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New INFRAM Model Creates Healthcare Infrastructure Benchmarks

Posted on November 14, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

During the frenzy that was healthcare organizations rushing to implement EHRs and chase government money, it was amazing to see so many other projects get left behind. One of the biggest areas that got left behind was investments in IT infrastructure. All the budget was going to the EHR and so the infrastructure budgets often got cut. There were some exceptions where upgrades to infrastructure were needed to make the EHR work, but most organizations I know chose to limp along with their current infrastructure and used that money to pay for the EHR.

Given this background, I was quite intrigued by the recent announcement of HIMSS Analytic’s INFRAM (Infrastructure Adoption Model). This new model focuses on a healthcare organization’s infrastructure and whether it’s stable, manageable, and extensible. I like this idea since it’s part of the practical innovation we talk about in our IT Dev Ops category at the EXPO.health Conference. What we’ve found is that many healthcare organizations are looking for infrastructure innovations and the benefits are great.

The INFRAM model has 5 main focus areas:

  • Mobility
  • Security
  • Collaboration
  • Transport
  • Data Center

No doubt these are all areas of concern for any healthcare CIO. Although, I wonder if having all 5 of these in the same model is really the best choice. A healthcare organization might be at a level 6 for secruity, but only at a level 3 for mobility. Maybe that’s just fine for that organization. I guess at the core of this question is whether all of the capabilities of stage 7 are capabilities that are universally needed by all healthcare organizations.

I’m not sure the answer to this, but I think a case can be made that some organizations shouldn’t spend their limited resources to reach stage 7 of the INFRAM benchmark (or even stage 5 for some organizations). If a healthcare organization makes that a priority, it will probably force some purchases that aren’t really needed by the organization. That’s not a great model. If the above 5 focus areas had their own adoption models, then it would avoid some of these issues.

Much like the EMRAM model, the INFRAM model has 7 stages as follows:

STAGE 7
Adaptive And Flexible Network Control With Software Defined Networking; Home-Based Tele-Monitoring; Internet/TV On Demand

STAGE 6
Software Defined Network Automated Validation Of Experience; On-Premise Enterprise/Hybrid Cloud Application And Infrastructure Automation

STAGE 5
Video On Mobile Devices; Location-Based Messaging; Firewall With Advanced Malware Protection; Real-Time Scanning Of Hyperlinks In Email Messages

STAGE 4
Multiparty Video Capabilities; Wireless Coverage Throughout Most Premises; Active/Active High Availability; Remote Access VPN

STAGE 3
Advanced Intrusion Prevention System; Rack/Tower/Blade Server-Based Compute Architecture; End-To-End QoS; Defined Public And Private Cloud Strategy

STAGE 2
Intrusion Detection/Prevention; Informal Security Policy; Disparate Systems Centrally Managed By Multiple Network Management Systems

STAGE 1
Static Network Configurations; Fixed Switch Platform; Active/Standby Failover; LWAP-Only Single Wireless Controller; Ad-Hoc Local Storage Networking; No Data Center Automation

STAGE0
No VPN, Intrusion Detection/Prevention, Security Policy, Data Center Or Compute Architecture

As this new model was announced, I had a chance to talk with Marlon Harvey, Industry Solutions Group Healthcare Architect at Cisco, about the INFRAM model. It was interesting to hear the genesis of the model starting first as an infrastructure maturity model at Cisco and then evolving into the INFRAM model described above. Marlon shared that there had been about 21-24 assessments and 35 organizations involved in developing this maturity model. So, the model is still new, but has had some real world testing by organizations.

I do have some concern about the deep involvement from vendor companies in this model. On the one hand, they have a ton of expertise and experience in what’s out there and what’s possible. On the other hand, they’re definitely interested in pushing out more infrastructure sales. No doubt, HIMSS Analytics is in a challenging position to balance all of this.

That said, a healthcare CIO doesn’t have to be beholden to any model. They can use the model where it applies and leave it behind where it doesn’t. Sure, I love having models like INFRAM and EMRAM to create a goal and a framework for a healthcare organization. There’s real value in having goals and associated recognition as a way to bring a healthcare IT organization together. Plus, benchmarks like these are also beneficial to a CIO trying to convince their board to spend more money on needed infrastructure. So, there’s no doubt some value in good benchmarking and recognition for high achievement. I’ll be interested to see as more CIOs dive into the details if they find that INFRAM is focused on the things they really need to move their organization forward from an infrastructure perspective.

Value Based Care: Successes, Challenges, and Changes – #HITsm Chat Topic

Posted on November 13, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

We’re excited to share the topic and questions for this week’s #HITsm chat happening Friday, 11/16 at Noon ET (9 AM PT). This week’s chat will be hosted by Matt Fisher (@Matt_R_Fisher) on the topic of “Value Based Care: Successes, Challenges, and Changes”.

The transition of the healthcare industry from fee for service to value based care (or alternative payment methodologies) garners significant attention from regulators, providers, vendors and many others in the industry. To frame the discussion, value based care generally refers to payment for quality, or in other words trying to focus on outcomes. The change represents a substantial shift in the approach to paying for healthcare services in the United States.

While value based care refers to payment for quality as an overarching concept, there are a multitude of means of structuring payment arrangements for quality. Examples include capitated agreements, bundled payments, pay for quality, and others. Common themes around the structures are not paying based on the volume of services, which arguably drives collaborations to break down siloes.

With a few years of value based care under the belt, how have efforts gone and where are those efforts heading? Join the chat to weigh in with your thoughts.

Topics for this week’s #HITsm Chat:
T1: Which value based care models have been successful to date and how do you define success? #HITsm

T2: How are new and/or developing #healthIT tools helping or hindering the ability to transition to value based care? #HITsm

T3: What are misperceptions that have developed around value based care models and how are they inaccurate? #HITsm

T4: What role do Medicare and Medicaid programs have in pushing the industry to value based care and how does the recommitment of CMS impact the change? #HITsm

T5: What changes do you see on the horizon for value based care programs? #HITsm

Bonus: What type of value based care program not currently existing should be developed or implemented? #HITsm

Upcoming #HITsm Chat Schedule
11/23 – No Chat – Thanksgiving Break

11/30 – The Global Impact of Health IT
Hosted by Vanessa Carter (@_FaceSA)

12/7 – TBD
Hosted by Michelle Currie (@mshlcurrie)

12/14 – TBD
Hosted by Claire Pfarr (@clairepfarr) from @OneViewHC and the @Savvy_Coop Community

12/21 – Holiday Break

12/28 – Holiday Break

We look forward to learning from the #HITsm community! As always, let us know if you’d like to host a future #HITsm chat or if you know someone you think we should invite to host.

If you’re searching for the latest #HITsm chat, you can always find the latest #HITsm chat and schedule of chats here.

Transition to Value-Based Payments Top Concern for Long-Term and Post-Acute Care

Posted on November 12, 2018 I Written By

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

On 1 October 2019, CMS will flip from a volume-based reimbursement model for Long-Term & Post-Acute Care Organizations (LTPAC) to a value-based one. This looming transformation was the top concern for most of the 2,000 attendees at PointClickCare’s annual user conference – #PCCSummit18.

PointClickCare makes a cloud-based EHR platform for LTPAC and HomeCare Organizations. According to the company, 60% of all Senior Living and Skilled Nursing Facilities (SNFs) in North America use their platform. Each year, PointClickCare hosts a user conference, called PCCSummit, where customers gather to get a preview of new features and to discuss the industry’s most pressing challenges.

Sweeping LTPAC changes by CMS

The top challenge on the minds of #PCCSummit18 attendees was, by far, the sweeping reimbursement changes being implemented by the Centers for Medicare & Medicaid Services (CMS) on 1 October 2019.  Referred to as the Patient Driven Payment Model (PDPM), it contains three significant changes for SNFs:

  1. A new value-based payment model
  2. Adopting ICD-10
  3. New reporting requirements

“The move to PDPM is going to be a challenge for everyone in the industry,” said Dave Wessinger, COO and Co-Founder of PointClickCare. “I think everyone will agree that moving from a volume-based reimbursement model to a value-based one is ultimately better for healthcare and for patients, but getting there is going to take some work. We are investing millions of dollars in product R&D, implementation resources and training to help make this transition as smooth as possible for our customers – who are all worried about PDPM.”

There were several sessions at #PCCSummit18 dedicated to PDPM. Each session was standing-room only.

A new value-based payment model

PDPM is the first step taken by CMS to shift LTPAC from a volume-based reimbursement model to one that is more value-based.

Currently, SNFs are reimbursed based on the minutes of therapy that patients/residents receive. The daily rate is determined by the type of therapy and SNFs are paid for as long as that therapy is administered. SNFs are required to conduct an assessment at pre-determined intervals to determine if further therapy is needed.

Under PDPM, CMS will base payments to SNFs on patient characteristics (diagnosis and comorbidities) rather than the type and duration of therapy being provided. According to CMS, there are several key advantages of this approach:

  • Removes therapy minutes as the basis for therapy payment (which may have encouraged some SNFs to provide unnecessary therapies to patients)
  • Enhances payment accuracy for nursing services by making nursing payment dependent on a wide range of clinical characteristics
  • Introduces payment adjustments that better reflect changes in resource use over a stay

Under PDPM, each patient/resident will be assigned a case-mix classification that drives the daily reimbursement rate for that individual. This classification is based on the diagnosis, acuity and characteristics of the patient/resident. Unlike the current payment model, the daily reimbursement rate is not uniform. It declines over time. This was done because evidence suggests that most therapies have diminishing returns the longer they are administered – unless the condition of the patient/resident changes.

The following slide illustrates the difference. It was presented by Genice Hornberger, RN, Senior Product Advisor at PointClickCare. The column on the left shows the uniform reimbursement for a 30-day SNF stay under the current RUG-IV payment model. The column in the middle shows what it the daily payments would be like under PDPM with accurate documentation.

Notice how the daily rate under PDPM starts off much higher at almost $915/day vs $631/day. This is in recognition of the work required of SNFs when new patients/residents are admitted.

The right-most column is very interesting. It shows the daily reimbursement rate for the case where patient documentation is inaccurate (ie: missing meds or missing patient conditions). This would result in $1,800 less under PDPM vs the current reimbursement model.

Adopting ICD-10

One of the goals CMS had for PDPM was to “promote consistency with other Medicare and post-acute payment settings by basing resident classification on objective clinical information while minimizing the role of service provision in determination of payment”.

To achieve this goal, CMS is mandating the adoption of ICD-10 standard in LTPAC. This will align long-term and post-acute care with their acute-care counterparts and make it easier for CMS to track Medicare patients moving between different parts of the healthcare system.

During the research and development stage of PDPM, found that almost half of SNF claims assigned generic ICD-9-CM codes as the principal diagnosis for residents in their care, which had limited usefulness in classifying residents. It also made it difficult for CMS to perform detailed analysis of LTPAC data.

Under PDPMD, ICD-10 codes will be used to map residents to the clinical categories that represent the primary reason for SNF care and are also sued for resident classification which determine the reimbursement rate.

New Reporting Requirements

Under the current reimbursement mechanism, SNFs are required to file patient/resident assessments with CMS 5 days, 14 days, 30 days, 60 days and 90 days into the stay. For longer stays, only quarterly assessments need to be filed.

Conducting, documenting and electronically transmitting these assessments requires a lot of time and effort by staff. In consultation with industry leaders, CMS is reducing the reporting requirements under PDPM.

Instead of regularly scheduled assessments, SNFs will now only be required to file a report when a patient/resident is admitted, discharged or has a change in condition. CMS expects to save itself $2B over the next 10 years from this reduction in paperwork and calculates SNFs will save on average, 183 hours per facility per year.

CMS tools to help transition

To help make the transition to PDPM, CMS has made several guides and online tools freely available to SNFs. One very useful tool is a customized analysis of each SNF’s current reimbursement vs future reimbursement under PDPM.

CMS used historic claims data from each SNF and corresponding acute-care data for patients transferred to SNFs (because only the hospital data had the requisite ICD-10 coding to determine the new patient/resident classification under PDPMD) to come up with an estimate of that SNF’s reimbursement under PDPM.

The analysis reveals that most SNFs would be at or above current reimbursement levels. A few therapy-heavy SNFs with non-complex patients will see lower reimbursements.

PointClickCare helping with PDPM transition

Given the importance of PDPM and the worries expressed by its customers, PointClickCare has created additional tools to help in the transition.

The team at PointClickCare smartly realized is the key to PDPM is having accurate documentation of each patient/resident. Any diagnosis, condition change or medication that is not documented will have a negative impact on reimbursements. Sandy Herbert, Senior Director of Product Management at PointClickCare explains:

“There is a hidden gap that could significantly impact reimbursements that we want to make our customers aware of. Through the CMS online tool, they can see an estimation of their reimbursement under PDPM, but baked into that estimation is an assumption of perfect documentation. Everything about the patient/resident needs to be captured and documented properly in the system – if anything is missed it means less money. However, with the change in classification method and the new reporting requirements, SNFs will have to be much more diligent in enforcing good documentation habits in order to maintain their level of reimbursement.”

At #PCCSummit18, the company unveiled an online PDPM assessment tool that calculates what a customer’s PDPM reimbursement would be based on the actual documentation in the system. In most cases, this amount is below the amount the CMS estimate.

In her presentation Hornberger showed an example of how significant this gap can be (see slide above). For a typical 30 day stay, PointClickCare found that certain aspects of the record were not coded properly which would result in a smaller claim being submitted to CMS. Their analysis showed that on average, a SNF would only receive $17,100 for that 30 day stay versus $18,900 under the current system and well below the $19,600 that would be possible under PDPM.

PointClickCare has made their assessment tool – PDPM Risk Assessment – freely available to its customers. Their team of consultants are also working with customers to address the gaps that are identified by the free assessment.

“PointClickCare has a history of working well with clients, especially when it comes to data,” said Timothy Carey, Director of Data and Performance Analytics at BaneCare. “Having the right data available to our leadership is critical. It’s what we need to help improve our processes and workflows. As far as I’m concerned, data from the PointClickCare system is like gold. It shows us where things are going wrong and where we can improve.”

Judging from the smiles on the faces of attendees who got a preview of their customized PDPM Risk Assessment at #PCCSummit18, the data is clearly reducing the anxiety around the transition.

Conference on Drug Pricing Inject New Statistics Into Debate, Few New Insights (Part 2 of 2)

Posted on November 9, 2018 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The first part of this article described the upward pressures on costs and some of the philosophical debates over remedies. This section continues the discussion with several different angles on costs.

Universal access and innovation

It’s easy to call health care a human right. But consider an analogy: housing could also be considered a human right, yet no one has the right to a twenty-room mansion. Modern drug and genetic research are creating the equivalents of many twenty-room mansions, and taking up residence means the difference between life and death for someone, or perhaps between a long productive life and one of pain and deformity.

Universal access, often through a single-payer system, is in widespread use in every developed country except the United States. Both universal access and single payer are credited with keeping down the costs of health care, including drugs. It makes sense to link single-payer with lower drug costs, because of the basic rules of economics: size gives a buyer clout, as we can see in the ways Walmart lords it over their suppliers (documented in a 2006 book, The Wal-Mart Effect, by Charles Fishman). At the conference, Sean Dickson from the Pew Charitable Trusts gave what he called an “economics 101 course” of health care and how the industry diverges from an ideal market. (He did not come out in favor of single-payer, though.)

How much fat can be cut from pharma? My guess is a lot. As we saw in the previous section, profits from pharmaceuticals tower above profits in most industries. But we don’t have to stop by simply shaving payments to shareholders, or even management compensation. I know from attending extravagent health care conferences that there’s a lot of free cash floating around the health care industry in general, although it’s unevenly distributed. (Many hospitals, nursing homes, and other institutions are struggling to maintain adequate staffing.) In industries possessing such easy money, it does trickle down somewhat. Gaudino pointed out ruefully that health care is one of the few fields left that can give ordinary people a middle-class income, something we don’t want to lose even as employment continues to rise in that space. But easy money also leads to bloat, and this is almost certainly true throughout health care, including pharma.

Even so, projections of the cost of universal access are dizzyingly high, placing pressure on the historic universal access model in Massachusetts and forcing Vermont to give up single-payer. The pressures that could be applied to the health care field by the US government would certainly outweigh the negligible impact that Vermont–with its population of a mere 600,000–could exert. But it’s unlikely that the easy wins falling out of single-payer (squeezing drug companies, eliminating the administrative overhead of handling health insurance) could make up for the staggering costs of adding whole new swaths of a high-need, difficult population to government rolls.

What we need to lower health costs is an overhaul of the way health care systems conceive of patients, taking them from conception to the grave and revamping to treat chronic conditions. T.R. Reid, in his book The Healing of America, says that universal access must come first and that all the rest will gradually follow. I would like to have at least a strong concept throughout the health care system of what the new paradigm will be, before we adopt single-payer. And in theory, adopting that paradigm will fix our cost problems without the wrenching and contentious move to single-payer.

What non-profits can teach us

So how do we recompense manufacturers while getting drugs to low-income people who need them? Some interesting insights did turn up here at the conference, through a panel titled From Development to Delivery Globally. All three speakers operate outside the normal market. One is a representative of Gilead Sciences (mentioned earlier), whereas the other two represent leading non-profits in international health care, Partners in Health and the Bill & Melinda Gates Foundation. Nevertheless, their successes teach us something about how to bend the cost curve in traditional markets.

Flood said that Gilead Sciences made an early commitment to get its AIDS drug to all who needed it, without regard to profit. At first it manufactured the drug and distributed it in sub-Saharan Africa at cost. That failed partly because the cost was still out of reach for most patients, but also because the distribution pipeline was inadequate: logistics and government support were lacking.

So Gilead took a new tack: it licensed the drug to Indian manufacturers who not only could produce it at a very low cost (while maintaining quality), but understood the sub-Saharan areas and had infrastructure there for distributing the drug. This proved highly successful. I’m betting we’ll find more drugs manufactured in India over time.

Hannah Kettler of the Gates Foundation described how they set 50 cents as an affordble price for a meningitis vaccination, then went on to obtain that price in a sustainable manner. The key was to hook up potential buyers and manufacturers in advance. The buyers guaranteed a certain number of bulk purchases if the manufacturers could achieve the desired price. And armed with a huge guaranteed market, the manufacturers scaled up production so as to reduce costs and meet the price goal.

The Gates model looks valuable for a number of drugs: guarantee an advance market and start out manufacturing at a large scale to reduce costs. This will not help with orphan diseases, of course.

More generally, in my opinion, developed countries have to define their incentive to provide aid of any kind–medicine, education, microloans, or whatever. Is it enough of an incentive to empower women and keep population growth under control? To avoid social conflicts that turn into civil wars? To avoid mass emigration and refugee crises? What are solutions worth to us?

The contributions of artificial intelligence

Aside from brief mentions of advanced analytics by Gaudino and Taylor, the promise of computer technology came up mainly in the final panel of the conference, where Petrie-Flom research fellow Sara Gerke offered some examples of massive costs savings that AI has created at various points in the drug development chain. These tend to be isolated success stories, but illustrate a trend that could relieve pressure on prices.

I have reported on the use of AI in drug development in other articles over the years. This section consolidates what I’ve seen: although AI can potentially help at any point in an industry’s business, it seems particularly fertile in two parts of drug development.

The first area is the initial discovery of compounds. Traditional research can be supercharged by analyses of patient genes, simulations of molecule behaviors, and other ways of extracting needles from haystacks.

The second area is the conduct of the clinical trial. Here, techniques being tried by drug companies are variants of what clinicians are doing to engage and monitor patients. For instance, clinical subjects can wear devices with minimal disruption to their lives, and report vital signs back to researchers on an ongoing basis instead of having to come into the researcher’s office. AI can also find suitable subjects, increasing the potential pool. Analytics may reveal early whether a clinical trial is not working, allowing the company to save money by shutting it down early, and avoiding harm to subjects.

Of course, we all look forward to some marvelous breakthrough–the penicillin of the 21st century–that will suddenly open up miracle treatments at low cost for a myriad of illnesses. Current research is pushing this medical eschaton further and further off into the unforeseeable future. We are learning that the genome and human molecules interact in ways that are much more complex than we thought, that a lot is dependent on the larger biome, and that diseases are also cleverer than we thought and able to work around many of our attacks.

Analytics will certainly accelerate medical discoveries. In doing so, it could drastically reduce the costs of drug discovery, and therefore reduce risk and ultimately prices. But stunning new drugs for rare diseases could also vastly increase prices.

Baby steps

I’ll end with a few suggestions made by conference participants to create a more competitive market or reduce prices. Outside of explicit price setting (on which participants were deeply split), the proposals looked like small contributions to a situation that requires something big and bold.

  • Price transparency came up several times.
  • Grogan would like Congress to re-examine reimbursement for Medicare Part D (especially the donut hole and catastrophic coverage) to give both PBMs and vendors incentives to lower costs.
  • Gaudino said that Australia does a much better job than the US of collecting data on the outcomes of using drugs, which they can use to determine whether to approve the drugs. The U.S. payment system is more privatized and fragmented, making it impossible to collect the necessary data.
  • Caljouw praises the efforts of the Massachusetts Health Policy Commission, which has no power to set costs but meets with providers and asks them to reconsider the factors that lead to jacked-up prices.
  • Caljouw also mentioned laws requiring price transparency from PBMs.
  • Several participants suggested reversing the decision that allowed companies to air advertisements directly to consumers. (I’m afraid that if all the misleading drug ads disappeared from the air, a bunch of television networks would go out of business.)
  • Taylor cited pressure by Wall Street on drug companies to maximize prices without regard for the social impacts–an intense kind of pressure felt by no other industry except fossil fuels–and called for the extension of socially responsible investment to drug companies.

I’d like to suggest, in conclusion, that we may be focusing too much on manufacturers, who are taking enormous risks to cure difficult diseases. A University of Southern California study found that 41% of the price is absorbed by intermediaries: wholesalers, pharmacies, PBMs, and insurers. Whether through single-payer or through other changes to the health care system, we can do a lot without constricting innovators.

Conference on Drug Pricing Injects New Statistics Into Debate, Few New Insights (Part 1 of 2)

Posted on November 8, 2018 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The price of medications has become a leading social issue, distorting economies around the world and providing easy talking points to politicians of all parties (not that they know how to solve the problem). Last week I attended a conference on the topic at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School.

On one level, the increasing role that drugs play in health care is salutary. Wouldn’t you rather swallow a pill than go in for surgery, with the attendant risks of anesthesia, postoperative pain opiates, and exposure to the increasingly scary bacteria that lurk in hospitals? Wouldn’t you rather put up with a few (usually) minor side effects of medication than the protracted recovery and discomfort of invasive operations? And even when priced in the tens of thousands, drugs are usually cheaper than the therapies they replace.

But drug costs are also deeply disrupting society. They are more and more dominant in the health care costs that take up nearly a fifth of the total output of the U.S., and the outsized demands that medications put on both private and public pocketbooks lead to drug pricing being a rare bipartisan issue.

Michael Caljouw from Blue Cross Blue Shield of Massachusetts pointed out at the conference that in Massachusetts, health care has skyrocketed from 20% to 45% of entire state budget in 20 years, and similar trends are found in other states. He says that an expensive new drug can “blow through” budgets set a year in advance. Bach cited statistics showing the prices for cancer drugs are rising exponentially, while the drugs get only slightly more effective over time.

Drug costs also eat into the limited savings of the elderly, dragging many into bankruptcy or poverty. As reported at the conference by Peter Bach of the Memorial Sloan Kettering Cancer Center, high costs drive away many patients who would benefit from the medications, thus leading to worse health care conditions down the line.

Similar problems can be seen internationally as well.

Petrie-Flom drew together a stellar roster of speakers and panelists for its one-day conference. However, when one shakes out all the statistics and recommendations, the experts turn out to lack answers. Their suggestions look like tinkering around the edges, just as the federal government did over the past year with new rules such as citing prices in drug ads and tweaking the Medicare Part D reimbursement formulas. Thus, I will not tediously cover all the discussions at the conference. I will instead raise some key issues while tapping into these discussions for fodder.

The loudest statement at the conference was the silence of the pharma industry. Representatives of everyone you could imagine with skin in this game appeared on the podium–insurers, clinicians, pharmacy benefit managers, the finance industry, regulators, patent activists, think tanks, and of course lawyers–with one glaring exception: drug manufacturers. I’m sure these companies were invited. But the only biopharmaceutical firm to show up was Gilead Sciences, and the talk given by Amy Flood, senior vice president of public affairs, was not about normal drug development but about the company’s commendable efforts to disseminate an HIV drug through sub-Sahara Afica. Given the intense political, social, and geographic contention over AIDS, her inspiring story had little in the way of models and lessons to offer mainstream drug development. I will cover it later in the section ‘What non-profits can teach us.”

Failure by the vast bulk of the pharma industry to take up the sterling opportunity represented by this conference to present their point of view, to me, comes across as an admission of guilt. Why can’t they face questions from an educated public?

The oncoming sucker punch

A couple days before the conference, Stat published a heart-warming human interest story about a six-year old being treated successfully for a debilitating rare condition, Batten disease. Rather than giving in to genetic fate, the parents pulled together funding and doctors from around the country, pushed the experimental treatment through an extremely fast-track FDA approval, and saw positive results within a year.

The tears tend to dry from one’s eyes–or to flow for different reasons–when one reads the means used to achieve this miracle. The child’s mother is a marketing professional who raised nearly three million dollars through crowdfunding. An article in the November/December issue of MIT Tech Review describes six other families who raised money for personalized genetic treatments. Another article in the same issue–which is devoted to big data and genetic research in medicine–discusses personalized vaccines against cancers, while a third lays out the expenses of in vitro genetic testing. This is not a course of action open to poor, marginalized, uneducated people. Nor is such money likely to turn up for every orphan disease suffered somewhere in the world.

I hope that this six-year-old recovers. And I hope the three-million-dollar research produces advances in gene science that redound to the benefit of other sufferers. But we must all consider how much society can spend on the way to an envisioned utopia where cures are available to all for previously untreatable conditions. As conference speakers pointed out, genetic treatments assume an “N of 1” where each patient gets a unique regimen. This doesn’t scale at all, and certainly doesn’t fit the hoary old pharmaceutical paradigm of giving a monopoly over a treatment for a decade or so in exchange for low-cost generic imitations for all eternity afterward.

Yet government needs to keep funding biotech research, and creating a positive regulatory environment when venture capitalists and other investors will fund the research. Joe Grogan of the Office of Management and Budget, keynoting at the conference, claimed that Germany used to have the pre-eminent biotech industry and let it shrivel up through poor policies. In the same way, biotech could leave the United States for some other country that proves welcoming, probably China.

Dueling models

Some panelists enthusiastically promoted what they openly and officially called Willingness To Pay (WTP) or “what the market will bear” pricing, but which I call “stick it to ’em” pricing. Others called for the price controls that are found in almost every developed country outside the U.S. Various schemes being promoted under the umbrella of “value-based pricing” were generally rejected, probably because they would allow the companies to inflate their prices. However, Jami Taylor of Stanton Park Capital suggested that modern data collection and analytics could support micropricing, matching payment to the outcome for each patient.

Interestingly, nobody believed that drug prices should reflect the costs of producing them. But everybody understood that drug producers must be adequately reimbursed. That is why people from many different perspectives came out in opposition to “charity” and “compassionate” discounts or rebates offered by many pharma companies, sometimes reaching 10% of their total expenditures. In a typical sequence of events, a company enjoying a breakthrough for a serious condition announces some enormous price in the tens or hundreds of thousands of dollars. After public outcry (or to ward off such outcry) they start awarding deep discounts or rebates.

Why are discounts and rebates poor policy? First, they bind the recipients to dependence on the company. This is why, according to Annette Gaudino of the Treatment Action Group, Médecins Sans Frontières rejected a donation from a manufacture of a vaccine.

More subtly, high list prices set a bar for future prices. They allow the companies to jack up prices for brand-name drugs by double digits each year (as shown in a chart by Surya Singh of CVS Health) and to introduce new drugs at inflated prices–only to take off the edge through more discounts and rebates.

Grogan would like Europeans to pay higher prices, following the common perception that US consumers are subsidizing the rest of the world. But other speakers contended that Europeans offer fair compensation that can keep drug companies sustainable. A recent administration proposal to force manufacturers to match foreign drug prices seems to take the same attitude.

Aaron Kesselheim of Harvard Medical School participated in a study that demonstrated the robustness of European price controls in a clever manner. He and colleagues simply examined which drugs were withdrawn from the German market by manufacturers who didn’t want to undergo their rigorous price-setting regime, run by the Institute for Quality and Efficiency in Health Care (IQWiG). The 20% of drugs that were withdrawn were those demonstrated to be ineffective or to be no better than lower-priced alternatives.

Gaudino also tried to slay the opponents of price controls with an onslaught of statistics. She cited a JAMA study finding that bringing a cancer drug to market costs well under one million dollars, less than half of the billions often cited. The non-profit Drugs for Neglected Diseases initiative (DNDi) can produce a new medicine for a total cost of just 110 to 170 million dollars. And the average profit for pharma companies has stayed level at around 20% for decades, far above most industries.

With all these endorsements for price controls, the shadow of possible negative effects on innovation hover over them. In the next part of this article, I’ll examine technical advances that might lower costs.

Combatting Communication Problems in Community Healthcare Clinics

Posted on November 7, 2018 I Written By

The following is a guest blog post by Tom Downes, CEO of Quail Digital.

The notion of a community healthcare clinic is constantly evolving from the traditional model of a local clinic staffed by general practitioners and nurses, serving mainly rural populations. There is now a renewed interest in these organisations and their potential to deliver a more integrated care service within the community. However, in order to successfully make this transition, there is a need to better equip these clinics with the tools to ensure they’re able to cope with the extra demand and the ever-evolving medical treatments that are being practised.

With an estimated 33 million people visiting community healthcare clinics each year, these organisations are an essential part of the healthcare system. Whilst they are investing vital time into evolving their structure and delivering a focused range of medical services, without the right technology in place staff productivity will suffer, hindering their ability to make the most out of not only the current resources available, but any new, innovative resources they decide to invest in.

A collaborative approach

To foster a more productive, collaborative environment, communication should be implemented across the entire team. From diagnostics to preventive treatment, clinical procedure and rehabilitation, delivering a diverse set of services can create a stressful environment, if the team, from receptionist to clinicians, are wasting valuable time trying, without success, to communicate. But as services expand, enabling staff to speak easily with one another to seek answers to questions, locate the right individual and better manage the flow of patients through the appointments process, has become even more important.

Community healthcare clinics traditionally rely on telephones to communicate internally, but these can often go unanswered. Additionally, this device commonly only works when just two people want to communicate with each other, restricting the ability to send messages, updates and instructions to the whole team. Naturally, therefore, the likelihood of missing key information or mishearing a fellow colleague is increased, creating unnecessary stress and delays.

And this dated communication tool will not be able to facilitate the growing numbers of staff working in these clinics. As nearly 62 percent of all community healthcare clinics are in an urban setting they are providing services for extremely dense populations, therefore they require a greater amount of staff to help accommodate this demand. Team this up with the intense competition these urban clinics have with multiple clinics and medical centres serving the same geographic, and the need for a better communication tool that will help them provide a positive experience is even more important.

Clear Communication

Providing clear, discrete communication to all members at reception and in the clinics will have an extremely positive impact on the running of the community healthcare clinic. Lightweight headset technology will help the team working in these clinics to reduce unwanted hold-ups, improve workflow and offer a much improved experience for each of those patients who walk through the door. And with the ability to coordinate easily with one another, the team can become more productive and efficient to ensure they’re prepared for the demands felt by this expanding healthcare system.

Critically, in this most challenging of jobs, adopting a headset system that operates on a single channel will ensure all members of staff are in permanent communication. This way, doctors, nurses or receptionists are able to approach their colleagues who are working in another part of the clinic with any urgent query or question they may have. This immediate and non-obtrusive communication method is particularly important during times of expansion and innovation, as every team member will be learning and adopting new methods and structures.

Conclusion

Community healthcare clinics are evolving and there is now a growing need to implement digital solutions to provide staff with the ability to hear everything clearly, at all times. There are also other daily practices that can help facilitate a more tranquil environment. Along with headset technology, eliminating unnecessary, frantic noise across the clinic will drastically reduce the distractions all doctors, nurses and receptionists have to face. Not only will this have a positive impact on stress-levels, but it will also make it a lot easier to communicate effectively amongst the team. Daily team meetings are also vital for every member of staff in a community healthcare clinic. With a better understanding of everyone’s workload for that day the team will have greater visibility of who is available to assist with other tasks and enquiries.

By implementing communication tools and ensuring greater visibility across the team clinical operational efficiencies will be increased while staff stress levels will be reduced and their wellbeing improved.

About Tom Downes
Tom Downes founded Quail Digital in 1995 to design headset systems for ‘team’ communication. The philosophy being that the easier and more freely a team can speak with each other in the workplace, the better their outcomes, wellbeing and productivity. Quail Digital designs and manufactures systems for the healthcare, retail and hospitality sectors, and has offices in Dallas, TX and London UK. Quail Digital is the leading provider of communications systems in the OR, and a sponsor of Healthcare Scene.

AI in Healthcare – #HITsm Chat Topic

Posted on November 6, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

We’re excited to share the topic and questions for this week’s #HITsm chat happening Friday, 11/9 at Noon ET (9 AM PT). This week’s chat will be hosted by Jon White @technursejon on the topic of “AI in Healthcare”.

The idea of Artificial Intelligence (AI) isn’t new. We’ve seen robots and intelligent computers in film and on television for decades, and read about them in science fiction novels for even longer. As the processing power of computers and computing devices has taken off, and more and more data is captured from all facets of our lives, the science fiction from our parents’ generation is becoming the reality of today.

Though we may be far from witnessing the androids popularized in film and TV, there are elements of AI that are currently in use in many industries. AI has the potential to drastically change the way we live and work.

In this #HITsm chat, Jon White (@TechNurseJon) will lead a discussion on AI in healthcare, exploring its potential and pitfalls.

Check out the questions for this week’s #HITsm chat below.

Topics for this week’s #HITsm Chat:
T1: Artificial intelligence (AI) is a broad term, covering a variety of technologies. What does “AI” mean to you? How do you define it? #HITsm

T2: What impacts can AI have on healthcare, and how soon do you expect to see it? #HITsm

T3: What impacts do you see AI having on the healthcare and health IT workforce? #HITsm

T4: How can AI be integrated with other technologies to improve the delivery and effectiveness of healthcare? Where would you like to see it integrated? #HITsm

T5: AI relies on a significant amount of data. For many applications in healthcare, much of that data is derived from patient records. How will privacy concerns affect adoption? #HITsm

Bonus: What barriers are there to full-scale AI adoption in the healthcare environment? #HITsm

Upcoming #HITsm Chat Schedule
11/16 – Value Based Care: Successes, Challenges, and Changes
Hosted by Matt Fisher (@Matt_R_Fisher)

11/23 – No Chat – Thanksgiving Break

11/30 – The Global Impact of Health IT
Hosted by Vanessa Carter (@_FaceSA)

12/7 – TBD
Hosted by Michelle Currie (@mshlcurrie)

12/14 – TBD
Hosted by Claire Pfarr (@clairepfarr) from @OneViewHC and the @Savvy_Coop Community

12/21 – Holiday Break

12/28 – Holiday Break

We look forward to learning from the #HITsm community! As always, let us know if you’d like to host a future #HITsm chat or if you know someone you think we should invite to host.

If you’re searching for the latest #HITsm chat, you can always find the latest #HITsm chat and schedule of chats here.

Decommissioning Legacy EHRs

Posted on November 5, 2018 I Written By

The following is a guest blog post by Sudhakar Mohanraj, Founder and CEO, Triyam.

Every product has a lifecycle. The lifecycle of Electronic Health Record (EHR) software begins when it is implemented at your facility and ends when it’s no longer in use. When a facility decides to move to a new EHR, it’s natural to focus planning around the new software system.  However, not considering the legacy EHR can leave you wondering what should happen to all of the historical patient financial and medical data. You have many choices. This article will discuss some of the challenges and options that will influence your cost, legal compliance, and stakeholder satisfaction.

Three common mistakes to avoid when moving to a new EHR

  1. Hanging on to the legacy EHR

Some say: “we will worry about shutting down the old system later after the new EHR is up and going.” Taking that path is risky and expensive.

Consider the cost. Until you get all your historical data off the legacy system, you need to pay vendors licensing and support fees. You may infrequently be using the old system, which makes these fees particularly unwarranted.  In addition, you continue to pay your employees to operate and maintain the old system.

To learn more about retiring Legacy EHRs register for this free live webinar. Industry experts will share Key lessons and Best Practices on data management strategies for EHR system replacements. You can also get answers to your questions about any specific requirements.

Some say, “I will stop paying my old vendor.  I don’t need any more updates or support.” However, sooner or later, hardware and software will break or become incompatible to newer technology. Older systems are an easy target for hackers and thieves.

Over time, your employees will forget passwords, how to navigate the old system or leave for other jobs. Then, when you, a patient, or your boss needs some report from the old system, you are caught short. Over time, data retained on an old, unsupported, infrequently used system increases the risk of being lost, stolen, corrupted, and not accessible by newer technology.

Bottom line: keeping an old, infrequently used system will needlessly eat up your time and money.

  1. Migrating all historical data from the legacy system to the new EHR

Some facilities are surprised to learn that the new EHR vendor will not convert all the historical data to the new computer system.

The new system is organized differently than the legacy system with different data elements and structures. There is never a one-to-one match on data mapping between the old and new systems.

It is difficult to validate the accuracy and completeness of data you want to import from the old system. The new EHR vendor doesn’t want to risk starting with an inaccurate database.

This is a golden opportunity to start with a clean slate. For example, you can take this time to reorganize, re-categorize, re-word codes, and tables. Now is the time to set up master files properly, and to make the system more efficient.

The new EHR vendor will lobby for you to start with a clean slate and populate the new database with only current patients, current balances, and current information.

  1. Ignoring Legal Compliance Requirements

Federal and state laws require healthcare facilities to retain medical and financial reports for 5 to 15 years and make these reports available to patients and others upon request. Keeping these records will help to avoid penalties, fines, and loss of certifications. Consult your compliance office, accountant, and HIPAA director to know Federal, IRS, and state-specific requirements.

Use this Data retention tool to find the retention requirements for your state.

Why data archival is an excellent choice

What are the best practices to deal with historical data? Data from the old system needs to be organized in a safe, secure place so that the information can be found and made readily available to those who need it in a timely fashion. In other words, it needs to be archived.

An archive is a separate system from your new EHR. It contains all your historical data and reports. When users sign into the archive program, depending on their user rights, they may see all or some of the historical reports. The most common functions of the archive system include:

  • Search and query clinical and financial data for “Continuity of Care.
  • Download, view, print, and share reports for “Release of Information.

Archival is a new concept. KLAS research is creating a new product category for this.  Listen to this on-demand webinar from the head of EHR Archive studies at KLAS Research.

In the archive, you can see all patients and their previous charts, medications, treatments, billings, insurance claims, payments, and more.  You will also see the historical vendor, employee, and accounting records.

What type of data goes to the archive? All sorts. You can retain discrete data or non-discrete data, structured data (like SQL, XML, CCDA), or unstructured data that is logically grouped and presented in a human-readable form like pdf reports, Excel spreadsheets, CCD, jpeg, or mp3 files.

Mergers and data consolidation

Archival is essential even when there isn’t a transition to new EHR. During a merger, the new entity frequently wants to consolidate patient financial and clinical data from multiple legacy systems into a common platform. Data archiving may be the best solution for dealing with multiple EMR/EHRs. Archival is less expensive than complex conversion and transformation efforts. Besides lower costs, it allows users to research on consolidated data using business intelligence and analytics tools running on one common unified database.

Outsourcing and vendor selection

Outsourcing has become an increasingly popular option for archival solutions for three reasons – cost, experience, and convenience. IT managers are already stretched to limits of time, resources, and budget.  Outside vendors can save the day by offering services for less cost.

When searching for an archival vendor, consider the following:

  • Experience in extracting data from your legacy systems which are no longer supported
  • Complete turnkey solutions – planning, pilot testing, data conversion, user acceptance, and decommissioning
  • Archival product features and ease of use
  • Great customer references
  • Cost of archiving should only be a fraction of the cost of retaining legacy system

The number one failure when implementing a new EHR is procrastinating the archival of legacy data. Hopefully, you can use a few of these ideas to maximize the benefits of your historical data, minimize costs, and best serve your user constituents.

About Triyam
Triyam delivers expert solutions in EMR / EHR Data Conversion and Archival.

Triyam’s data conversion services help hospitals and clinics to freely migrate from one EHR vendor to another without losing any historical patient data. Triyam’s EHR archival product, Fovea is a vendor neutral, innovative and intuitive platform to store all your legacy data. Fovea includes a powerful search engine and extensive reporting for Business Intelligence and Analytics. Triyam is a proud sponsor of Healthcare Scene.

Scripps Research Translational Institute Partners To Develop AI Applications

Posted on November 2, 2018 I Written By

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

The Scripps Research Translational Institute has agreed to work with graphics processing unit-maker NVIDIA to support the development of AI applications. The partners plan to forge AI and deep learning best practices, tools and infrastructure tailored to supporting the AI application development process.

In collaboration with NVIDIA, Scripps will establish a center of excellence for artificial intelligence in genomics and digital sensors. According to Dr. Eric Topol, the Institute’s founder and director, AI should eventually improve accuracy, efficiency, and workflow in medical practices. This is especially true of the data inputs from sensors and sequencing, he said in an NVIDIA blog item on the subject.

Scripps is already a member of a unique data-driven effort known as the “All of Us Research Program,” which is led by the National Institutes of Health. This program, which collects data on more than 1 million US participants, looks at the intersection of biology, genetics, environment, data science, and computation. If successful, this research will expand the range of conditions that can be treated using precision medicine techniques.

NVIDIA, for its part, is positioned to play an important part in the initial wave of AI application rollouts. The company is a leader in producing performance chipsets popular with those who play high-end, processor-intensive gaming which it has recently applied to other processor intensive projects like blockchain. It now hopes its technology will form the core of systems designed to crunch the high volumes of data used in AI projects.

If NVIDIA can provide hardware that makes high-volume number-crunching less expensive and more efficient, it could establish an early lead in what is likely to be a very lucrative market. Given its focus on graphics processing, the hardware giant could be especially well-suited to dominate rapidly-emerging radiology AI applications.

We can certainly expect to see more partnerships like this file into place over the next year or two. Few if any IT vendors have enough scientific expertise in-house to make important gains in biotech AI, and few providers have enough excess IT talent available to leverage discoveries and data in this arena.

It will be interesting to see what AI applications development approaches emerge from such partnerships. Right now, much AI development and integration is being done on a one-off basis, but it’s likely these projects will become more systematized soon.

Nurses and Patient Loads: The Solution Lies in Process Change, Not Maximums

Posted on November 1, 2018 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

Shortages of clinical staff plague communities around the world. Even my state of Massachusetts, a medical Mecca, has a shocking dearth of professionals in mental health. Health care reformers understand that shortages much be addressed through a careful and deep investigation into the hospital and clinic processes and practices. Streamlining processes through data analytics and the deft application of new technologies for monitoring and recording information will probably help.

Nurses probably experience the crunch of patient loads more than other staff. Unfortunately, some of them try to force a quick fix on their institutions through mandatory maximums. They ignore process, ignore holistic systems thinking, and ignore the potential of technology. Massachusetts is facing just such an ill-planned effort right now in a ballot question that would fix arbitrary patient loads. The public is being asked to regulate an area that can’t possibly understand. (The inscrutable text of this ballot question, number 1 on the ballot, is available about one-quarter of the way down this web page.) But Massachusetts was not the first to face this choice, and will probably not be the last.

In 2003, California passed limits on patient loads that are somewhat of a model for the Massachusetts law, and whose effects are hotly debated. Texas apparently considered a similar law, but I assume it went nowhere because I could find no other reference to it. Massachusetts has a law applying narrowly to emergency rooms, and every state has regulations for nursing homes.

Nurses don’t have it easy; that’s clear. But the solutions must be systemic. Opponents of Massachusetts ballot question 1 point to all kinds of negative effects that the proponents refuse to consider, such as the loss of non-nursing staff who are crucial to helping the nurses get their jobs done. The basic problem is that hospitals and other facilities are not making use of the computing advances, and related process improvements, available in this year 2018.

Health care giant Kaiser Permanente found that clinicians were spending 15 to 40 percent of their doing “hunting and gathering” for supplies before the company optimized its supply chains. The Boston Globe cites numerous management techniques that free up clinicians’ time, some right in Boston. A 2011 NIH report found that nurses spend only 37% of their time taking direct care of patients. Of course, other activities such as administration and documentation are important, but they are begging for process improvement. Partners Health Care has embarked on a large-scale effort to automate repetitive, “soul-crushing” work, and have found that staff are much happier and are spending more time using the skills they were trained to use in handling people issues. Currently, the effort affects HR, finance, and operations. I’m sure nursing would turn up opportunities for improvement when it comes their turn.

We shouldn’t have to spend 35% of nurses’ time on documentation, using systems that are notoriously inefficient and poorly automated. A recent survey showed that most doctors believe that automating common tasks such as documentation could improve clinicians’ efficiency. Nurses use the same systems, so their workloads could probably be reduced through similar improvements in technology.

Some nurses tell me, “Much of our job involves a human touch; it can’t be automated.” The NIH study shows that plenty of tasks that are amenable to computerization, and doing so will give nurses more time to apply their human touch–or as health care workers like to say, “work at the top of their license.”

The proponents of the Massachusetts ballot question count on a knee-jerk distrust of corporations (or at least of large health-care institutions). They have succeeded in winning over many people who call themselves political “progressives,” but a large segment of the Massachusetts public–according to polls, a slightly larger segment–intrinsically sense the ballot question’s flaws, so the polls are running against its passing.

We cannot improve health care and reduce costs if institutions take the status quo for granted. Voting “yes” on question 1 in Massachusetts would accept and perpetuate the assumptions behind our nursing practices. It’s hard to accept that profound systemic problems will take time and data to ameliorate, but the sooner we face that realization, the better we can deal with our clinical staffing problems.