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Palomar Health innovation officer Portale stepping down June 30

Late word from the West Coast on Thursday is that Orlando Portale, chief innovation officer of Palomar Health in San Diego County, Calif., for the past seven years, is leaving at the end of June.

According to a quick e-mail from Portale, “I’m going to focus on advising health technology companies, private equity firms and healthcare organizations.” He already has dabbled in some of those areas, helping Palomar start up Glassomics, which he calls the world’s first incubator for healthcare applications and technology that run on wearable computers, including Google Glass.

Qualcomm Life provided an operating grant to Glassomics, so I wouldn’t be surprised if Portale ends up at that San Diego-based venture. Then again, Portale has a deep résumé, including senior positions at the former Sun Microsystems, health insurer WellPoint and government IT contractor Science Applications International Corp. (SAIC).  I’m sure he will have plenty of opportunities coming his way in short order.

In an e-mail to Portale — and copied to executives and board members — Palomar CEO Michael Covert said: “I want to personally thank you for everything that you have done for Palomar Health. Your efforts have put us on the map in the world of innovation and technology. We had a vision of what we could be and you helped to make it a reality. I am forever in your debt. Please let me know if I can be of support or help to you in the future. … I wish you only the best. Let us stay in touch as your career moves forward.”

 

May 29, 2014 I Written By

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Check out my new MSA bike tour site and blog

As I hinted a couple of months ago, I’m planning a rather epic cycling tour this summer to raise awareness of and funds for multiple system atrophy, the disease that killed my dad. Since this is a health IT blog, I don’t want to keep going off-topic to promote that effort, so I’ve set up a tour site, blog and Facebook page just for that purpose. The Multiple System Atrophy Coalition also put out a press release on my behalf. Check those links out, like the Facebook page and please share freely.

I could still use some sponsors for the tour, particularly a hotel chain that has locations in places such as Valparaiso, Ind., Kokomo, Ind., Celina, Ohio, Kettering, Ohio, Columbus, Ohio, Waynesburg, Pa., Grantsville, Md., and Hagerstown, Md. Jersey/t-shirt printers would be welcome, too.

Thanks for your attention. And now back to health IT. Hey, here’s a health IT connection: If any quantified selfers want to help me track my health and performance during the tour, please let me know.

 

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Video: Aneesh Chopra on ‘The Daily Show’ for a long interview

Everybody else has the news about CMS offering leniency with Stage 2 Meaningful Use, letting providers use EHRs with 2011 certification to meet Stage 2 standards because so few vendors have been certified to the 2014 standards previously required for Stage 2. I won’t rehash here.

I will, however, share the very extended interview Jon Stewart had last night with former White House CTO — and, before that, HHS CTO — Aneesh Chopra on “The Daily Show.” Stewart is a comedian with a known liberal bias, but he is not a bad interviewer when dealing with a serious subject.

Stewart has been hammering the VA over its backlog of new registrations, and stepped it up in the wake of the recent revelation that VA bureaucrats in Phoenix were gaming the system to make it look like waits weren’t as bad as they really were. He’s also criticized the federal government for failing to link medical records between the Military Health System and the VA — you know, what we in health IT call interoperability. (In Part 4, Chopra discusses lack of interoperability in the broader healthcare sense.)

I found out about Chopra’s appearance last night shortly before the show aired. Unfortunately, we were having heavy rain at the time, and my satellite TV got knocked out, so I missed it. It’s OK, because the Chopra interview was long — more than 22 minutes — and the version that was on TV is heavily edited. Here’s the full interview of the “Indian Clooney,” as Stewart called Chopra, from the show’s Web site.

Part 1  (4:41)

 

Part 2 (7:27)

 

Part 3 (5:19)

Part 4 (5:35)

 

May 21, 2014 I Written By

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APSO vs. SOAP, continued

A couple weeks ago, I had a story in Healthcare IT News about the growing use of the “APSO” notes for documenting patient encounters. APSO flips around the traditional SOAP format (subjective, objective, assessment, plan), ostensibly making it easier to view progress notes in electronic health records.

As I reported, APSO is in wide use at University of Colorado Health and at Lucile Packard Children’s Hospital in Palo Alto, Calif. Baystate Health in Springfield, Mass., found that hospitalists focused most of their attention on the “impression and plan” sections of patient records, essentially the AP part of APSO/SOAP. Physicians at Epic Systems, according to University of Colorado’s Dr. C.T. Lin, are recommending APSO as a best practice.

Yet, the inventor of the SOAP note, Dr. Larry Weed, still believes his format is superior. You saw his comments in the Healthcare IT News story. But every time I have the privilege of speaking to the nonogenarian Renaissance man, he always has more to say than I can fit into the average article. I often can’t keep up in my note taking, but, fortunately, in this case, Weed and his son/occasional co-author Lincoln, took the time to put their thoughts in writing for me.

I left most of their comments out of the story due to space limitations. I don’t have that problem here, so I present their entire statement to me:

The following represents our collective thoughts, including references to relevant portions of Medicine in Denial [their 2011 book].

The supposed advantage of the APSO alternative — that it begins with the physician’s assessment rather than data — is actually a failing. This sequence tends to make the note provider-centered rather than patient-centered, and judgment-based rather than evidence-based.  In contrast, beginning the progress note with data disciplines the provider’s assessment. The provider must think in terms of specific data, specific problems on the problem list to which the data relate, and the interrelationship of each problem to the other problems on the list. Moreover, it’s important to begin the progress note with subjective (symptomatic) data from the patient rather than so-called “objective” data,  As Medicine in Denial states (p. 168):
“… progress notes should begin with subjective data, because progress should be assessed from the patient’s point of view.  Practitioners should be alert to discrepancies between subjective and objective data (for example, where the patient does not feel better when lab results show improvement). These discrepancies may signal an error in data or misstatement of the patient’s problem.”
In short, provider thinking can be disciplined with problem-oriented SOAP notes as a standard of care. Yet, regulators and academics who are in a position to act on this issue have shied away from the whole notion of standards of care for organizing data in medical records. See our comments on ONC’s Stage 2 regs and our comments on the PCAST Report.
The need for standards of care in medical records goes far beyond the SOAP vs. APSO issue in progress notes. In fact, that issue is secondary. Two more fundamental issues for medical records are the following:
  1.  Determining initial inputs to the record. Initial inputs are determined by selection of data needed for the patient’s problem situation, and once the data are collected, analysis of the results.  Both selection and analysis are fatally compromised when determined by the physician’s clinical judgment. External standards and tools, based on a combinatorial standard of care, must govern the selection and analysis. Once that happens, then judgments of patient and practitioners (not just physicians) may supplement the combinatorial minimum standard.  See Medicine in Denial, pp. 53-61, 69-79, 136-37, 145-52.
  2.  Organizing the medical record around the problem list. Once initial data are collected and a complete problem list is defined, then care plans, orders, and progress notes should be problem-oriented, that is, labeled by the problem(s) to which they relate on the problem list. This disciplined practice is essential to justifying provider actions in terms of defined patient needs. Yet this practice is not followed or enforced with consistency. Indeed, some EHR systems do not even enable electronic links between the problem list and care plans, orders and progress notes. See Medicine in Denial, pp. 134-35, 144, 159-60, 166-67.
Like so much else in medicine, medical record practices are a Tower of Babel. Medicine need standards of care for managing clinical information (knowledge and data) no less than the domain of commerce needs accounting standards for managing financial information. This failing is a primary root cause of the health care system’s failures of quality and economy.

For that matter, Lin had more to say than what you saw in the story. He discussed the supposed importance of the subjective and objective elements. “That’s true in cases where there is diagnostic uncertainty,” Lin said. But he added that those components are still there for reference, jut not up front.

Lin called SOAP “a phenomenal innovation,” but suggested that EHR complexity sometimes makes it difficult to find the assessment and plan. For example, he said that a non-Epic EHR in the emergency department at UC Health has as many as 17 different screens for progress notes. “At least with APSO, you would collect the assessment or plan in the first half,” Lin said.

Because SOAP is so entrenched, Lin ran into much resistance when he proposed switching to APSO at 40 affiliated practices. He, of course, heard the tired, “But we’ve always done it this way” defense.

“I learned myself about culture change very acutely,” Lin said. “I was literally shouted out of the room by our physician leadership.” He had neglected to prepare the heads of various departments and clinics for the change in advance of the meeting where he announced the plan.

He subsequently had to have individual conversations with all 40 practice directors. And then Lin dropped a great quote from none other than Niccolo Machiavelli (speaking of Renaissance men): “Those who benefited from the old order will resist change very fiercely.”

Yes, that’s absolutely perfect for an industry as resistant to change as healthcare. But is APSO superior to SOAP? I’d love to hear your thoughts.

May 20, 2014 I Written By

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Some truths about health IT and innovation

This morning at the annual SAS Health Analytics Executive Conference in Cary, N.C., former national health IT coordinator Dr. Farzad Mostashari dubbed Dr. Eric Topol “the high priest of personalized medicine.”

That reminded me of an e-mail I received a couple weeks ago, suggesting that someone should start a blog called, “What’s Eric Saying?” As this correspondent explained it, all you need to do is read Topol’s Twitter stream to know where health IT and the practice of medicine are headed. I checked it out. It’s true.

Some examples:

 

 

 

And that’s just since Monday.

Meanwhile, Mostashari added some truisms himself this morning. “Med speed is slow. Tech speed is fast,” he said, apparently paraphrasing current TEDMED owner Jay Walker. Then, speaking as a physician, Mostashari said, “Most of what determines our outcomes isn’t what happens in our office.” Which is kind of what Topol has been trying to get across for several years.

If only the financial incentives would encourage care outside the office, we might be getting somewhere. It’s starting to happen, but, as it says above, med speed is slow.

May 14, 2014 I Written By

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Still no consensus on digital/mobile/connected health

A while back — three months, to be exact — I asked readers if they had a preferred term to describe “the application of new, personalized technologies to healthcare.” I gave you the choice of digital health, connected health, wireless health, mobile health and telehealth, and surmised that the results would not be conclusive. On that part, I was right:

digital health poll resultsHowever, I was surprised that connected health, a relatively underutilized term, did so well and that telehealth got but one vote. Wireless health certainly has kind of become passé, but I was surprised nobody picked it at all.

In any case, these results, however unscientific they may be, are representative of the fact that it is so hard to reach consensus on anything in health IT. They also are symbolic of the silos that still exist in newer technologies.

May 6, 2014 I Written By

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IBM acquiring Epic or Cerner? I dunno

The “unconfirmed rumor of a huge acquisition” that HIStalk (a.k.a. the National Inquirer of health IT) tweeted about on Wednesday apparently is that IBM was going to acquire Epic Systems. Mr. HIStalk on Thursday expressed some reservations.

 

 

So am I. The announcement was supposed to happen Friday morning, which is right now (10 am EDT as I write this). IBM is in the Eastern time zone and Epic is in the Central time zone; for that matter, Cerner also is on Central time, and when you think “huge” in health IT, really only Epic and Cerner come to mind. If there were to be an announcement not involving anyone on the west coast, it probably would have happened already.

In any case, I’m told that IBM has been rather quiet with analysts of late. I actually haven’t been able to find the ages of Epic honchos Judy Faulkner and Carl Dvorak, but they’ve been at this for some 35 years. Cerner CEO Neal Patterson is 65 and has an ownership interest in the Sporting KC soccer team. He’s also been in the health IT business for 35 years.You’d think any or all of the three have to be thinking of retirement, or, in Patterson’s case, moving on to the hobby of running a pro sports franchise. Except that Faulkner seems to love what she does.

Cerner’s stock price has dipped a bit in the last couple of months, but it has risen by 259 percent in the past five years, according to Yahoo! Finance. It still seems as if the health IT business has plenty of room to grow, especially among the biggest players, who promise to be the biggest beneficiaries of consolidation on the lower end of the market.

Until I hear something more substantive, I am not buying the IBM-Epic rumor. IBM-Cerner seems a tad more likely, but I still need to hear more.

May 2, 2014 I Written By

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