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The Difficult Healthcare Problems Lie at the Crossroads

Posted on December 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.

Sometimes you stumble upon a quote which captures healthcare so perfectly. That’s what I felt when I heard this quote from Jonathan Sheldon at Oracle.

The real difficult problems sit at the crossroads of multiple domains – requires you to integrate data from separate domains.

-Jonathan Sheldon, Oracle

While many like to talk about the healthcare market, I’ve always felt that was a false framework. There’s no one healthcare market. At least not in the US. The world of healthcare is made up of hundreds of markets that have some overlaps and need to work together, but each market is very different. The simplest market to see is the ambulatory vs acute care vs post-acute care market. Each of these markets is so drastically different, that it’s really not useful to think of them as the same market. The same is true of specialties and even many regions.

The challenge of healthcare is that it spans all of these domains. And if you want to keep someone healthy and provide them an amazing patient experience, then you have to be able to span all of these different markets.

I guess that’s why the Jonathan Sheldon quote resonated with me so much. Healthcare faces a lot of difficult challenges, but one of the most difficult challenges is managing a patient’s care across all of these domains. All of us that have worked in healthcare have seen this first hand. It’s completely different cultures and often very different objectives.

While crossing these domains is one of the most challenging problems in healthcare, it is also some of the most rewarding.


Process Re-engineering Can Produce Results, Lumeon Finds

Posted on November 19, 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.

A rigorous look at organizational processes, perhaps bolstered by new technology, can produce big savings in almost any industry. In health care, Lumeon finds that this kind of process re-engineering can improve outcomes and the patient experience too–the very Triple Aim cited as goals by health care reformers.

A bad process, according to Robbie Hughes, Founder and CEO for Lumeon, can be described as, “The wrong people have the wrong information at the wrong time.” One example is a surgery unit that Lumeon worked with on scheduling surgeries. The administrative staff scheduled the surgeries based on minimal contact with the clinicians–a common practice throughout the industry that might seem efficient. But unfortunately, people who are uninformed about the clinical aspects of the surgery make sub-optimal plans, directly leading to poorer outcomes. The administrative staff don’t use rooms and other resources effectively, and stumble over risks that the clinicians could have warned them about. Lumeon uncovered the problem during a single morning meeting with this particular hospital. By enabling the clinicians to better coordinate with the scheduling staff, the surgery unit more than doubled its presurgical screening capacity without asking for increased funding.

I recently wrote about a controversy over patient loads that erupted into a major political controversy (rarely a formula for rational process engineering). Thus, when talking to Hughes, I was sensitized toward the importance of good processes. The health care field is stuck in the kind of blindness toward process seen in the fictional medieval setting of Monty Python’s Jabberwocky, but some of the more forward-thinking institutions are doing the hard work of streamlining their processes. These include:

  • Cleveland Clinic, which reorganized their recommendations for patient behavior before and after surgery, called Enhanced Recovery After Surgery (ERAS)
  • BUPA, a major British insurer that has a formal process model
  • U.S. giant Kaiser Permanente, which uncovered enormous waste when clinicians search for supplies

The higher you rise above the scene, and the more you can think about the system rather than one silo, the more efficient you can become. The Kaiser inquiry covered the entire supply chain for each hospital. BUPA is fortunate to possess actuarial information that help it assign a predicted cost and likely outcomes to cancer cases, where the company can assign caretakers to patients as needed throughout the whole recovery process.

Another useful scope is the sequence leading from a patient’s initial contact to a successful outcome, a process or “pathway” that goes far outside the hospital’s walls and beyond the time in the doctor’s office or surgical unit.

Typically, Hughes says, one day is enough to find process improvements. Through interviews and through observation–because staff misunderstand and misrepresent their own processes–Lumeon can develop a process map, expressed visually like the post-operative pathway in the following figure.

Typical pathway, describing post-operative process

*Click to see Full Size – Typical pathway, describing post-operative process

The best motivation for taking a longitudinal view, of course, is risk-sharing. A doctor who will be rewarded or penalized for outcomes will be willing to invest in producing better outcomes. Similarly, an insurer such as BUPA will be motivated to reduce readmissions if it has a long-term responsibility for patients. Bundled payments are a round-about, highly diluted approach to risk-sharing.

Fee-for-service models mean having to define a deliverable that everybody can understand and achieve. A bundled payments model is far from this. UK outcome measures truly place risk on the provider. In the US, bundled payments dilute risk.

But Lumeon can find ways to improve processes even within a fee-for-service model by enabling health organizations to guide patients more successfully through their entire health journey. For instance, with the company’s Care Pathway Management solution, doctors can remind patients to come back in five years for a colonoscopy, thus potentially saving lives while ensuring the institution’s own revenue stream under fee-for-service. Other simple goals can be to make sure the patient has a complete list of tasks prior to surgery (such as not to drink water in the morning) in order to eliminate late starts or last-minute cancellations, which are very expensive as well as frustrating. Predictably, Lumeon finds a certain set of common problems over and over, regardless of medical disciplines or institutions. Hospitals sometimes optimize within each department, but not across multiple departments. Usually this change comes down to maximizing compliance with a known protocol, rather than trying to use sophisticated artificial intelligence techniques to look for new approaches that theoretically offer benefits.

Lumeon also works to minimize disruptions to existing workflows. Large institutions such as Kaiser can tell everybody to adopt a whole new way of doing things, but staff within most institutions might be more resistant. The staff can still be trained to do things like create quality standards and follow them, or call patients at certain intervals or after a procedure, but these processes need training before they become reliable and predictable. Culture and habit, not technology, turn out to be the biggest barriers to process improvement.

Software, too, must be molded to current ways of working. We all experience little tolerance in our work or everyday lives for non-intuitive computer interfaces that appear to be putting barriers in our way. For instance, I have never forgiven my phone vendor for changing the most common activity I do on the device (turning airplane mode on and off) from a three-step process to an eight-step process.

The most effective persuasion is evidence-based. If an institution can get one department or doctor to adopt a new process, and can then collect data showing that it improves outcomes and cut costs, other departments are likely to follow along. In contrast, staff are likely to be oblivious to a study from a journal with statistics from clinical trials, no matter how scientifically valid the study may be. Hughes says that resistance to change is often attributed to doctors, but he thinks that this resistance is primarily caused by change being forced on them without evidence. With proper, objective data supporting a change, doctors are often the first to lead new initiatives in the spirit of delivering better patient care.

New kinds of records are needed to keep track of outcomes and make use of the valuable data they provide. Ideally, Lumeon would integrate with electronic medical records, but the EMRs are rarely set up to hold and provide such information. Instead, Lumeon installs software on top of the EMR, calling their addition an “agility layer.”

Hughes identified two common practices that can interfere with process improvement. The first is the growing focus around “patient engagement,” which can be as superficial as sending reminders for online check-ins or as fundamental as giving patients access to data.

However, patient engagement by itself is not sufficient to deliver meaningful process improvement. Patient engagement measures can make a difference as an integral part of an effective operational process. For instance, there is no point in getting patients to fill in data online if it’s not going to be used by the clinicians.

Second, the focus on documenting compliance with standards, such as meaningful use, often becomes a documentation exercise rather than a way of improving care. Unfortunately, this is a problem that is seen all over the world by well-intentioned governments and funders who want to offer incentives for good behavior by paying for better processes. But this all too often ends in additional costs and effort to administer the care, rather than actually focusing on the basics.

A HIPAA Life Sentence… and SO Many Lessons

Posted on November 15, 2018 I Written By

Mike Semel is a noted thought leader, speaker, blogger, and best-selling author of HOW TO AVOID HIPAA HEADACHES . He is the President and Chief Security Officer of Semel Consulting, focused on HIPAA and other compliance requirements; cyber security; and Business Continuity planning. Mike is a Certified Business Continuity Professional through the Disaster Recovery Institute, a Certified HIPAA Professional, Certified Security Compliance Specialist, and Certified Health IT Specialist. He has owned or managed technology companies for over 30 years; served as Chief Information Officer (CIO) for a hospital and a K-12 school district; and managed operations at an online backup company.

In 2012 Accretive Health Care was banned from doing business in Minnesota for 2 – 6 years for a HIPAA violation.

In 2018 New York State suspended a nurse’s license for a year for a HIPAA violation.

But, a life sentence?

The New Jersey Attorney General announced a $ 200,000 HIPAA and consumer fraud penalty against an out-of-business Georgia medical transcription company. In 2016 ATA Consulting LLC d/b/a Best Medical Transcription breached the medical records of over 1,650 people treated by three New Jersey healthcare providers by publicly exposing their medical records to the Internet. And, their customer, Virtua Health, paid a $ 418,000 settlement for violations of both HIPAA and the New Jersey Consumer Fraud Act.

Tushar Mathur, owner of Best Medical Transcription, agreed to a permanent ban on managing or owning a business in New Jersey.

Wow.

A life sentence for a HIPAA violation.

And the medical clinic paying a $ 418,000 penalty for the actions of its vendor.

By a state, not the federal government.

What can you learn from this?

1. It’s shocking to see how many servers have been misconfigured, or protected data being stored on web servers, exposing patient records to the Internet. These HIPAA penalties were all for exposing patient records through the Internet:

LESSONS –

  • Have your servers installed by a certified professional using a detailed checklist to ensure that no data is exposed to the Internet.
  • Make sure your organization has enough data breach insurance to cover millions of dollars in penalties; that you live up to all the requirements of your policy; and that you consistently implement the security controls you said you have in place on your insurance application.
  • Make sure your outsourced IT provider has enough Errors & Omissions insurance to cover your penalties

2. Many doctors and business owners tell me that “the federal government will never get them” or that they are “too small to be of interest” to federal regulators.

LESSONS –

  • Regulators go after small businesses, which doesn’t always make headlines. The Federal Trade Commission forced a 20-employee medical lab to go out of business. The business owner fought the FTC and ultimately won in court, but his business was gone.
  • Don’t ignore your risk that your state Attorney General (who probably wants to be governor) wants by getting headlines about protecting consumers. The HITECH Act (2009) gave state Attorneys General the authority to enforce HIPAA. Violations also can be tied to consumer protection laws, not just HIPAA.
  • Lawyers are representing patients whose information was released without authorization. Patients have successfully sued doctors for HIPAA violations.
  • Doctors shouldn’t laugh off HIPAA or just complain (INCORRECTLY) that it interferes with patient care. A doctor went to jail for a HIPAA violation.

3. HIPAA is only one regulation with which you must comply.

LESSONS –

  • Don’t think that a ‘We Make HIPAA Easy’ web-based solution is enough to protect your assets from all your regulatory challenges.
  • Don’t think that a self-conducted Security Risk Analysis is a substitute for a professionally-designed HIPAA compliance program that will meet all the federal and state requirements you must follow.
  • Don’t think that an IT Security company doing a vulnerability or penetration test is a substitute for a HIPAA Security Risk Analysis or a robust compliance program.
  • Every state now has data breach laws the state Attorneys General love to enforce. These consumer protection laws protect Personally Identifiable Information (PII) held by medical practices. State laws have different requirements than HIPAA. For example, HIPAA requires that patients be notified no later than 60 days after a data breach. California requires just 15 days.
  • Because of the opioid crisis, many types of medical practices are now offering substance abuse treatment, which requires additional confidentiality measures. So do HIV, mental health, and STD treatments. You need to address all the regulations that apply to you.

4. Don’t blindly trust your vendors.

LESSONS –

  • Signing a Business Associate Agreement (BAA) isn’t evidence that your vendor really complies with HIPAA. According to the NJ Attorney General, Best Transcription signed a BAA with Virtua Health but:
  • Failed to conduct an accurate and thorough risk assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of ePHI it held;
  • Failed to implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to comply with the Security Rule;
  • Failed to implement policies and procedures to protect ePHI from improper alteration or destruction;
  • Failed to notify VMG of the breach of unsecured PHI; and
  • Improperly used and/or disclosed ePHI in contravention of its obligations under its Business Associate Agreement with VMG.

Make sure your vendors understand their HIPAA obligations. Even after five years, my experience is that many Business Associates have failed to keep up with the changes required by the 2013 HIPAA Omnibus Final Rule. Many talk about HIPAA in their sales and marketing but do not comply.

Remember that you are responsible for the actions of your vendors.

WHEN YOU ARE LYING AWAKE TONIGHT, ASK YOURSELF:

  • Are you really sure you can survive an investigation by your state attorney general?
  • Are you really sure your Business Associate vendors have conducted a HIPAA risk analysis; have implemented HIPAA security measures; have implemented HIPAA policies and procedures, are really protecting your PHI, and will notify you if there is a breach?
  • Are you willing to bet $ 418,000 (what Virtua paid) on it?
  • If you are a Business Associate, what do you think it will feel like if you are banned for life from doing business?

Doctors send patients to specialists all the time. Whether you are a medical provider or a vendor, do you have the trained and certified specialists you need that can help with all your regulatory challenges? Does your team need expert help to validate what is you and your vendors are doing and help you address any gaps?

Don’t risk your assets. Don’t risk a life sentence.

 

 

Will UnitedHealth’s New Personal Health Record Make An Impact?

Posted on October 26, 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.

Though the idea of a personal health record was a hot thing for a while, it didn’t become the fixture of the healthcare market that pundits had predicted. In fact, as many readers will recall, even deep pockets like Google and Microsoft couldn’t get their users to sign on to their PHRs en masse.

One of the main reasons the PHR model didn’t take is that people simply didn’t want to use them. In fact, at least at the time, the PHR was almost entirely a solution in search of a problem. After all, if a health data power user and patient advocate like myself didn’t want one, what hope did PHR backers have of interesting your average Joe Blow in aggregating their health data online?

Over time, however, the personal health data landscape has changed, with patient records becoming a bit more portable. While consumers still aren’t beating down the doors to get their own PHR, those who are interested in pulling together their medical records electronically have better access to their history.

Not only that, wearables makers like Apple and Fitbit are sweetening the pot, primarily by helping people pull self-generated data into their health record. Arguably, patient-generated data may not be as valuable as traditional records just yet, but consumers are likely to find it more interesting than the jargon-laden text found in provider records.

Given recent developments like these, I wasn’t entirely surprised to learn that UnitedHealth Group is picking up the PHR torch. According to an article in MedCity News, the giant payer plans to launch what sounds like an updated PHR platform next year to its 50 million benefited plan members.

Apparently, on an earnings call last week UnitedHealth CEO Dave Wichmann said that the company will launch a “fully integrated and fully portable individual health record” in 2019. Notably, this is not just a data repository, but rather an interactive tool that “delivers personalized next-best health actions to people and their caregivers.”

The new health record will be based on UnitedHealth’s Rally health and wellness platform, which the insurer picked up when it acquired Audax Health in 2014. The platform, which has 20 million registered users, works to influence members to perform healthy behaviors in exchange for the incentive dollars,

Over time, Wichmann said, UHG intends to build Rally into a platform which collects and distributes “deeply personalized” health information to individual members, MedCity reported. The idea behind this effort is to highlight gaps in care and help patients assess the care that they get.  Wichmann told earnings call listeners that the platform data will be packaged and presented to clinicians in a form similar to that used by existing EHRs.

UHG’s plans here are certainly worth keeping an eye on over the next year or two. I have no doubt that the nation’s largest commercial payer has some idea of how to format data and make it digestible by systems like Cerner and Epic.

But while patients have become a bit more familiar with the benefits of having their health data on hand, we’re not exactly seeing consumers stampede the providers demanding their own health record either, and I’m far from convinced that this effort will win new converts.

My skepticism comes partly from first-hand experience. As a recent UnitedHealth beneficiary, I’ve used the Rally application, and I didn’t find it all that motivating. Honestly, I doubt any online platform will make much of an impact on patient health on its own, as the reasons for many health issues are multifactorial and can’t be resolved by handing one of us a few Rally bucks.

Personal gripes aside, though, the bigger question remains whether consumers think they’ll get something valuable out of using the new UHG tool. As always, you can never count on them coming just because you built it.

AMA Releases Great Guide To Digital Health Implementation

Posted on October 25, 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.

In the past, I’ve been pretty hard on the AMA when it comes to digital health. Last year I gave the organization a particularly hard time when it rolled out its Physician Innovation Network platform, which is designed to help physicians network directly with health tech firms, as it seemed to be breaking little to no ground.

However, to be fair the AMA has been a relatively quiet but solid presence in health IT for quite some time.  Its health IT efforts include cofounding Health2047, which brings together doctors with established health IT companies to help the companies launch services and products, serving as one of four organizations behind mHealth app standards venture Xcertia and managing a student-run biotechnology incubator in collaboration with Sling Health.

But what it hasn’t done so far, at least to date, has been to offer physicians any hands-on guidance on using emerging health IT. Now, at long last, the AMA has taken the plunge, releasing a guide focused on helping physicians roll out digital health technology in their practice. At least this time around, I have to give the organization a high five.

The new guide takes a lifecycle perspective, helping practices work through the digital health implementation process from preparations to rollout to gathering data on the impact of the new technology. In other words, it lays out the process as a feedback loop rather than a discrete event in time, which is smart. And its approach to explaining each step is concise and clean.

One section identifies six straightforward steps for choosing a digital health technology, including identifying a need, defining success early on in the process, making the case for political and financial buy-in, forming the team, evaluating the vendor and executing the vendor contract.

Along the way, it makes the important but often-neglected point that the search should begin by looking at the practice’s challenges, including inefficiencies, staff pain points or patient health and satisfaction problems. “The focus on need will help you avoid the temptation to experiment with new technologies that ultimately will result in tangible improvements,” the guide notes.

Another offers advice on tackling more immediate implementation issues, including steps like designing workflows, preparing the care team and partnering with the patient. This section of the report differs from many of its peers by offering great advice on building workflow around remote patient monitoring-specific requirements, including handling device management, overseeing patient enrollment and interactions, and assuring that coding and billing for remote patient management activities is correct and properly documented.

The guide also walks practices through the stages of final implementation, including the nature of the rollout itself, evaluating the success of the project and scaling up as appropriate. I was particularly impressed by its section on scaling up, given that most of the advice one sees on this subject is generally aimed at giant enterprises rather than typically smaller medical practices. In other words, it’s not that the section said anything astonishing, but rather that it existed at all.

All told, it’s great to see the AMA flexing some of the knowledge it’s always had, particularly given that the report is available at no cost to anyone. Let’s hope to see more of this in the future.

How to Build an Effective Rural Virtual Care and Telehealth Strategy

Posted on October 10, 2018 I Written By

The following is a guest blog post by Lee Horner, CEO of Synzi.

Rural healthcare organizations are increasingly interested in implementing virtual care and telehealth solutions in order to better meet the needs of their facilities, staff, and patient population. In danger of closing their doors, rural hospitals are struggling to survive and thrive in a healthcare environment with razor-thin margins.

iVantage’s 2017 Rural Relevance Study reports that 41 percent of rural hospitals operate at a negative margin. Poor financial performance is impacting these hospitals’ ability to keep their doors open and serve rural communities. In fact, the National Rural Health Association (NRHA) reported that the number of rural hospital closures has risen to 87 in the last 8 years.

A rural hospital closure has significant impact to its community. These facilities provide fundamental healthcare services to nearly 57 million people across the country and are often an integral part of the local economy, providing jobs and a tax base for the community. John Henderson, CEO of the Texas Organization of Rural and Community Hospitals (TORCH) stated that hospitals are a critical element of a town’s survival: “Hospitals, schools, churches. It’s the three-legged stool. If one of those falls down, you don’t have a town.”

Virtual care technology can be a viable delivery option for healthcare facilities and residents in rural communities. To best build an effective virtual care strategy, rural healthcare organizations should short-list solutions which solve for limited bandwidth in rural areas, patient preference for mobile devices and communications, an organization’s current infrastructure and workflow, and security concerns.

Addressing Bandwidth Issues: Rural healthcare organizations may initially think that limited Wi-Fi and broadband availability will restrict telehealth adoption by a facility, a medical practice and/or the patients themselves. However, rural healthcare organizations can identify and implement solutions which work across any level of connectivity (whether cellular or Wi-Fi) to ensure that the providers and the patients can use the solution without issues. Various entities are actively pushing for continued investment in our nation’s broadband infrastructure and rural communities are a priority for future build-out.

Reflecting Patient Preferences: Patients are already using many devices – including smartphones, tablets, and/or computers – which also provide them with more convenient access to healthcare without requiring significant travel time and costs. Moving forward, rural healthcare organizations should prioritize solutions which are device-agnostic and should also ensure their patient communications work across any type of modality. Providers and patients already own many of these devices; a flexible virtual care platform will help organizations and individuals reap more benefits out of the investments they have already made in technology.

Optimizing Current Workflows: Healthcare organizations have ongoing clinical workflows, and may be wary of technology’s role in automating these processes. However, rural healthcare organizations’ existing workflows can be optimized by using a virtual care platform which ensures that the virtual care protocols are consistent with in-person protocols in terms of engaging at-home patients and/or reaching offsite specialists for a needed consult. The ideal solution should be intuitive and easy to use; providers will then be able to quickly incorporate virtual care into their practices.

Addressing Security Concerns: When exploring new technology, most healthcare organizations will initially question if a net-new solution meets safety and privacy standards. Rural healthcare organizations should prioritize solutions which are HIPAA-compliant and HITRUST-certified to ensure security, privacy and compliance. Although rural health providers will immediately understand the need to adopt a virtual care platform, IT departments and champions will also need to realize that the adoption of this new technology will benefit providers, patients, and ultimately, the sustainability of the healthcare organization. Virtual care technology is essential to rural healthcare as it helps close the time and distance gap in terms of providing patients with the care they need, when they need it – regardless of where the patients or the providers are located.

The rural population has noted gaps in both access and quality. An estimated one in five Americans live and work in rural areas across the nation, yet, there are 2,157 Health Professional Shortage Areas in rural areas compared to 910 in urban areas. Moreover, the Rural Health Information Hub reports that 19.5 percent of rural adults describe their health status as fair/poor vs. 15.6 percent of their urban counterparts. Virtual care technology can help address the gap in care by providing access to additional physicians and needed specialists at the click of a button. By leveraging external and/or associated hospitals and physician groups, rural hospitals strengthen their care within the vast populations and geographies they support.

Top 5 Ways Healthcare Applications Slow Down and What To Do About It

Posted on October 4, 2018 I Written By

The following is a guest blog post by Jeff Garbus and  Alvin Chang from Soaring Eagle Consulting.

We spend a lot of our lives tuning applications that people complain are too slow. In no particular order, here are some of our findings.

Poor indexing #1 – Unused Indexes, Missing Indexes can cause problems

While I’ve said, “in no particular order,” I do have to say this one is usually first. When applications go through Q/A / Stress test, there is often a lot more horsepower than there is data. As a result, the memory and CPU combination mask the otherwise bad performance. Once the application hits production, larger volumes of data are not managed as effectively.

On the plus side, you can almost always add an index (or indexes) without causing other application side effects.

Warning: Do NOT automatically add indexes as recommended by a DBMS’ tuning advisor; they often miss opportunities, and also often significantly over index by recommending multiple similar indexes rather than one enveloping one.

Be wary of overindexing as too many indexes can also create overhead that will cause processes to slow.

Bad queries #2 – Too much data returned by a query

Sometimes you are simply bringing too much data back from the database to the front end. I saw a search recently that brought about a half million rows of data back to the end user. I asked, “What is the user going to do with that much data?” Answer: “They are going to look at the first few rows and refine the search.”

This unnecessarily stresses the disk CPU, memory, and the network.

Easiest solution: Bring back only the data the user is going to work with. Perhaps the first few hundred rows. Save time, disk resources, and network resources.

Bad queries #3 – Overuse of temporary tables

Many applications use temporary tables incorrectly or are wasteful with them. For example, they are used

  • When the programmer wants to avoid joins (which the server is very good at!);
  • Are filled with lots of data, then rows are deleted (why load them in the first place?);
  • Or too many columns are used (why select * when the columns aren’t being used?) – this increases network bandwidth, as well as making the table unnecessarily big
  • Joining temp tables is another way developers often misuse server resources. Without indexes, this is very costly

Avoid temporary tables

Bad Queries #4 – Attempting to do it all in one Giant Query. 

Sometimes the opposite can also be true. When attempting to write a query for a process, Developers can get stuck in the mindset that a single query can solve all possible conditions of a query.  This leads to large complicated queries that in addition to being difficult to decipher. Can also generate excessive numbers of worktables as it attempts to place large subsets of data into worktables.

Large Reports #5 Combine reporting and transactional activity

It is very common to allow reporting off highly transactional databases. The problem is that reporting creates shared locks on resources, and transactions can not modify the data while the locks are held. In addition, reports are often ad hoc, so that the load on the server is unpredictable.

Easy solution: replicate production data to a reporting server. If replication or other high availability is unavailable, use dump/load to keep day old data for reporting purposes (this is often sufficient).

Allow direct downloads of data

Some companies allow “super users” (also sometimes called “analysts”) to download production data, real time, to applications like Microsoft Access. In addition to being a likely security violation, this also creates blocking issues for the online users.

Solution: Data replication, as above.

If you’d like to learn more about how to improve slow applications, sign up for our webinar “Are your Servers, Apps, and EHR systems ready for a spike in website traffic?

About Jeff Garbus and Alvin Chang
Jeff Garbus founded Soaring Eagle Consulting 20 years ago, and Alvin has been his right hand for almost 30 years now. Together they have authored or coauthored 20 books and dozens of articles on Database Management. Soaring Eagle Consulting is an On Shore HIPPA and PCI compliant remote database management company that is available for projects and consulting work on Architecture, Performance and Tuning, Scalability, application development, migrations and 24×7 full operational support. Do your DBAs need a best friend? Jeff, Alvin, and the On Shore GURU level database team are here to help you!

Soaring Eagle is a proud sponsor of Healthcare Scene.

MGMA 2018 Keynotes Hit Back-to-Back Home Runs

Posted on October 2, 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.

Not far from legendary Fenway Park, MGMA hit back-to-back home runs with their opening keynotes: Simon Sinek and Mel Robbins. Both had us completely enthralled and hanging on their every word. It was an incredible way to start a conference.

I have never been more excited for a set of keynotes than I have for the 2018 MGMA Annual Conference #MGMA18Annual. When the agenda for the conference was officially released I was pleasantly surprised to see not one, but TWO well-known keynote speakers.

Simon Sinek is best known for his TEDTalk – “How great leaders inspire action” which became one of the most popular ever produced. In it Sinek talks about getting past WHAT you offer and HOW you offer it in order to reach the crucial WHY you do what you do. It is one of my favorite videos to watch.

Sinek’s #MGMA18Annual keynote was based on his latest work on Finite vs Infinite Games of Leadership. For a preview you can watch this video of his presentation at Google.

According to Sinek a finite game is one where there known players, fixed rules and an agreed upon objective. Baseball, football and hockey are classic examples of finite games. Infinite games, have known and unknown players, changeable rules and the objective is to keep the game going. With infinite games there are no winners or losers. The only way the game ends is when the second-to-last player loses the will or the resources to continue playing the game.

Sinek used the Cold War as an example of an infinite game. The Soviet Union was the second-to-last player and they dropped out when they lost the will and the resources to keep playing. Sinek warns that when you pit a finite player vs an infinite player you are in fact playing an infinite game and inevitably the finite player loses. That is because the finite player is playing to WIN whereas the infinite player is playing to keep playing. Sooner or later the finite player will drop out – not prepared to dedicate as much resources to the game as the infinite player.

Sinek applied this finite vs infinite game analogy to business and found that too many companies are finite players in an infinite game. “We talk about being number 1.” said Sinek. “We boast about beating the competition, but in fact that isn’t the case at all in business. There is no winner. You are either ahead or behind, but you can’t actually win in the game of business. You just have to keep playing.”

According to Sinek, one of the keys to succeeding in an infinite game is to have a Just Cause. Such a cause will help you rally the necessary resources and will to keep playing the game. Ending child poverty, and making the sum total of human knowledge searchable are examples of Just Causes.

Healthcare clearly has a Just Cause – to help people live longer, healthier lives. So why is healthcare in such a quagmire? (something Sinek claims is typical of finite players in an infinite game). This was one of the questions posed by a member of the audience at #MGMA18Annual. Sinek’s answer was brilliant.

“I believe that the problem in healthcare is that many organizational leaders have mistakenly taken the industry’s Just Cause and made it their own. Healthcare as industry is supposed to keep people healthy. However, the job of the leaders of healthcare organizations isn’t to make people healthy. No! Their job is to take care of the people who deliver care to patients.”

Imagine how different healthcare would be if administrators, healthcare leaders and government officials all had the same goal: taking care of the physicians, nurses and support staff under their influence. Think about the level of care a patient would receive if the doctor and the nurse felt that the organization they worked for had their back? How different would the patient experience be?

Home Run #1.

Mel Robbins, #MGMA18Annual’s second keynote speaker, kicked off Day 2 of the conference with a rousing session centered on her transformative 5 second rule. Her simple rule has helped people stay sober, save their marriages and turn-around failing careers. The rule is so simple that she felt obligated to call it out in her opening: “After I tell you the secret of the 5 second rule, most of you will likely say to yourself – that can’t possibly work, but trust me it does. And that’s the beauty of it, it’s simple.”

In a nutshell, Robbins method involved counting down from 5 whenever you find yourself starting to have a negative thought or when you feel yourself making an excuse NOT to do something you know you should.

Roll out of bed and see your running shoes, but then look outside and see that a few dark clouds. Don’t let the excuse fully form in your mind. Instead, change your mental soundtrack by counting down 5 – 4 – 3 – 2 – 1 and then do it. See a task that you’ve been putting off all day, 5 – 4 – 3 – 2 – 1 and dive in. Sounds too simple right?

Robbins spent much of her time on stage giving scientific evidence and examples of how this 5 second rule actually works. She talked about being on “autopilot” – a mental state where your brain falls back on learned behaviour to guide the actions you take. Procrastination and self-doubt are the autopilot settings for most of us. According to Robbins, in order to break free of autopilot, you need to engage your frontal cortex – which is what happens when you count down from 5.

This simple brain hack puts you back in control of your actions and suddenly the excuses melt away and you get on with the necessary task. That essay suddenly gets written, the house gets painted, the phone call gets made and the important email gets sent.

Robbins was quick to point out that her 5 second rule did not apply to life-or-death medical decisions, nor should it be used to make important financial or life-altering decisions. It was meant to be used when we start hearing the voice of our inner doubts.

I must admit that when I first watched Robbin’s TEDTalk I did not internalize her message. I fell into the trap and thought it was too simple to be effective. Hearing her deliver her message live at #MGMA18Annual changed my mind. It’s only been a day but already I’ve used Robbin’s 5 second rule to climb the stairs instead of using the escalators at the convention center, opt for water instead of soda,  and write this blog before going to bed.

Home Run #2

Thank you MGMA organizers.

Patient Billing And Collections Process Needs A Tune-Up

Posted on October 1, 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.

A new study from a patient payments vendor suggests that many healthcare organizations haven’t optimized their patient billing and collections process, a vulnerability which has persisted despite their efforts to crack the problem.

The survey found that while the entire billing collections process was flawed, respondents said that collecting patient payments was the toughest problem, followed by the need to deploy better tools and technologies.

Another issue was the nature of their collections efforts. Sixty percent of responding organizations use collections agencies, an approach which can establish an adversarial relationship between patient and provider and perhaps drive consumers elsewhere.

Yet another concern was long delays in issuing bills to patients. The survey found that 65% of organizations average more than 60 days to collect patient payments, and 40% waited on payments for more than 90 days.

These results align other studies that look at patient payments, all of which echo the notion that the patient collection process is far from what it should be.

For example, a study by payment services vendor InstaMed found that more than 90% of consumers would like to know what the payment responsibility is prior to a provider visit. Worse, very few consumers even know what the deductible, co-insurance and out-of-pocket maximums are, making it more likely that the will be hit with a bill they can’t afford.

As with the Cedar study, InstaMed’s research found that providers are waiting a long time to collect patient payments, three-quarters of organizations waiting a month to close out patient balances.

Not only that, investments in revenue cycle management technology aren’t necessarily enough to kickstart patient payment volumes. A survey done last year by the Healthcare Financial Management Association and vendor Navigant found that while three-quarters of hospitals said that their RCM technology budget was increasing, they weren’t necessarily getting the ROI they’d hoped to see.

According to the survey, 77% of hospitals less than 100 beds and 78% of hospitals with 100 to 500 beds planned to increase their RCM spending. Their areas of investment included business intelligence analytics, EHR-enabled workflow or reporting, revenue integrity, coding and physician/clinician documentation options.

Still, process improvements seem to have had a bigger payoff. These hospitals are placing a lot of faith in revenue integrity programs, with 22% saying that revenue integrity was a top RCM focus area for this year. Those who would already put such a program in place said that it offered significant benefits, including increased net collections (68%), greater charge capture (61%) and reduced compliance risks (61%).

As I see it, the key takeaways here are that making sure patients know what to expect financially and putting programs in place to improve internal processes can have a big impact on patient payments. Still, with consumers financing a lot of their care these days, getting their dollars in the door should continue to be an issue. After all, you can’t get blood from a stone.

Healthcare AI Could Generate $150B In Savings By 2025

Posted on September 27, 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.

Is the buzz around healthcare AI solutions largely hype, or can they deliver measurable benefits? Lest you think it’s too soon to tell, check out the following.

According to a new report from market analyst firm Frost & Sullivan, AI and cognitive computing will generate $150 billion in savings for the healthcare business by 2025.  Frost researchers expect the total AI market to grow to $6.16 billion between 2018 and 2022.

The analyst firm estimates that at present, only 15% to 20% of payers, providers and pharmaceutical companies have been using AI actively to change healthcare delivery. However, its researchers seem to think that this will change rapidly over the next few years.

One of the most interesting applications for healthcare AI that Frost cites is the use of AI in precision medicine, an area which clearly has a tremendous upside potential for both patients and institutions.

In this scenario, the AI integrates a patient’s genomic, clinical, financial and behavioral data, then cross-references the data with the latest academic research evidence and regulatory guidelines. Ultimately, the AI would create personalized treatment pathways for high-risk, high-cost patient populations, according to Koustav Chatterjee, an industry analyst focused on transformational health.

In addition, researchers could use AI to expedite the process of clinical trial eligibility assessment and generate prophylaxis plans that suggest evidence-based drugs, Chatterjee suggests.

The report also lists several other AI-enabled solutions that might be worth implementing, including automated disease prediction, intuitive claims management and real-time supply chain management.

Frost predicts that the following will be particularly hot AI markets:

  • Using AI in imaging to drive differential diagnosis
  • Combining patient-generated data with academic research to generate personalized treatment possibilities
  • Performing clinical documentation improvement to reduce clinician and coder stress and reduce claims denials
  • Using AI-powered revenue cycle management platforms that auto-adjust claims content based on payer’s coding and reimbursement criteria

Now, it’s worth noting that it may be a while before any of these potential applications become practical.

As we’ve noted elsewhere, getting rolling with an AI solution is likely to be tougher than it sounds for a number of reasons.

For example, integrating AI-based functions with providers’ clinical processes could be tricky, and what’s more, clinicians certainly won’t be happy if such integration disrupts the EHR workflow already in existence.

Another problem is that you can’t deploy an AI-based solution without ”training” it on a cache of existing data. While this shouldn’t be an issue, in theory, the reality is that much of the data providers generate is still difficult to filter and mine.

Not only that, while AI might generate interesting and effective solutions to clinical problems, it may not be clear how it arrived at the solution. Physicians are unlikely to trust clinical ideas that come from a black box, e.g. an opaque system that doesn’t explain itself.

Don’t get me wrong, I’m a huge fan of healthcare AI and excited by its power. One can argue over which solutions are the most practical, and whether AI is the best possible tool to solve a given problem, but most health IT pros seem to believe that there’s a lot of potential here.

However, it’s still far from clear how healthcare AI applications will evolve. Let’s see where they turn up next and how that works out.