The second class of healthcare startups starts in November.
Call it "this old hospital" by the banks of the Ohio River in the Pittsburgh area, if you must. But Suburban General Hospital, essentially shuttered three years ago, has been reborn recently as a healthcare startup accelerator, enjoying the benefits of hospital-grade facilities.
Jeff Cohen, MD, who first came to Pittsburgh in 1985, saw the demise of Suburban General firsthand, but now finds himself the executive in charge of the birth of AlphaLab Health, a new accelerator supporting early-stage startups in their efforts to bring innovations to market, navigating key risk points of scientific, clinical, and commercial development.
"When I first came to Pittsburgh in 1985, it was the downturn of the steel industry, and I would see all these men that were unemployed steel workers," Cohen says. "A large part of the Steeler nation came from people that just got jobs and went elsewhere, but they were always Steelers fans."
After weathering double-digit unemployment rates, the region began to be seen differently.
"It evolved into a med-bed economy," Cohen says. "A lot of that was the perseverance of the educational infrastructure in the regionand the philanthropic community, is quite substantial." Hospital consolidation in the region followed, as detailed in The Next Shift: The Fall of Industry and the Rise of Health Care in the Rust Belt, by Gabriel Winant.
"Long story short, we lost ten hospitals in this area in about the last ten years, and the question is, what do you do with a closed hospital?" Cohen says. At the time, he was president of Allegheny General Hospital, located six miles sound of the shuttered Suburban General campus, which AGH owned. AGH continues to handle some of the most complex healthcare cases in the state.
By 2018, the 240,000-square-foot Suburban General facility was entirely closed, except for 18,000 square feet of minimal usage, including an urgent care center. "You could sell it, but it's not worth a lot," Cohen says. "It's part of the bond covenants, so it's hard to get rid of. It sits in a very poor community, which during the steel days was an upper middle-class community."
Leadership decided to launch a "study in disruption," to spawn new healthcare startup companies amidst this economically depressed community, focusing on making a dent in the kind of social determinants of health that healthcare at large has focused on lately.
Cohen assumed the title of chief physician executive of community health and innovation for the Allegheny Health Network, which in 2013 became a division of Highmark Health.
Jeff Cohen, MD, chief physician executive, community health and innovation, Allegheny Health Network. Photo courtesy of AHN.
"The biggest advantage that hospitals have is they have to have life safety equipment in them, specifically HVAC systems equivalent to BSL-1 and BSL-2" biosafety levels, Cohen says.
Starting the week of October 13, AlphaLab Health is converting a former 10,000-foot ICU into wet lab space, he says. "We're getting the preamble together to do all that – the zoning, changing the usage," he says.
In exchange for low-cost use of the facilities, access to AHN's 2,000 physicians, as well as patients, space to test their innovations, and introductions to the greater Pittsburgh life sciences community and beyond, AlphaLab Health takes a minimum of 1% to 2% equity stake in each startup. "[Additionally] we mentor them in the areas that they need to worry about in the healthcare system," Cohen says. The non-profit startups get access to some facilities, such as lab space, for "essentially zero," cost, he adds.
AHN being owned by Highmark, a payer organization, also gives startups insights into the economics of healthcare, and for this, AlphaLab Health does not take the lion's share of equity that other venture capitalists demand of startups.
"Specifically, the University of Pittsburgh's model is they have to own everything, and I'm not being critical," Cohen says.
AlphaLab Health received about 80 applications before selecting the first class of seven startups, mostly mentored virtually in the first year of the program. As an early measure of success, the startups have raised more money between themselves than AlphaLab Health expected in its original business case, Cohen says.
The next phase of startup development is choosing six more start-ups out of 130 applications, at the beginning of November. "We're stimulating interest in this region," Cohen says. "For the Pittsburgh region, this is a place that you can go and try your idea. If it's going to work, great. If it isn't, you're going to fail fast, and you're not going to spend all the money on amenities like real estate."
It's also worth noting that Pittsburgh’s life sciences sector is already 150 companies strong with a concentration in medical devices and healthcare tech. According to AHN, from 2009 to 2019, the sector saw 204 company expansions resulting in 22K+ life science jobs being created and retained, along with nearly $4 billion in capital.
AlphaLab Health won't just be injecting healthcare tech into the Pittsburgh community, either.
"Hospitals have kitchens, and kitchens feed people that are food insecure," Cohen says. "We have other facilities that we can stand up programs in. We can actually measure the outcomes, and we're starting to see an abatement of cost of ER usage for people by doing something novel like dealing with their social determinants and feeding them."
The cost of living is "still very acceptable" in Pittsburgh, and Cohen hopes the startups decide to remain in the Pittsburgh area, revitalizing its economy.
"If their ideas are successful, we're going to create [investment] rounds to get them to the minimal viable product proof of concept," he says.
The old hospital even lends itself to being spruced up for little money to accommodate the needs of startups.
"We took the old patient rooms, cleaned them up, took out the beds, stuff like that," Cohen says. Add some paint, and some of the ample office furniture retrieved from warehouses, and "it looks like an office with a private bathroom," he adds. Add a $300 TV on the wall of a larger room and "all of a sudden, you've got a first-rate conference room." There's ample parking outside, too.
"It's been a very fun project," Cohen says. "It just points out that there is a relationship between healthcare outcomes and economics as the hospital closes. The actual physical three-dimensional building can be repurposed for a lot of things."
The effort has even garnered national attention, because AHN can do all this at a highly competitive price point, he adds.
Editor's note: This story was updated on October 15, 2021.
The initiative helps Connecticut to be a leader in the percentage of population that has been vaccinated.
Continuing a recent trend of avoiding the requirement to download mobile apps, and instead simplifying patient engagement via text and simple web pages, Hartford HealthCare helped lead the charge that allowed the state of Connecticut to have one of the highest COVID-19 vaccination rates in the nation.
The health system, based in Hartford, Connecticut, uses a platform from Upfront Healthcare that powers text-messaging engagement between patients and providers.
During the push to vaccinate the Hartford HealthCare community, the health system sent out 1.5 million texts, and 600,000 people engaged with the texts and pursued COVID-19 vaccinations, says Barry Stein, MD, MBA, FSIR, FACR, RPVI, vice president, chief clinical innovation officer, and chief medical informatics officer at Hartford HealthCare.
"I don't think you could do any other campaign where people could reach 600,000 respondents in one shot," Stein says.
The key success factor was keeping the technology simple, and that meant not requiring registering or logging into a traditional web site, visiting a patient portal, or downloading a mobile app. Instead, patients simply click on a text message on their mobile devices and engage by answering a set of questions that leads to scheduling a first or second COVID-19 vaccination.
Responding to the texts sent patients to specially built, simplified "micro sites" that allowed them to schedule their vaccination visits.
"We had a partner [in Upfront] that had the technology knowhow to send the message out in a seamless, provocative way," Stein says. "We had a message from Hartford HealthCare: 'We're here for you, we understand.' We collected the information in a seamless way. And we delivered everything we had promised simply and easily. From the consumer standpoint, it looked so easy."
Hartford HealthCare utilized patient engagement technology from Upfront to get past limitations in logic and artificial intelligence that kept the mission from being completed solely using its Epic electronic healthcare software, Stein says.
"We had a partner [Upfront] that was extraordinarily agile," Stein says. "Every day, we were meeting for 15 minutes, making sure everything was fine. And quickly, we rolled this out."
Barry Stein, MD, MBA, FSIR, FACR, RPVI, is the vice president, chief clinical innovation officer, and chief medical informatics officer at Hartford HealthCare. Photo courtesy of Hartford HealthCare.
The average number of engagements per patient was 4.3, according to Carrie Kozlowski, chief operating officer and co-founder of Upfront.
"They just loved that [the text] was unobtrusive and it was easy," Stein says. "We were engaging them across all the steps of the vaccine, so informing them, reminding them of their first dose, making sure they didn't skip their second dose, all the way through that experience."
Asked how the rest of the population engaged with vaccination resources, Stein says "not every patient in Connecticut belongs to Hartford HealthCare. There are other alternatives that exist." Among those were pharmacies and mass vaccination sites set up by the state and other governmental agencies.
Removing barriers
Hartford HealthCare President and CEO Jeffrey Flaks has made diversity, inclusion, and equity an imperative at the organization, Stein says. So as part of the vaccination effort, the system made special outreach to patient populations in certain ZIP codes and partnered with FEMA to send trailers to several communities to deliver vaccinations, he says.
The vaccination outreach did not require recipients to create an Epic MyChart account or enter a Social Security number, "because that was going to be a deterrent," says Kozlowski.
Instead, the microsites presented patients with vaccine visit options to select from, without having to go through extra steps, Kozlowski says.
"It was a good collaboration across several different technology teams at Hartford with our team to make that happen very quickly, to just remove the barriers for folks that may make an extra step harder, and then less likely to go ahead and get vaccinated," Kozlowski says.
"For that to happen, there's so many different functions that have to quickly sit together and remove legacy unintentional barriers that have significant impact, both internally as well as externally," Stein says. "Our innovation layer had the connective tissue to work in a cross-functional, interdisciplinary way. It wasn't just technology [professionals] meeting Upfront. It was sometimes revenue cycle, legal compliance. We all sat in the room together, figuring out how do we solve the problem to remove the friction.
"The only way to accelerate innovation is to get the right minds in the room from different lenses, looking at the same problem and be accountable to one another to solve them and not to punt them."
The microsite also offered real-time rescheduling of vaccination appointments if a patient needed to reschedule.
"We did not want to be wasting one dose," Stein says. "Not one, because every dose is a potential life saved."
Other uses for text outreach program
With the vaccination success story as a proof point, Hartford HealthCare has moved to expand use of the text messaging/microsite concept to meet other patient engagement challenges.
"In Medicare Advantage plans, it's important to have your annual visit for quality metrics and for good health," Stein says. "A significant amount of patients don't come in for that."
So, the same technology is now being deployed to remind those patients to schedule their annual exam, in partnership with urgent care provider GoHealth Urgent Care. Other kinds of preventive healthcare screenings are also being fit into the text outreach program.
Also, the same technology is allowing Hartford HealthCare employees to opt-in to receive texts before coming to work, where they can attest to their good health for working that day.
In addition to the executive roles he plays, Stein continues his work as a radiologist for Hartford HealthCare. "You've got to be where the work is being done to understand and be in touch with where the problems are," he says. "If you want to solve a problem, especially in healthcare, it's important not to develop distance that can amplify missed translation" of problems as communicated from workers to leadership, he adds.
"I liken technology to administering a drug," he says. "It's got to be engineered correctly. And it's got to be given for the right reason to the right patient. And if you think about it, all the steps and technology, how quickly you can be delivering something has been engineered incorrectly to an incorrect population.
"It's important to partner with partners, both inside and out, that are intentionally listening to the customer, and to the problem that we're trying to solve, and not trying to force their way of doing things."
Editor's note: This story was updated on October 8, 2021.
54% of appointments booked online have been for new patients.
Technology-driven culture change at Inspira Health Network was the key ingredient to a growth spurt in outpatient activity at the New Jersey healthcare nonprofit.
Specifically, leaders at Inspira Health persuaded physicians to allow patients to schedule their own appointments, which previously had been booked the traditional way, by having patients call or otherwise communicate with physicians' staffs, who had, until that time, sole possession of the available time slots for appointments.
The innovation required expansion in August 2020 of a technology working in conjunction with Inspira Health's Cerner Millennium electronic health record (EHR) software.
Thomas Pacek is the vice president and chief information officer at Inspira Health. Photo courtesy of Inspira Health Network.
The technology whose use expanded was Kyruus, which was brought in at Inspira Health to power search the system's healthcare provider directory on the web and in Inspira Health's MyInspira mobile app. "We started with that," says Thomas Pacek, vice president and chief information officer at Inspira Health. "People can find a physician by specialty, location, or if you want a female or male physician. Once that was operational, we added the [Kyruus] self-scheduler capability."
"There were many lessons for us to learn, especially around the engagement of the physicians and how important it was to have their buy-in," says Amy Mansue, president and CEO of Inspira Health.
The pandemic played a catalytic role in this process, by creating expectations in the minds of the public that many tasks, inside and outside of healthcare, which were previously conducted via phone or in person, could transition to being completed on digital platforms.
"People have learned that they can run their lives from their computers," Mansue says. "And they have different expectations, and those apply to healthcare."
Amy Mansue is the president and CEO of Inspira Health. Photo courtesy of Inspira Health Network.
Still, it took "many, many months of conversations with our physicians, getting them comfortable to open up their schedules, and allowing patients to schedule themselves," Pacek says.
Kyruus technology initiates the self-scheduling, then hands off to the Cerner EHR to create the appointment and subsequent reminders to patients.
Prior to implementing self-scheduling, Inspira Health, during the pandemic, had been experiencing a high-call abandonment rate at its call center, Mansue says. "They couldn't respond to all the volume."
Out of 4,255 appointments that have been made using the self-scheduling technology across 86 owned-practice providers, 54% are new patients. Beyond the owned-practice providers who are set up for self-scheduling, another 441 providers on Inspira’s medical staffs can be found using the search and match tool on the Inspira Health website.
Data from Kyruus also highlighted differences in care between providers. One doctor would reserve 40 minutes for treatment of a new patient, but another reserved only 30 minutes. Leadership was able to work with physicians to standardize length of appointments.
"It's physician equity, and patient equity, as far as how many patients can be seen in a day," Pacek says.
"Having patients schedule in, it requires some giving up of control," Mansue says. "It allowed us to have some dialogues that we needed to have anyway and hadn't had. Getting [providers] to standardize and understand the importance of it from the patient perspective has been a critical component of this work."
The growth in the number of patients helped physicians to embrace the new self-scheduling system. That growth also put demands on Inspira Health to hire additional physicians in certain areas.
"It helped us feed our strategic plans, as we went forward to identify where the needs are of our community," Pacek says.
In fact, based on the growth prompted by physician directory services including self-scheduling, including an 11% surge in organic search traffic, Inspira Health is looking at hiring 100 new physicians, including physicians who will replace others who are retiring, Mansue says.
The growth of telehealth during the pandemic also played a role.
"We saw during COVID that the national data showed us that 40% of the people were willing to change their physician and their health system, if they couldn't schedule online and couldn't schedule a telehealth visit," Mansue says. "They wanted that flexibility and convenience."
"Physicians wanted to see people in person," Pacek says. "But that's not always what the consumers want. This system has given us data that's allowed us to see that."
Patients are looking for the kind of experience in healthcare that they already experience in other industries, Mansue says.
"You go into a Target, you know how you're going to interact," she says. "You know basically what's in what area. Patients are looking for that same type of consistency from us in healthcare."
Visits involving a physician exam are not scheduled as telehealth appointments, and the self-scheduling templates are set up to recognize that appropriately, he adds.
Inspira Health is also in the process of adding self-service rescheduling of appointments, something that previously required calling the physician's office, Pacek says.
At this point, the system hasn't yet begun to actively market the capability, in part because the work of hiring the additional 100 physicians has not yet been completed, Mansue says. "We had no sense that we would get this much new patient growth," she says.
In addition, Inspira Health's call center is now piloting the ability for call center workers to schedule appointments for patients, using the same Kyruus software, Pacek says.
Editor's note: This story was updated on October 6, 2021.
One innovator cites 2021 NASEM study: Primary care supply growth equals improved population health.
Kyna Fong, PhD, is the CEO and co-founder of Elation Health, a platform for independent primary care practices that strengthens the relationship between patients and physicians.
Fong's expertise as a health economist and digital health leader has been featured in publications including Forbes and Fast Company, and she is the recipient of several awards, including The Top 100 Harvard Alumni In Technology Of 2021. She holds a PhD in economics from the Stanford University Graduate School of Business.
Kyna Fong, PhD, is the CEO and co-founder of Elation Health. Photo courtesy of Elation Health.
In a recent interview, Fong spoke with HealthLeaders about the continuing woes of electronic health record (EHR) technology, and other obstacles keeping healthcare from becoming more seamless through digital technology.
HealthLeaders: What is the biggest challenge with electronic health record (EHR) technology?
Kyna Fong: The greatest challenge with most EHR technology today is that it wasn't built for physicians. These companies have built EHRs for billing and coding compliance, to then sell to administrators. How doctors feel about using the technology, how it impacts their relationship with their patients, how it drives them to serious burnout—it's just not part of the traditional EHR business today.
At Elation, however, we have always put the clinician first. For the last decade, we've been designing technology to recognize the sanctity of the provider-patient relationship, and to drive human interaction to support health that cares—to make it more personal, not less.
HealthLeaders: Why is rebuilding and supporting primary care so important to the health of the healthcare ecosystem?
Fong: A May 2021 NASEM study concluded that primary care is the only discipline of medicine where a greater supply is equated to improved population health, longer lives, and greater equity. Operating on the front lines of healthcare, primary care providers are uniquely positioned to serve as the keystone of a modernized, high-functioning healthcare system that can enhance patient care and reduce healthcare costs. Primary care is the heart of a sustainable healthcare system, and I believe we will be in a much better place when three things happen.
1. Independent primary care is recognized and paid fairly for delivering the tremendous value only primary care can provide
2. Technology enables, not disrupts, the craft of medicine and the sanctity of the physician-patient relationship
3. Every patient has a primary care provider they trust
HealthLeaders: Do you believe primary care can be fixed?
Fong: Absolutely! I wouldn't be here if I thought otherwise. At Elation we've found it isn't primary care that necessarily needs fixing, it is the broken economics surrounding primary care. The vast majority of primary care providers are trying to do right by their patients and are being fought at each turn by the existing payment models and incentive structures. We're seeing tremendous strides, especially over the past eighteen months of the pandemic, towards value-based options and models that economically align physicians with the health of their patients. I predict an unlock in primary care on the horizon, where primary care providers will take the driver's seat in making healthcare sustainable again.
HealthLeaders: What are the positive and negative impacts of traditional EHRs?
Fong: Traditional EHRs were designed for fee-for-service coding and keeping patients inside a subspecialty-driven health system silo. Instead of improving patient care as EHRs originally intended, those design missteps have led to a host of negative consequences, made worse by the pandemic, including wide-scale physician burnout and depression. Traditional EHRs work best in subspecialties where there is a narrow focus on a specific problem, and they work poorly when supporting the comprehensive, proactive, collaborative, relationship-based nature of the work of primary care. To correct this, EHRs need to be rebuilt from the ground up with a completely different lens—one that is care-driven rather than billing-driven.
Unfortunately, it's hard to imagine today's incumbent EHRs keeping up with this changing environment. Not only are they mired in old technologies from decades ago, but their design is aptly described as "death by a thousand clicks." Their companies are burdened by decades of investment in the old model of fee-for-service care. We are beginning to see tremendous innovation in clinical technology, particularly in those parts of the healthcare system that are not beholden to legacy vendors, i.e. independent practices and upstart innovators. With that innovation, I anticipate those providers will outperform and leapfrog traditional enterprise healthcare systems. There's a reason every new primary care upstart on the market today either builds their own technology or uses a modern API-based EHR platform like Elation that is set up for longitudinal, collaborative, patient-trust-driven care.
HealthLeaders: What can be done about the complexity and costs from EHRs that have long burdened physicians?
Fong: There's so much amazing work that EHR technology can take on for clinicians to reduce overhead and allow them to focus on their craft, if done right. These systems need to be accountable to clinicians and match the way they care for patients; technology should create delight rather than anguish so that clinicians can focus on building the kind of trusted provider-patient relationships we know are essential to better health, without the hassle of getting paid at a price point that independent doctors can afford. The key is putting the clinician and patient experience first.
When my brother and I set out to build Elation, we saw EHRs turning physicians into data entry clerks -- taking precious time away from patients and focusing it instead on checkboxes and dropdowns. After countless hours shadowing physicians and watching how they use medical records in their practices, we prioritized making Elation an intuitive system that enhances rather than detracts from the doctor's relationship with the patient.
HealthLeaders: Is there a model where EHRs can be successfully implemented without traditional barriers?
Fong: The EHR industry has manufactured a lot of barriers to implementation—whether it's the lack of usability in the user interface leading to hours upon hours of required training; the storage of data in proprietary formats to restrict data access and transfers; the barriers to integrating with adjacent products due to a combination of price gouging and antiquated technologies; or the byzantine contracts full of red tape. At Elation, we've worked hard to overcome these obstacles and make implementation as painless as possible.
HealthLeaders: What are you hearing from physicians relating to EHRs? How is technology making a difference in healthcare for their patients?
Fong: For our customers, technology is making all the difference. Primary care is by nature collaborative. It can't be siloed. In designing for primary care from the start, Elation's EHR technology had to be open and connected. Patient information is managed in a Collaborative Health Record (CHR) where medication lists, lab results, and notes can be shared in real-time across our network within the patient's care team. We also have a very active application programming interface (API), with around 300 partners building on top of Elation today, some of whom are making more than 30,000 API calls daily to the system. Technology for this model has to support the physician-patient relationship first, and it has to support the cognitive expertise of physicians, not just the counting up of billable services.
HealthLeaders: Who has more power these days: independent physicians, patients, or healthcare systems?
Fong: While asking who has the power is an important question, especially in this moment, we must also ask: What is the impact of that power? President Biden recently reminded us of a tangible impact of this power when he said to "the nation's family physicians and general practitioners...you're the most trusted medical voice to your patients. You may be the one person who can get someone to change their mind about being vaccinated." Ultimately, we want patients to control the money, have power of choice, and be fully informed about their health and how to navigate the complex healthcare system. Primary care physicians are uniquely positioned to partner with patients toward this end, through education, coordination of care, and advocacy.
We must also consider power within the context of the existential threats facing healthcare systems today—the U.S. spends on average twice as much on healthcare compared to other developed countries, while Americans are getting sicker with 60% affected by chronic disease. Despite the U.S. healthcare system having mastered managing symptoms and saving lives, it continues to overlook restoration, disease prevention, and wellness promotion to the detriment of patients and the physicians who care for them.
HealthLeaders: Interoperability is an ongoing challenge with EHRs. How important is interoperability across a patient's care team?
Fong: The success of primary care requires clinicians sharing information and knowing what is happening with a patient's health longitudinally, across all settings. For many of our customers, interoperability is the most important aspect that can either enhance or hinder a patient's care team. Increased interoperability between EHR systems will make healthcare data more universally shareable, facilitating patient care and allowing for seamless referrals and transitions between health providers. No faxing necessary.
Patient follow-ups rise 1800% as unstructured radiologist notes, usually unrelated to the reason for the initial exam, are parsed and fed into patient EHRs.
A patient safety initiative at Kentucky-based Owensboro Health is utilizing machine-driven natural language understanding (NLU) to automate the patient follow-up process.
Owensboro Health had been relying upon human staff reading radiologist notes, but the new machine-driven process has boosted the number of follow-ups by 1800%, says David E. Danhauer, MD, chief medical information officer at Owensboro Health.
A typical scenario would involve a patient who presents at an emergency department for a symptom such as chest pain that ends up being unrelated to the reason for the eventual follow-up, Danhauer says.
A radiologist would discover something on an X-ray that prompts the radiologist to note in the radiology report that a repeat test, such as a CT scan, should be ordered, but on an issue totally unrelated to why the patient is at the ED, he says.
"The problem is, that follow-up wouldn't happen," Danhauer says. "Later, that little nodule becomes a significant tumor with metastasis that was missed."
David E. Danhauer, MD, is the chief medical information officer at Owensboro Health. Photo courtesy of Owensboro Health.
To harvest these follow-ups, Owensboro Health turned to technology vendor 3M M*Modal, which integrated its NLU technology with Owensboro's Epic electronic health record (EHR) software.
Another example of the kind of follow-up that radiologists spot would be a small aortic aneurysm in the abdominal area, "but it needs follow-up on a routine basis every six months to see what size that's getting to be, so they can manage it before it gets to be a critical issue," Danhauer says.
"Those are recommendations that need to be followed up by either their primary care provider or the referring physician," he says. "We find that many times those got missed or not followed through on, in the midst of all the work that a provider has to do."
Radiologists were aware that some of these incidental findings were being missed, but an initial attempt to use the EHR to flag them was only minimally successful. "In our EMR, we developed a follow-up button that the radiologist would just simply click," Danhauer says. "It would go to a work queue in our electronic record, and we would have ancillary staff that would check each of those and say, 'Okay, I need to call this primary care doc or ED doc.' " If none could be contacted, staff would be expected to contact patients directly to initiate follow-up tests.
But the manual clicking was a new step the radiologists had to remember to do, and despite continuing staff education among radiologists and physicians, the percentage of follow-ups performed "was in the teens," even after three years, Danhauer says.
The NLU technology was already installed at Owensboro Health, though it was underutilized, mostly in voice dictation and recognition, Danhauer says. "All our vice presidents got together to say, make a dent" in the low follow-up rates, he adds.
"We tweaked our NLU tool to capture all the words that a radiologist would say [that meant] 'this patient needs a follow-up.' We ran every single one of our radiology reports through this NLU engine, looking for those specific terms, but also making sure we are taking them in context."
For example, it would be an error to consider the term follow-up if it were preceded by the word "no," or if it contained in the phrase "no follow-up needed," so the system had to be able to exclude those occurrences of the phrase.
Working with both M*Modal and Epic, Owensboro Health was able to catch and flag all the needed follow-up work through software processing alone, even merging different types of exams needed for the same patient so that the patient only needed to be called once to schedule all the follow-ups, Danhauer says.
"We ran every single one of our radiology reports through this engine, and we can now have it in our EHR as the source of truth," he says.
Prior to the NLU/EHR integration, Owensboro Health was averaging between 150 and 200 follow-ups a month. "We went live in October 2020 with the electronic version," Danhauer says. "It was a partial month. Every month after that, it exploded. We went to the 3,000 and 4,000 numbers [monthly]."
As a quality check, Owensboro Health continued having its radiologists mark follow-ups manually, and analysis of that manual marking found that the NLU/EHR detection system had found 100% of the follow-ups that radiologists had manually flagged, Danhauer says.
In addition, Danhauer's team continues to train the system to reduce the number of false positives—cases where the system indicated a follow-up was needed, but radiologists and physicians concluded there was no such need, he says.
The three-hospital Owensboro Health system is in Kentucky's Davis County and covers most of western Kentucky, Danhauer says.
The success of the NLU/EHR integration has prompted clinicians to look for other applications, such as searching through clinicians' notes to find all patients who have had aortic stenosis and a TAVR, he says.
Also, yet to be determined is the exact extent that the follow-ups now being performed are impacting positive outcomes on patients' health and longevity, Danhauer says.
The tech has easily paid for itself in the additional $500,000 in revenue the additional follow-up exams have generated, Danhauer says. Owensboro Health has also begun reviewing the findings with its malpractice carriers to see what savings might be achieved through this quality improvement, he adds.
A letter to ONC demands rule change, but some physician supporters say the change was necessary.
A federal rule that took effect July 1 has prompted a physician group to write The Office of the National Coordinator for Health Information Technology (ONC) to prevent what it sees as new harm to patients receiving automated test results before a physician can speak to them.
The rule, part of the 21st Century Cures Act passed by Congress in 2016, does permit certain exceptions to automated sharing information with patients to protect them from harm, but according to an information blocking FAQ page posted by ONC, pausing the release of the results is not covered by that exception.
"It would likely be considered an interference for purposes of information blocking if a health care provider established an organizational policy that, for example, imposed delays on the release of lab results for any period of time in order to allow an ordering clinician to review the results or in order to personally inform the patient of the results before a patient can electronically access such results," the FAQ states.
The group of physicians taking issue with this directive is the American Medical Group Association (AMGA), which represents more than 450 multispecialty medical groups and integrated delivery systems employing 177,000 physicians who care for one-in-three Americans.
Darryl Drevna, senior director of regulatory affairs at the American Medical Group Association (AMGA). Photo courtesy of AMGA.
"AMGA strongly supports transparency and the need for patients to have access to their data and clinical information," states the group's July 27 letter. "However, we are concerned—and have heard reports from our members—about the unintended consequences of immediately providing patients with access to the data and information at the same time as their providers.
"By providing immediate access to clinical findings absent any context or explanation, the rules are causing patient harm, hindering effective communication between patients and their care providers, and complicating care coordination efforts."
Instead, AMGA recommends the ONC "move quickly to revise the rules to prevent patient harm and foster improved communication by expanding the definition of harm and allowing for some delay in the release of the laboratory and other results."
AMGA member Rick Bone, MD, vice president of medical management at Advocate Health Care in Chicago, has received firsthand life-altering medical news from his own physician, and sees such news as potentially causing mental trauma when delivered through automatic information systems first.
"There are certain diagnoses that I think should be delivered by the provider, before the patient gets a chance to see them," says Bone, who was diagnosed with prostate cancer.
"Even though I'm a physician, there's an emotional response no matter who you are," he says. "It's different when somebody can talk you through it."
Without having the physician deliver the news, "the emotional side takes over," Bone says. "That's what we're trying to prevent. From personal experience, there is a certain gut reaction that is not intellectual."
A huge argument for releasing results without physician gatekeepers is the potential for and actual occurrence of missed communications. For example, a lab may send the results to the wrong physician and may have no way of knowing that the result went astray.
In such cases, patients end up believing there are no results at all. "The end result is a lot of misunderstandings about who was to say what and when," says Peter Basch, MD, senior director of health IT quality and safety, research, and national health IT policy at MedStar Health in Washington, D.C.
"That practice of no news equals good news, and you'll hear from me when you need to, is, in my opinion—and it's probably shared conventional wisdom now—a very dangerous practice," Basch says.
"To say that errors don't happen on a daily basis is absolutely wrong," Bone says. In recognition of this, he suggests that any rule change include a "fail-safe" time interval, after which the result will go to patients, no matter what the news.
Some physicians continue to argue about whether a waiting period of 24, 48, or 72 hours should be implemented for more serious laboratory, pathology or other test results, particularly if cancer diagnoses are involved, but they agree that a waiting period for some results is preferable to the new ONC rule, Bone says.
Another issue advocates raise: sometimes it isn't clear who the gatekeeper is or should be. For instance, does a cancer diagnosis belong to a patient's oncologist, or to the primary care physician?
"I'm not disagreeing but show me a law that comes out of Congress that isn't messy at some point," Bone says.
Improved care coordination also could make a big difference, says Darryl Drevna, senior director of regulatory affairs at AMGA.
"Let's give the care team a chance to communicate internally. That way, you don't have this automatic computer driving the train."
There have been numerous times in Basch's nearly 40-year career where patients expect to see results every time, and when they don't, they call him, only to find out that he did not receive the results.
"On balance, we are much better off starting with a presumption of immediate patient access to information as soon as it is available," Basch says. "Our job as clinicians is to prepare for the world of information mobility."
Asked if there is room here for additional guidance by ONC, Basch says "perhaps clearer guidance will be forthcoming."
If the automatic release of serious health tests proves to be mentally harmful to patients, "that might be an idea that needs some clarification," Basch says.
The FDA's emergency use authorizations in early 2020 remain mostly in effect, creating potential risks to patient safety.
The COVID-19 pandemic is well over 18 months old, yet medical devices that the U.S. Food and Drug Administration (FDA) temporarily authorized for use remain, for the most part, still in use under that emergency edict.
That is a big problem, says Marcus Schabacker, MD, PhD, president and CEO of ECRI.
Early this year, ECRI named "complexity of managing medical devices with COVID-19 emergency use authorization" (EUA) at the top of its annual list of health technology hazards for 2021.
"We're not arguing for universal revocation of emergency use authorizations," Schabacker says. "We are saying there are risks associated with EUAs. We believe the FDA definitely, but also the hospital, has an obligation to manage this proactively."
Marcus Schabacker, MD, PhD, is the president and CEO of ECRI. Photo courtesy of ECRI.
The FDA granted emergency device EUAs at a time when many essential devices needed to treat the pandemic, such as ventilators, were in short supply. Inventors stepped forward, devising makeshift ventilators and related devices to address the shortage.
And yet, these devices have gone through a massively abbreviated authorization process, not having had to demonstrate safety and efficacy in the same rigor as the FDA's two main authorization mechanism, the 510(k) Premarket Notification, and the Premarket Approval (PMA).
EUAs are not new. "It hasn't been used very often," Schabacker says. But since the beginning of the pandemic, the FDA has approved more than 1,000 EUAs for medical devices, therapies, drugs, and other consumables, he says.
But the FDA's 510(k) and PMA approval process ultimately does not end up covering all devices in use in healthcare. For instance, Class III devices already on the market in 1976 or before are not subject to PMAs.
In 2020, the FDA listed numerous categories of device EUAs that were covered during the COVID-19 pandemic:
Blood purification devices
Continuous renal replacement therapy and hemodialysis devices
In vitro diagnostic devices (IVD) for molecular diagnostic tests, antigen diagnostic tests, and serology tests for SARS-CoV-2, and IVDs for management of COVID-19 patients
Infusion pumps
Personal protective equipment
Remote or wearable patient monitoring devices
Respiratory assist devices
Ventilators and ventilator accessories
Other medical devices
"So far, the FDA has gone one by one and only revoked two handfuls—only nine of the many hundreds have been revoked so far," Schabacker says.
ECRI urges the FDA and hospitals that are using those EUA-authorized devices " to assess the necessity of maintaining the EUA," he says.
"We have a process for a reason in the United States, to ensure the safety and efficacy of medical devices, therapies, and therapeutics," Schabacker says. "For good reason, that can be shortcutted, which the FDA did in 2020, but there's an obligation to protect the public, and the patients in particular, that these EUAs now get reviewed and revoked."
There is also a burden on the healthcare suppliers to withdraw such devices until they have been proven safe and effective, he says. Hospitals should be seeking alternative products that have ordinary 510(k) or PMA approval, and substitute them, wherever possible, for devices currently in use under the FDA's EUA process, he adds.
In addition, the surge in EUA-approved devices is causing further delays in the already-lengthy process of submitting any device for 510(k) or PMA approval, Schabacker says. "It's just exaggerating the problem," he says.
In addition, hospitals need to be vigilant to know when a device has had its EUA revoked, Schabacker says.
"If these EUAs get revoked, and [hospitals] continue to use these devices with an EUA, they're out of compliance," he says. "They're seeing liability risks. They're essentially using a non-approved, non-authorized device. And if anything happens to the patient, their liability risk would go dramatically up."
ECRI believes that its tools, also instrumental in helping providers manage medical device product recalls, help providers manage these risks, Schabacker says.
ECRI is urging its customers to have a plan in place to ensure continued operation in the event that devices they are using have their EUAs revoked, he says.
"Once the EUA has been revoked, you cannot continue to use the device," Schabacker says. The one exception to this is devices currently in use with a patient, such as a ventilator, but even those ventilators would need to be removed, once that patient is off that ventilator.
So far, ECRI is not aware of any adverse events happening to patients that can be ascribed to a medical device that only has EUA authorization, Schabacker says. But this might also be due to delays in device-related adverse event reporting due to COVID-19.
"What we did see is that during the height of the pandemic, the likelihood of reporting any events went down," Schabacker says. "I think healthcare providers were simply overwhelmed and did not have the time and the focus to report potential events."
Asked if organizations such as the American Hospital Association or AdvaMed, the Advanced Medical Technology Association, have expressed concerns about the lingering device EUAs, Schabacker says neither organization had been in touch with ECRI with concerns.
Social determinants of health data drives predictions that can trigger interventions even before a hospitalization ends.
Northwell Health, a nonprofit integrated healthcare provider with 23 hospitals and 830 outpatient facilities in New York state, reduced readmissions by 23.6% by augmenting its post-discharge workflows with artificial intelligence (AI) to better address nonclinical barriers to care and risk factors.
"This data is being refreshed several times a day, as new information about the patient is coming to the platform electronically," says Zenobia Brown, MD, MPH, vice president and medical director at Northwell Health for its population healthcare management organization.
The platform Brown refers to is provided by Jvion, AI software used to identify at-risk patients through various social determinants of health (SDOH), including non-healthcare-related data about patients purchased by Jvion.
"If there are things that can happen in the hospital that improve outcomes such as risk of kidney failure, you should make sure before the patient leaves that they have a renal consult or a follow up with a nephrologist," Brown says.
After discharge, SDOH data continues to flow into the patient's profile in the AI platform. "That information continues to refresh," Brown says. "Throughout that 30-day period, so that people kind of can go up and down in their risk level."
Zenobia Brown, MD, MPH, is the vice president and medical director of population health at Northwell Health. Photo courtesy of Northwell Health.
The Jvion platform also makes recommendations on various interventions for each rising risk factor. "It's prescribing what are the most urgent interventions," Brown says. "We have used this to be more tactical and focused."
Nonmedical data included in these determinations includes patient-reported legal needs, food insecurity, housing insecurity, and transportation needs, correlated with the SDOH data gathered by Jvion, Brown says.
Northwell Health began the project in the summer and fall of 2019. "There is a fair amount of operational ramp-up so you can have a density of patients that you've intervened on, to show the statistical proof that this had an impact," Brown says. "Even with the highest readmission rates, only one in five people are being readmitted."
Given that, the process to prove out the efficacy of the technology took an additional six months, which is why the results were only recently reported, during the HIMSS conference in early August.
The population studied included Medicare and Medicaid beneficiaries, generally 65 years of age or older. These patients typically are afflicted with comorbidities such as heart failure, COPD, pneumonia, acute myocardial infarction, and who may have had procedures including coronary artery bypass surgery, Brown says. No patients with COVID-19 were included in the initial analysis.
Translating those reduced readmissions into dollars saved is a longer, trickier process.
"The way hospitals get penalized is deeply retrospective, meaning it's based on a three-year average, and it's lagged about 18 months," Brown says. So far, Northwell Health is not commenting on its initial dollar savings estimates.
In addition, Northwell Health is the co-owner of a health plan known as HealthFirst. "Where we are in a bundle, one of the things we're looking to demonstrate is the savings to the plan based on these [reduced] readmissions," Brown says. "Obviously, we're trying to stop human suffering, but who benefits besides the patient is the plan. The plan then is able to demonstrate the savings to the plan, not so much to the hospital."
Over time, incorporating SDOH data into care will become the new standard of care, Brown says. "Our complex care vector, which is avoidable admissions, is launching here in the fall and winter," she says. The analysis will target patients who are likely to show up in the hospital in the next 30 days, and then doing interventions to keep them from decompensating and needing hospitalization, she adds.
These interventions will target patients that often have a combination of chronic diseases, such as hypertension and diabetes, she says.
Patients give their consent ahead of time for Northwell Health and Jvion to collect their non-medical information ahead of time, Brown says.
"You’ve got to have a foundation of doing the right thing for patients that is reliable and [with] consent," Brown says.
Brown is in charge of Northwell Health's value-based strategy and execution of that strategy. "It is up to me that these numbers are improving," she says. "It is up to me to collaborate with Northwell hospitals to make it happen and to bring to bear the tools that the hospital needs to be successful. So, our business unit works as a support or an engine for the hospitals to execute on this readmission strategy. And we do that in partnership."
Brown's population health organization is a business unit of 350 to 400 employees, a team of navigators following patients after discharge, an analytics team that is taking in claims data across populations, "and an administrative team that knows all the CMS rules, understands how all this technology works with each other, and makes sure the right people get the right reports," she says. "It is a big operation in Northwell to execute on this and other population health strategies."
Centene Corporation sees services delivered by TV and mobile services aligning with its social determinants of health initiatives.
With the majority of American seniors wanting to stay in their homes and age in place, innovation continues to expand the kinds of engagement, incorporating social determinants of health, which can keep those populations thriving, even during the pandemic.
Populations who are challenged by living alone, struggle with mobility, seldom venture away from home, and struggle with chronic loneliness are beginning to see manifestations of this innovation. Now, a Medicaid managed care company is piloting technology from Uniper Care Technologies to engage seniors in a new way.
"As a managed care company, we are always trying to find innovations that are of interest to our membership that have positive outcomes on health," says Laura Chaise, vice president of long-term services and supports and Medicare-Medicaid plans at Centene Corporation, based in St. Louis.
A key to connecting and engaging these seniors is to make the technology seamless. Participating providers install the Uniper Care platform in seniors' TV sets or mobile devices, creating an overlay for two-way communication via the internet via a cellular router provided to seniors at no cost to themselves.
This communications overlay delivers a variety of engagement services, ranging from yoga classes to virtual senior centers during the pandemic, says Avi Price, chief operating officer and company co-founder at Uniper Care Technologies.
These services are delivered by various community-based organizations and governmental organizations, sharing best practices and customized content, connecting seniors with live interactive cultural and wellness programming, including content provided by Uniper Care itself.
In doing so, the offering is intended to tackle social isolation, loneliness and depression, conditions known to lead to a host of medical problems.
"This type of work is high on our list, going back to our broader social determinants strategies," Chaise says. "There are other parallel initiatives around food and security around housing, employment, and transportation."
Uniper Care's offerings meet the objectives of millions of dollars set aside in the American Rescue Plan for Older Americans Act to apply technology to community-based services for seniors.
There are currently 75 Centene members using Uniper Care in the company's initial pilot. Centene has about 360,000 members across 15 states, Chaise says. For dually-eligible individuals, Centene has more than
1 million dually-eligible individuals across multiple products, she adds.
"Some of those folks are with us just for Medicaid, some of them are with us just for Medicare, and some are with us for both," Chaise says.
Another aspect of the Uniper Care platform is its ability to integrate internet-based telehealth services, delivered to TVs, overlaying regular TV programming via the TV's HDMI interface.
"Due to the pandemic, the willingness to use telehealth has skyrocketed," Chaise says. At present, Centene is not using the telehealth provided by Uniper through its platform. "I do think it is a nice feature we might explore in the future," she adds.
Currently, Centene has a number of other national telehealth initiatives, around physical health, behavioral health, and other health aspects, Chaise says.
"Uniper has a very specific kind of population focus," Chaise says. "While we have other tools that are much more broadly used and available, I could see a scenario if we had a cohort of older adults who were very comfortable using [telehealth], because that's what they use for fitness classes or socialization, or whatever it is, to be able to leverage a technology that they're already comfortable with, for other purposes. But it would be premature for us to explore that at this time."
Centene already provides an array of benefits for senior members going beyond typical medical services, Chaise says.
"We are already providing people with home-delivered meals, personal attendant services, transportation, with the ability to go to a day center," she says.
"That's part of the reason why we were interested in Uniper, is understanding how this could fit within that portfolio of options, depending on different people's needs and willingness, interest to leave the home, versus being in the home, and being able to connect with people remotely," she says.
During the pandemic, "a lot of day centers had to close," Chaise says. "This has been a unique time to look at technologies like Uniper, and to understand what role they play in the long term."
In addition, numerous day centers have, because of the pandemic, taken the opportunity to diversity their offerings and find ways of staying connected with seniors who are no longer able to come to the centers, she says.
"There are certain things about going to a day center that are difficult to replicate remotely, like physically seeing your friends, playing cards, seeing a nurse or a healthcare professional on site or a social worker or counselor," Chaise says. "It's not the same as having a hot meal, right? It’s not the same. But I do think it could be part of a broader array of options for older adults, who are trying to stay active and trying to stay connected."
One other advantage of the extensible Uniper Care platform is the ability for seniors to gather in open rooms and peer-led groups without intermediaries in the middle, Price says.
Other large U.S. organizations leveraging the Uniper Care platform include managed care organizations in Florida, community-based organizations such as Jewish human service agencies, and area agencies on aging in Miami, Broward, Tampa, and Sarasota areas, Price says.
Content providers include Johns Hopkins Medicine and the Alzheimer's Association, he adds.
CarePort spinoff from Allscripts gains national traction with post-acute providers.
Post-acute care coordination, a series of repetitive but common tasks, often consumes vast staff resources, chasing open slots at skilled nursing facilities, home health agencies, and long-term acute care facilities. Such tasks are often prey to a never-ending stream of emails, faxes, and phone calls.
A growing number of health systems, hospitals, and even payers are converging on a more efficient platform that integrates with popular electronic health records and even allows close monitoring of key value-based initiatives such as bundled payment programs.
"Partnering with CarePort was a really good way to get a more comprehensive feed of data, and to get it in real time," says Alex Brennsteiner, manager of network performance at Helion, a wholly owned subsidiary of integrated payer-provider Highmark Health in Pittsburgh.
Alex Brennsteiner, manager of network performance at Helion, a wholly owned subsidiary of integrated payer-provider Highmark Health in Pittsburgh. Photo courtesy of Helion.
CarePort is a care coordination technology platform from a company formerly a division of Allscripts, but recently acquired by WellSky, a software company spanning the hospital, post-acute care, and community care continuum. As CMS begins a new round of audits in the wake of its recent healthcare provider interoperability rulemaking, platforms like these are becoming more important to demonstrate compliance with such CMS regulations, says Lissy Hu, CEO of CarePort.
Using the CarePort platform, Helion has integrated about 125 skilled nursing facilities, representing more than 70% of such facilities in its western Pennsylvania service area, Brennsteiner says.
Previously, data flowed haltingly between local area hospitals, Highmark Health acute care facilities, Helion, and such skilled nursing facilities, he adds.
Area patients could end up at large community hospitals in the area, outside of the Highmark Health network, and then data concerning their admissions, discharges, and transfers (ADT) would find its way to other interested healthcare organizations only with difficulty, he notes.
"Previously, we were lucky if something was faxed to us, essentially manually, and that was few and far between," Brennsteiner says.
The CarePort platform displays and conveys these ADT actions and status between connected care coordinators, nurse case managers, and social workers in real time, and is able to ingest care plans being generated by electronic health records, both in hospitals and in post-acute care facilities.
"We have some doctors here and there that use it" as well, Brennsteiner says. "One of our quality leaders uses it every single day for his practice, to go in and look at all those transition events from the previous day and identify opportunities where a readmission could have been avoided."
Primary care practices using the platform run daily ADT reports and may even scrub the report looking to optimize a bundled payment or identify a frequent emergency department utilizer, Brennsteiner says. "Maybe I would try and get that patient scheduled for a three-day follow up as opposed to a seven day," he says.
Real-time information facilitates transitional care management billing to Medicare
Additionally, the platform helps participants to bill for Medicare services performed. Since 2013, CMS has had a separate fee schedule for payments under the Medicare Physician Fee Schedule (PFS) for transitional care management (TCM) services rendered to beneficiaries whose medical conditions meet Medicare requirements.
To bill a TCM encounter, providers have to complete a 48-hour follow-up report.
"That's why the real-time nature of CarePort is so helpful," Brennsteiner says. "That TCM encounter is reimbursed at a much higher rate than a traditional evaluation and management code. From a sustainability perspective, it's also a good revenue generator for the system."
The increased visibility of these events, shared between CarePort users, allows stakeholders to make more informed decisions about patient care, Hu says.
"We are in over 1,000 hospitals, and over 100,000 post-acute care providers at this point," Hu says. In approximately 30% of the transitions coming out of U.S. hospitals, "those patients [who] are in need of a post-acute care, community care, or any type of post-discharge care, that will be coordinated through the CarePort platform."
Hospitals are under increasing length-of-stay pressures, increasing demand for post-acute care, and the need for patients to be referred with safe discharge plans, Hu says.
For Helion, the CarePort care coordination transformation has translated into nearly 10,000 additional year patient encounters, Brennsteiner says. Allegheny Health Network, the hospital system arm of Highmark Health, is using CarePort to aid in moving from a traditional fee-for-service primary care model to a multidisciplinary model that incorporates other services such as pharmacy resources and behavioral health, in order to optimize transitional care, he adds.
Another feature of CarePort allows care coordinators to tag certain patient attributes, such as diagnoses of congestive heart failure, in order to allow physicians, using their Epic EHR software, to comply with American Heart Association criteria, Brennsteiner says. The platform eliminates duplication of efforts to complete this compliance, he adds.
Highmark has continued to reach out to outside hospitals to try to engage them in sharing ADT information via CarePort. "It's been a mixed bag," Brennsteiner says. "Interestingly, one of our most advanced health system partners in terms of risk-bearing entities was the first to sign on and has had incredibly positive feedback in terms of how this has helped them."
Helion is looking to further optimize its use of the platform, Brennsteiner says.
A tool to break down silos between payer and provider operations
"Right now, case management at the health plan doesn't have the access to the electronic medical record at the health system, so there's just an inherent blindness in different parts of the organization," he says. "CarePort is really the first solution that I'm aware of, that we can use to kind of break down some of those silos and start to coordinate better."
For instance, specialty case management at the health plan is beginning to be coordinated with the Highmark Cancer Collaborative to reduce duplication of efforts, Brennsteiner says.
The CarePort approach has also proven superior to earlier care coordination efforts centered on KeyHIE, the Keystone Health Information Exchange, he adds.
"CarePort has the ability to integrate an HIE's data into the system," Brennsteiner says. "That being said, there's a pretty wide variability in terms of HIE quality. A lot of these HIEs are missing a lot of the post-acute data that we've captured within CarePort. The other thing unique to CarePort is we're able to build" the patient attributes mentioned earlier. An HIE is more of a traditional kind of live feed of ADT events, he adds.
"CarePort has allowed us to scale up without too much abrasion to the staff," he says. "From a primary care perspective, they're able to make sure they have the right slots in the schedule to accommodate transitional care visits. And with the additional revenue being generated because of the additional TCMs, that's something that can be reinvested back into the practices."
During the pandemic, Helion was tasked with managing hundreds of facilities, including isolation beds, and the changing acceptance criteria of post-acute facilities, and CarePort was able to add capabilities that tracked these resources and criteria throughout, Brennsteiner says.