX Center. I watched videos, read the books they suggested, and asked questions.

In short, I learned just enough to be dangerous, so let me offer a disclaimer. There is an enormous difference between the abilities and approaches of those that have mastered their fields and those of people just learning them. Unlike the novice musician or chef, the masters are so proficient with the tools of their trade that they are no longer restricted to sheet music or recipes. My intent isn't to make master designers out of clinicians or health IT professionals (nor of me) but to show just how important and accessible the basics of design truly are. While I'll surely misrepresent aspects of this field, I am convinced that

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Connecticut Legislature Considers Giving Statewide HIE Another Try

Connecticut Legislature Considers Giving Statewide HIE Another Try | Healthcare and Technology news |

Although it is surrounded by states that have had relative success with statewide health information exchange efforts, Connecticut has struggled to develop an HIE. Last year it pulled the plug on its earlier efforts after spending $4.3 million in federal grant money. But legislators are taking another stab at it. Last week the state Senate passed a comprehensive healthcare bill that would establish a statewide HIE, according to the Connecticut Mirror, an online publication. 

The Mirror story quotes Senate Minority Leader Len Fasano, R-North Haven, as warning that the lack of a neutral, statewide system can give large health systems a business advantage, steering patients to other providers within the same system.

In written testimony earlier this year, Yale New Haven Health System noted that an earlier form of the bill did not take into account what many hospitals are already doing to share data and provide access to healthcare agencies and community physicians.

Between 2010 and 2014, the Health Information Technology Exchange of CT, or HITE-CT, spent $4.3 million unsuccessfully trying to create an exchange before being shut down by the state.

A state auditor’s report noted that the exchange was never able to provide services to stakeholders and thus, never developed a self-sustaining revenue stream.

“HITE-CT was unable to meet its strategic and operational schedule primarily due to its inability to adapt quickly to changing market conditions. The exchange’s board of directors recognized that the terms in the original contract with its vendor required significant modification to reflect the evolving market place for an integrated statewide electronic health information infrastructure,” the audit said. “A lengthy renegotiation period with its primary vendor reduced the exchange’s options for achieving sustainability. The resulting amended contract with the vendor had a reduced scope for deliverables. It no longer included the establishment of an operational statewide health information exchange that could provide desired revenue producing services to stakeholders through fees and other assessments.”

The responsibility for health information exchange efforts rests with the state Department of Social Services, and the bill allows DSS to propose an alternative solution to a centralized statewide HIE, the Mirror article said. The bill now goes to the Connecticut House for consideration.

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Curbing medical errors with the cloud

Curbing medical errors with the cloud | Healthcare and Technology news |

Medical errors. The term is frightful to everyone involved in healthcare: not just the patients, but the doctors, staff, and administrators as well. A July 2014 Senate hearing on patient safety revealed that medical errors were the third most prominent cause of death in the United States, directly behind heart disease and cancer. Erin McCann of Healthcare IT News reports that these medical errors cost the nation a colossal $1 trillion each year. 400,000 Americans die annually due to these preventable mistakes.

What to make of that number, 400,000? Forbes contributor Dan Munro suggests that the same number of people would be killed if the largest commercial plane, an Airbus A-380, fell from the sky each day throughout the year. 

Deaths aren’t the only thing to be concerned about, though. Medical errors also lead to 10,000 major complications daily.  It is reported that misdiagnosis affects 12 million patients per year. Why, with all this amazing technology, are medical errors still occurring? Our amazing healthcare IT systems come along with challenges and revolutionary potential, both of which are addressed by the health data cloud.

Challenge – interoperability

Registered nurses specifically mentioned interoperability issues between different systems and devices as a major reason mistakes are made. Their perspectives were collected through a survey by the independent Gary and Mary West Health Institute.

Three in five nurses (60 percent) said that there would be fewer errors if medical equipment was completely integrated and drawing on the same information rather than relying on manual transcription. "I have seen many instances where numbers were incorrectly transcribed or put in reverse or put in the wrong column when typed manually, which can cause errors," one registered nurse commented in the survey.

Even more shocking: 50percent of RNs told the researchers that they had seen an error occur because hardware was not coordinated. Nurses must often set up digital devices and gauge the information they present; they also must regularly jot down numbers from one device and input them into others if they aren’t interoperable.

Since medical errors are not just a consumer safety issue but are also incredibly costly to healthcare companies, West Health Institute argued that the total savings to be achieved by integrated healthcare infrastructures could reach $30 billion.

How do you solve this interoperability issue? Simple, said Edmund Billings, MD: “Cloud-based interoperability, which has revolutionized travel, banking and shopping, could yield great benefits in healthcare as well.”

Revolutionary potential – EHR & big data

Mansur Hasib of Information Week believes that two basic elements – electronic health records and artificial intelligence – could help to reduce mistakes that occur in healthcare settings. EHR provides consistency to the data (assuming there aren’t interoperability issues resulting in inaccurate information). Artificial intelligence essentially gives local doctors remote access to the knowledge and skill of top-notch doctors. 

Data from electronic health records could easily fuel artificial intelligence environments – systems that are becoming smarter every day, as groups of prominent physicians work with tech companies to create AI programs that can provide a seasoned professional opinion related to any treatments or recommendations in real-time. Hasib asserts that access to that broader pool of knowledge will minimize the number of errors that are made in hospitals as the remote AI system can provide an immediately available second opinion. 

Since the basic building block of AI is big data, artificial intelligence is just one way healthcare cloud data analytics can be used to improve quality of care. Since healthcare data on a cloud can now be updated within a few minutes of changes in the source systems, it can empower doctors, payers, and national health systems to identify gaps in care, perform prescriptive analytics, provide interventional decision support, optimize treatment plans…the possibilities are limited only by one’s imagination.

Big data is not just about building AI systems but all types of applications to provide clinicians and administrators with a more robust picture of treatments and processes – in turn leading to fewer mistakes and healthier healthcare.

Rhedyn Duncan's curator insight, March 25, 2016 3:19 AM

Over 400,000 Americans die each year due to incorrect medication administration. I found this to be a truly shocking figure. This blog calls for the urgent development of an electronic system to administer medications. I think this is vital. This topic is partially sensitive to me because I have seen the potential dangers first hand. During a recent human performance workshop, which I had to attend with Rio, medical errors were presented as an example to explain the importance of correct health and safety interventions, and the fact that it can save lives. 


One of the speakers used true story about how an accidental heparin overdose nearly killed the infant twins of actor Dennis Quaid. Outraged by the hospital’s mistake Dennis and his wife did some further research into how the error occurred, and found it has happened on many occasions before. This is due to the adult dose and the infant dose being packaged in nearly identical bottles. 


With an ageing population, I believe that current pressures on the hospital system will continue to increase, possible leading to an increase in human error with medication administration. These mistakes must stop. I definitely agree with this scoops notion of automated medical systems to all, and removing the chance of human error from the process completely.!

The Smoking Gun: How U.S. Health Care Came to Cost Insanely More

The Smoking Gun: How U.S. Health Care Came to Cost Insanely More | Healthcare and Technology news |

Cost is the big factor. Cost is why we can’t have nice things. The overwhelmingly vast pile of money we siphon into health care in the United States every year is the underlying driver of almost every other problem with health care in the United States from lack of access to waste to fragmentation to poor quality. We can’t afford to fix the problems, cover everyone, do real outreach, build IT systems that are interoperable and transparent and doc-friendly — or so it seems, because at least on weak examination every fix seems to add even more cost. And in the old ways of doing things in health care, the way we have been used to doing business, the conclusion of the weak examination has been correct: Despite the tsunami of money, there is never enough to do it right.

Health care that costs more than it needs to is not just an annoyance; it’s a big factor in income inequality in the United States. The financial, physical and emotional burden of disease are major drivers of poverty. At the same time, the high cost of health care even after the Affordable Care Act means that many people don’t access it when they need it, and this in turn deprives large swathes of the population of their true economic potential as entrepreneurs, workers and consumers. People who are burdened by disease and mental illness don’t start businesses; don’t show up for work; and don’t spend as much money on cars, smartphones and cool apartments. Unnecessary sickness is a burden to the whole economy.

How did we get this way? What was the mechanism that differentiated U.S. health care from all other advanced countries? The usual suspects (such as “We have the most sophisticated research and teaching hospitals,” or “It’s the for-profit health insurers” or “Doctors make too much”) all fail when we compare the United States with other sophisticated national systems such as those in Germany and France. Other countries have all of these factors in varying amounts — private health insurers, world-class research, well-paid physicians — and cost a lot, but still spend a far smaller chunk of their economy on health care. Blame has been leveled in every direction, but in reality no single part of health care has been the driver. The whole system has become drastically more expensive over the last three decades.

What’s the Mechanism?

Since the difference between the United States and other countries is so large and obvious, there should be some way we can look at health care spending that would make that mechanism jump out at us. And there is a way.

The Organization for Economic Cooperation and Development (OECD) gathers and publishes huge amounts of information about the top 40 or so national economies in the world. Go online and search for its database on national health expenditures as a percentage of each country’s economy. Don’t just look for recent data. We already know what that says: The United States throws twice as large a chunk of its economy into health care as most other countries; 50 percent more than the most expensive other countries. No, take the search back to the middle of the last century. Pull the data into a spreadsheet. Make the spreadsheet into a graph. Here’s what you get:

Wow. Suddenly a rather startling pattern emerges. Right side: Yes, the United States costs twice as much. Left side: Didn’t use to.

As economies grow in absolute size, they tend to dedicate a greater percentage to health care. After a certain point, somewhere around 9 percent, the cost continues to increase, but the rate of increase tends to flatten somewhat. Through the ’60s and ’70s we can see that happening. The United States, as the largest economy, is one of the most expensive, but it’s just there at the top of the pack. In the mid-1960s Medicare is implemented — the first big infusion of federal money into the health care economy — and does the U.S. line jump up? Not really. It flatlines for a year, then continues its moderate climb.

Something Wicked This Way Comes

Then something happens which is stark, sudden and large. Health care economies tend to lag national economies by a year or two; in bad economic times governments and private purchasers can’t cut health care expenditures immediately, but they do tighten their belts for the future. At a moment when the other most expensive health care economies (Germany, Sweden, Denmark) are flatlining or drifting lower in response to the global economic malaise of the early 1980s, the U.S. line goes nearly vertical, flatlines for a year or so, then leaps ever higher in a series of startling S-curves.

That first big leap is between 1982 and 1983. What was different in 1983 that was not there in 1982? DRGs, diagnosis-related groups — the first attempt by the government to control health care costs by attaching a code to each item, each type of case, each test or procedure, and assigning a price it would pay in each of the hundreds of markets across the country. The rises continue across subsequent years as versions of this code-based reimbursement system expand it from Medicare and Medicaid to private payers, from inpatient to ambulatory care, from hospitals to physician groups and clinics, to devices and supplies, eventually becoming the default system for paying for nearly all of U.S. health care: code-driven fee-for-service reimbursements.

Cost Control Drives Costs Up?

How can a cost control scheme drive costs up? In a number of ways: In an attempt to control the costs of the system, the DRG rubric controlled the costs of units, from individual items like an aspirin or an arm sling to the most comprehensive items such as an operation or procedure. The system did not pay for an entire clinical case across the continuum of care from diagnosis through rehab; or for an entire patient per year on a capitated basis, which would capture the economic advantages of prevention; or for an entire population. While it is more cost-effective (as well as better medicine) to provide a diabetes patient with medical management, in-home nursing visits and nutritional counseling rather than, say, waiting until the patient needs an amputation, the coding system actually punished that efficiency and effectiveness. Under this system, we got paid for our inefficiencies, and even for our mistakes: Do-overs would often drop far more to the bottom line than the original procedure did.

The system punished, rather than rewarded, spending more time with patients, trying to help patients before their problems became acute, or maintaining a long-term, trusted relationship with patients. Under a code-driven fee-for-service system, getting serious about prevention and population health management would be a broad road to bankruptcy.

If extra items were deemed necessary (an extra test or scan, say), there were codes for that, and reimbursements awaiting. In so doing, the system rewarded doing more (“volume”) rather than whatever would be the best, most appropriate, most efficient treatment path (“value”). It provided a written, detailed catalog of reimbursements which rewarded diagnoses of greater complexity, rewarded new techniques and technologies with new and usually higher reimbursements, and especially rewarded systems that invested in a greater capability to navigate the coding system. At the same time, the reimbursements were constantly open to pressure from the industry. Each part of the industry, each region, each specialty, each part of the device industry, became fiercely focused on keeping those reimbursements up, and getting new codes for more costly procedures.

The business and strategic side of health care became a matter of making money by farming the coding system. Do more of what gets better reimbursement, less of what does not. Make sure every item gets a code and gets charged for. The codes became a manual for success, a handbook for empire.

Zeke Robinson's curator insight, May 26, 2015 9:21 PM

they shouldnt price healthcare so high it drives me crazy.people die because its so expensive.!

Physicians Need to Take Time for Themselves

Physicians Need to Take Time for Themselves | Healthcare and Technology news |

Doctors and their office staffs, like nearly everyone else, are living to ripe old ages. As such, they need to pace themselves for the long haul. A personal story helps illustrate the point: I worked with my friend Peter, for Smyth Manufacturing Company, the famed book binding equipment manufacturer, the summer before we entered college. It was my only time in a job shop, and I learned many lasting lessons, such as the importance of cleanliness in an industrial setting.

Before you left for the evening, you oiled your machine, wiped the floor and counters, and cleared away scraps and extraneous items so you could begin the next day without impediments. The craftsmen sometimes elaborately cleaned and reorganized items in the middle of the day as well, as they switched from one job to another. When you're working with potentially dangerous industrial equipment, you can't afford to have a stray bolt or paper clip lying around that could catch in a gear and fly across the factory floor into someone's face.

Control of their immediate environment

As deftly as these job shop professionals worked, they continually maintained control of their immediate environment because they understood its importance on many levels. In case you think they were being overly cautious or were paid some admirable hourly wage, guess again. These workers were paid by the piece, and they were known as "piece workers."

Any one of them could have easily increased their output on a given day by slacking off on cleaning and maintenance procedures. After all, if you can turn out seven pieces in a day spending 30 percent of your time cleaning and maintaining, you might be able to produce more than 10 pieces if you completely concentrate on your output. In the short-term, you could make more money. Longer term, you could injure yourself or others, create more waste, shorten the equipment's life, or get fired.

The lesson for us all: "pay as you go," clear the decks each night, arrive ready for the next day, and pace yourself for the long haul.

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An Appreciation for the Evolving Role of Nurses in Health IT

An Appreciation for the Evolving Role of Nurses in Health IT | Healthcare and Technology news |

It’s National Nurses Week (May 6-12), and before I get into the meat and potatoes of this blog, I’d like to take a moment to thank all of healthcare’s nurses for their continuing hard work and effort day in and day out. I’m someone who usually thinks that there are too many days and weeks devoted to people and groups, but I make an exception for this profession. To use a sports term referring to the most indispensible players on the team, even if not flashy, nurses are the “glue guys” in the healthcare industry.

In health IT specifically, nurses’ roles continue to grow in scope and importance. According to a June 2014 post from Kate Goddard, senior analyst at the Washington, D.C.-based The Advisory Board Company, “Engaging nurses is critical to the success of clinical IT-enabled initiatives. Nurses are often the first and last point of contact with a patient and, therefore, the first and last opportunity to prevent an error. This makes them an enormous asset in ensuring that clinical information systems do no unintentional harm to patients.”

In patient care organizations nationwide, informatics nurses continue to bring great value to the use of clinical systems and technologies at their healthcare organizations, according to the 2015 HIMSS Impact of the Informatics Nurse Survey. The results of the survey, released at the Healthcare Information and Management Systems Society annual conference in Chicago last month, indicated that informatics nurses bring greatest value to the implementation phases (85 percent) and optimization phases (83 percent) of clinical systems process.

What’s more, one-fifth of those survey respondents reported working for an organization that employs a chief nursing information officer (CNIO), a role that’s emerging as a major transformational leader in this era of healthcare reform. To this end, HCI Editor-in-Chief Mark Hagland just recently interviewed Judy Murphy, R.N., who last year became chief nursing officer and director, Global Business Services, at IBM Healthcare. Prior to that, Murphy had been chief nursing officer and director of the Office of Clinical Quality and Safety in the Office of the National Coordinator for Health IT (ONC).  Murphy is extremely well connected in the clinical IT world, and is a prime example of how nurses can be fabulous informatics leaders, a trend that is developing across healthcare organizations.

Indeed, the role of nurses in health IT continues to evolve. Last year, I wrote a story about eICU technology from the Andover, Mass.-based Philips, being deployed at the Baptist Health Eye Center building on the Baptist Health Medical Center-Little Rock (BHMC) campus in Arkansas.  There, the eICU control center acts as an air traffic control center, giving the ICU staff an extra set of eyes and ears, Vicki Norman, R.N., director of eICU care at Baptist Health, told me. At Baptist, physicians and nurses are staffed in the eICU control center and act as additional support to monitor critical care patients, and provide faster response times through use of computer technology as well as audio and video components. Norman said there is a staff of 15 critical care physicians and 25 critical care nurses in the control center, of who average 20 to 25 years of experience.

Similarly, at the Arizona-based Banner Health, physicians and nurses with Banner’s eICU operations center, known as Banner Telehealth, located in Mesa, monitor ICU patients in 430 ICU beds in 20 Banner hospitals across five states. The program has seen a reduction in both mortality and length of stay, Banner officials say. In fact, over the past two years, Banner’s ICU mortality rates have been among the lowest on the country. In 2012, ICU actual length of stay was 20,000 fewer days than predicted, based on patient acuity; and total hospital days were reduced by 49,000. Costs avoided: more than $68 million, say Banner officials.

At Banner, Alice Sneed, R.N., a longtime cardiovascular nurse, decided to become a telehealth nurse eight years ago when she realized that she was getting up there in age, making 12-hour days on the floor very tough on her knees. Sneed has been a critical care nurse for more than two decades, and her role has evolved from being a bedside nurse to the manager of an eICU “central command center,” through which she can now monitor patients and provide insights to nurses who are in six different locations. While a bedside nurse can usually monitor five to six patients at a time, Sneed manages nearly 40-45 patients in several locations across the country.

“My knees were giving out, but knew I needed to do something that would enable me to continue to use brain, experience, and education, and not kill myself. I really like technology, I saw the potential, what it can do, and thought since I like change, new technology, and doing cool stuff, I might like this idea. So I jumped ship,” Sneed told me in a recent interview.

For Sneed, the experience is a far different one than physically being on the floor, and she said that it “takes a special type of nurse.” She said the atmosphere is not as rushed, quieter, and certainly not for adrenaline junkies. “My brain has had to become much more muscular,” she said. “You multitask on the floor, but you’re taking care of one or two patients. I might have 45 patients, but some in the medical ICU, or the neurological unit, or in a tiny unit ICU in Brush, Colorado. I need to think differently about everyone of those patients. I have had to learn, neuro, transplant, and sepsis. But statistically, we’re saving more lives because of the eICU.”

The aforementioned HIMSS survey also found that respondents reported a direct positive impact on the quality of care patients receive as a result of the work of informatics nurses. Specifically, 60 percent of respondents indicated that informatics nurses have a high degree of impact on the quality of care. No question, the work Sneed, Norman, Murphy, and all other R.N.s are doing in clinical IT serve as a great reminder to the power and impact that nurses have on all aspects of the healthcare ecosystem. Happy National Nurses Week!

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The Pain (and Gain) of Building a Private HIE in NYC

The Pain (and Gain) of Building a Private HIE in NYC | Healthcare and Technology news |
Frat Iqbal, senior manager of information management at New York University’s Langone Medical Center, led off his presentation at HIMSS15 in Chicago with two photos that provided a stark reminder of what happens when information doesn’t flow properly through the healthcare system. They were two pictures of his brother two years apart, one in full health and the other wheelchair-bound and permanently disabled by multiple sclerosis.
“It took two years to diagnose MS as he went from doctor to doctor, lab to lab,” he said. “His life was ruined by inefficiencies in the healthcare system.”
Iqbal said it is a reminder of the importance of improving patient care at the community level, of connecting all the small practices in New York so that data can flow from their offices to specialists, labs and hospitals. 
NYU Langone has been working to build a private health information exchange to link 200 practices and 1,900 clinicians using 26 different EHRs as the state and country work toward building larger exchanges.
The HIE was established in mid-2011 and privately funded by NYU Langone Medical Center. The goal was to become a central repository of clinical information for community providers to review, reference and share data and to provide 360-degree care to patients, Iqbal said.
Anthony Antinori, senior director of clinical affairs IT at NYU Langone, said a private HIE has advantages over a public one. “We can make decisions quickly. We have a small ecosystem of private practices and one governing body. We are local and funded by a private organization, with no federal or state funding required,” he said. The HIE is able to rapidly align itself with the strategic goals of the organizations it is serving, he added.
Instead of dictating which EHRs it would support, NYU Langone decided to work with whatever the providers had. “We left it open. If the EHR has the capability, we will integrate with it. It’s more headaches for us, but we did that for the community,” he said. 
They knew it was going to be challenging, and it has been, Iqbal said. “It is one of the most complicated projects I have ever embarked on,” he said. Interfacing with all those EHRs has been a “project management nightmare,” he added. Project prioritization has been tough, in terms of deciding which data is most valuable to the HIE. A whole team has been focused on privacy and security of the 4 million patient records in the HIE.
There are technical challenges, but more difficult have been cultural changes and setting the right expectations, he said. Many physicians are not inclined to share data and don’t want to change. Most EHRs are designed to retain, not share, information. 
Some providers are resistant to change. They don’t care if more information is available and they don’t want to share information. With these providers, you really have to make them realize the benefit the HIE brings to the table, he said. (Members of the NYU Provider Network are mandated to connect to the HIE.)
Legal and policy issues were a challenge. Getting data sharing agreements vetted by the practices, vendors and NYU Langone’s legal teams took longer than the integration itself. Consent policies are also difficult to work through, he said.
Despite the huge challenges in getting it set up, the HIE offers an array of benefits. Here are a few listed in the NYU presentation:
• Providers gain immediate access to valuable clinical data that provides a more holistic view of patient health when using the HIE;
• Providers will be able to reduce unneeded patient visits and lower the cost of care;
• Providers can begin to embrace the powerful benefits of trend and pattern analysis toward new decision-making frontiers;
• HIE facilitates evidence-based medicine and creates a potential positive feedback loop between health-related research and actual practice.
• Patients can expect improved payment coordination and smoother care transitions
• Duplicative procedures or tests will be reduced and visit satisfaction will be improved when patients opt to participate in the HIE;
• The collection and linking of data across the HIE facilitates extensive and robust community health records that can foster the ability to quickly detect, respond and efficiently prevent threats to public health;
• The HIE will also enhance public health practices at all levels of government through infectious disease case investigation and health surveillance.
The next step, he said, is analytical innovation that will pull together payer data, HIE data and Epic data from the hospital system to get more proactive at recognizing issues and monitoring patients and populations.
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A Strive Towards “Meaningful” Data Exchange in the Midwest

A Strive Towards “Meaningful” Data Exchange in the Midwest | Healthcare and Technology news |

Although the successful exchange of health data has been a struggle in most U.S. regions, a commitment to the free flowing of information on a patient’s history—regardless of what local healthcare facility they have been at—has helped spur health information exchange (HIE) in the Midwest.

Indeed, the Lewis and Clark Information Exchange (LACIE) is one of the first fully operational, multiple-state HIEs in the country, providing patient information to healthcare systems and providers in Kansas and Missouri. Getting the HIE up and running to a point where it could successfully exchange data required a few key elements, starting with getting hospitals on board that were willing to share data. To this end, in the last 18 months, LACIE announced two major connections: first with the Kansas Health Information Network (KHIN), another major HIE in Kansas. This was a significant moment for data exchange in the Midwest, as in the past, the two organizations had failed to reach an agreement on sharing data.

A few months after that, LACIE announced that patients' electronic medical records (EMRs) were being securely shared with Tiger Institute Health Alliance (TIHA) in Columbia, Mo. In total, LACIE is now connected to 17 hospitals in two states in addition to three accountable care organizations (ACOs), the two aforementioned regional HIEs, multiple private HIEs, and the Kansas City Metropolitan Physician Association (KCMPA), a large independent physician group with 80 clinics and 350 providers. The 24 different EMRs those organizations use have been connected via a hub that has been put in place from Cerner, says Mike Dittemore, the executive director for LACIE. Dittemore says that LACIE connects to that hub so it doesn’t have to do all of the independent connections, leading to greater efficiencies and cost savings.

However, getting different provider organizations on board has not been easy, Dittemore admits. “There are always challenges with provider participation, and one of reasons we had the strategy to work with hospitals and get them on first is that we felt if we did a good job with them, that would spur participation from others. The best marketing out there as far as HIEs go is word of mouth by providers who actually use it,” he says. What’s more, LACIE’s board of directors consists of several physicians, including multiple CMIOs of organizations in the Kansas City area. “That’s really helped us, having these physicians have conversations with other providers or their clinics and talk to them about why it’s important to share this information and participate,” says Dittemore. “They can show other [providers] the value by being able to not tie up so much staff in administrative time in tracking information down that already exists in the HIE.”

Still, there are additional challenges for independent providers who have all kinds of mandates and rules they are struggling with, in addition to low reimbursement rates, Dittemore notes. “So we try to have a price point that works for them, and we also have found some grant funds through the Office of the National Coordinator for Health Information Technology (ONC). In Kansas, we used some of those funds to help folks to connect, but it’s always an uphill climb to get individual providers on board. We do think that if we can get in and meet with clinic managers, maybe not the providers themselves, but a trusted person they go to, and show them the value, getting these smaller providers on board might not be as hard,” he says.

One of these physicians on LACIE’s board is board chair, Gregory Ator, M.D. CMIO and practicing physician at the University of Kansas Hospital. Ator says that as of late, LACIE has become much more focused in getting smaller practices on board. “It’s been a great experience, it’s very refreshing to see all of these large organizations that are not competing around the ‘this is my data and you can’t have it’ concept, but rather the ‘let’s compete around quality of care and let information freely flow’ concept. That’s been quite refreshing, and moving forward we’re looking at the next tier of smaller physician practices,” Ator says.

LACIE further attempts to make the exchange process more doable by not charging organizations a fee to connect. “We have always believed in connecting to other HIEs, be it community, regional, or state. But we don’t pay other organizations to connect nor do we charge others to connect to us,” Dittemore says. “LACIE is a public type of entity. We think that’s why it’s here, for the spirit of moving information regardless of where they reside. We have been adamant about that, but not all facilities feel the same way. So that’s been a barrier,” Dittemore notes.

Making HIE Valuable

Currently, LACIE is consistently seeing 100,000 queries per month going through the HIE, and according to Dittemore, one of the things that really helps provide value to its providers is getting robust information trading rather than just checking a box. “If checking a box is what you want, our HIE won’t be for you. We’re about the meaningful trading of information,” he says.

To this end, all of LACIE’s connected providers are encouraged to share radiology reports, discharge reports, clinic visits, and any summaries, Dittemore adds. “What we have found is that when you have that type of information above and beyond the continuity of care document (CCD) or consolidated-clinical document architecture (C-CDA), it really provides a great platform for providers to go in and look at the information and find out what is really going on with patients in those last visits,” he says. “We want to try to get rid of the fax machine, or reduce its use by as much as possible. Having this robust information available does help providers to move onto other duties like taking care of patients. They become valuators rather than investigators,” says Dittemore.”

Expanding on the notion of meaningful data exchange, Ator notes that fax machines are how providers are doing HIE right now, and what’s more is that Direct also has issues with people’s addresses as well as its own technological problems. “I am an Epic customer at KU, so we have a number of Cerner operations in town as well as Epic operations, and when you log into Epic for instance, we can go out to the HIE and search for a patient, at which point a very robust matching algorithm kicks in and we get textual documents presented in reverse chronological order. Operative notes, progress notes and discharge summaries are all within Epic without a separate log-in,” Ator explains. “Our providers don’t have to dig through exchange formats such as CCDs and CCDAs to see it in a meaningful manner. And that’s Cerner shop looking at Epic and vice versa,” he says.

Value to providers is further seen in the form of impacting patient outcomes. According to Ator, the strongest use case now is in the ER. “The patients here in a big city circulate around the EDs, and it’s fabulous to have the notes as it was was signed from an organization right down the street that a person might have checked into,” he says. “So we have seen improved outcomes around the ED, and the literature backs that up. I think that it is clear there is benefit in ED world, but rest is bit too soon to call,” Ator says.

Dittemore also says that value has been seen on the care management side. Kansas City has multiple medical facilities and acute care facilities, but even more non-acute facilities, he says. Just because a patient happens to go to a provider or an urgent care clinic that they have affiliation with, they might not go there for all care, and that’s something that needs to be seen in the HIE, he says. Also with specialists, making sure to ensure patients have done the appropriate follow up and have been to specialists allows care managers to see if that has happened and if not, find out why, Dittemore says. “Was it a transportation problem, an illness or what? It gives them something to go off of when they reach back out to the patient. Care managers have seen great value in this to manage that care between multiple facilities that might not be financially related to one other. That’s been rewarding,” he says.

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