Many Ways of Skinning a Statistical Cat

By SAURABH JHA MD 

In this episode of Firing Line, Saurabh Jha (aka @RogueRad), has a conversation with Professor Brian Nosek, a metaresearcher and co-founder of Center for Open Science.

They discuss the implications of this study, which showed that there was a range of analytical methods when interrogating the database to answer a specific hypothesis: are soccer referees more likely to give red cards to dark skinned players? What is the significance of the variation? Does the variation in analysis explain the replication crisis?

Listen to our conversation at Radiology Firing Line Podcast.

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Consumers are Dishing On Healthcare Experiences—Be Part of the Conversation

By KARYN MULLINS 

Consumers aren’t taking their healthcare providers’ words for it anymore. They’re taking charge and leading a digital revolution where individuals have the power to make their own educated decisions about care.

According to the Healthcare Consumer Insight & Digital Engagement report by Binary Fountain, a leading online reputation management platform, 51 percent of people who have a physician share their personal healthcare experiences via online ratings, review sites and social media.

Once shared, this information is immediately available to the entire world with just the click of a button. And people are taking full advantage of this. In fact, 80 percent of respondents in the 2018 Customer Experience Trends in Healthcare report by Doctor.com have used the internet to make a healthcare-related search in the past year. Another 81 percent said they read reviews about a referred provider.

Consumers’ accessibility to detailed, personalized experiences could make or break medical sales companies. Unfortunately, if these trends aren’t addressed appropriately, medical sales teams around the country will feel the impact.

By further empowering the general public, medical sales leaders can give their teams the tools needed to excel in the field. Here’s how:

Open up and face the experiences 

Whether your product is a bionic arm, a new miracle medication or a tongue depressor, every patient will have their own experience. Each of these experiences are valid and deserve recognition. No matter how absurd or irrelevant a comment or rating seems to you, it will ring true to others researching your product.

In today’s technologically accessible world, ignoring negative feedback will make consumers trust your company even less. Consumers want to see proof that you’re listening and taking action to improve experiences. If current consumers didn’t have a positive experience with one of your products, why should others give anything associated with your company a try?

The answer should be because you’re on their side.

Show this by acknowledging comments—even the most negative. In the comments, note a timeline for when you’ll check back in. When that time arrives, ask how they’ve been doing and explain where you’re at in the process of ensuring others aren’t impacted by the same negative experience.

Equip your sales team with educational materials and updated information that will prepare them for the same type of feedback in the field. This helps doctors immediately address situations, giving them an improved chance of sending patients away with a more positive experience associated with your products.

Talk to consumers intelligently

Consumers have the power of research at their fingertips. They trust their ability to research and believe there is power and truth in reviews. ‘Dumbing down’ responses or talking your way around a situation is no longer acceptable.

People want to be spoken to as experts—because their goal is to be the top advocates for their own health. Increase their trust in you and your team by speaking to them as such. Put the power of your research in their hands, give them options, and speak directly to consumers — not just healthcare providers.

Encourage your sales team to participate and take action by sharing research on their social media sites. Along with product research, add actionable tips that consumers can follow to control and improve their health. As your tips catch on, trust in your company, products, and sales reps will increase.

Use reviews to your advantage

Consumers aren’t the only ones at an advantage thanks to improving technology. Informed, data-based decisions are giving medical sales companies the power to stay on top of their game like never before.

Make both negative and positive comments work to your team’s advantage. Track where your consumers are leaving comments and reviews to understand where you can effectively connect with the most people. See if there are trends in which social media sites they use most often and if there’s a pattern in misinformation regarding your products or companies.

Constantly monitor this information and frequently update your team. Providing them with direct, consumer information gives them the power to educate and advocate — the two most powerful tools in today’s healthcare experiences.

Karyn Mullins is the President at MedReps, a job board which gives members access to the most sought after medical sales jobs and pharmaceutical sales jobs on the Web. 

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EMRs, APIs, App stores & all that: More data

By MATTHEW HOLT, with OLIVIA DUNN & KIM KRUEGER

Today I’m happy to release an update to some unique data about a pressing problem–the ability of small health tech vendors to access data from the major EMR vendors and integrate their applications into those EMRs. For those of you following along, in 2016 when Health 2.0 first ran this EMR API survey, we confirmed the notion that it’s hard for small health technology companies to integrate with the EMR vendors. Since then the two biggest vendors, Epic & Cerner, have been much more aggressive about supporting third party vendors, with both creating app stores/partnership programs and embracing FHIR & SMART on FHIR.

In 2018, we conducted a follow-up survey to see if these same issues persisted and how much progress has been made. In this report, we break down the results of the 2018 survey and compare them to the results of our 2016 survey. As in 2016, survey response rates weren’t great, but in this year’s survey we asked a lot more questions regarding app store programs, specific resources accessed, troubling contract terms and much more. And if you look at the accompanying slides, we also pulled some juicy quotes.

The key message: In 2016 we said this, The complaint is true: it’s hard for smaller health tech companies to integrate their solutions with big EMR vendors. Most EMR vendors don’t make it easy. But it’s a false picture to say that it’s all the EMR vendors’ fault, and it’s also true that there is great variety not only between the major EMR vendors but also in the experience of different smaller tech companies dealing with the same EMR vendor.

In 2018, things are better but not yet good. A combination of government prodding (partly from ONC implementing the 21st Century Cures Act, partly in the continued growth of pay for value programs from CMS), fear of Apple/Google/Amazon, genuine internal sentiment changes at least at one vendor (Cerner), and maturity in dealing with smaller applications vendors from three others (Allscripts, Athenahealth, Epic), and the growth of third party integration vendors like Redox and Sansoro, is making it easier for application vendors to integrate with EMRs. But it’s not yet in any way simple. We are a long way from the all-singing, all-dancing, plug-in interoperability we hoped for back in the day. But the survey suggests that we are inching closer. Of course, “inching” may not be the pace some of us were hoping to move at.

All the data is in the embedded slide set below, with much more commentary below the fold.

Health 2.0 EMR API report 2018

It’s getting better but….EMR Vendors are still a bottleneck

Despite the new app stores and public statements, small health tech companies trying to integrate their applications with the big EMR vendors still regard them as difficult to work with, imposing unnecessary costs and putting up barriers to data access. But when we asked how they compared to 2 years before, 63% of small health tech companies thought that EMR vendors were making a modest improvement in allowing easier API-access and other forms of data access for third-party tool integration, while 23% thought the improvement was significant. When asked the same thing about providers (hospitals), only 54% said modest improvement, while 23% said providers had improved significantly. Worth noting that we didn’t get a response from Apple, which now has data access for over 100 hospitals! (Helps to be big and rich, and not just with hospitals! Cough, cough, FDA)

Most respondents believe that providers want to get them easier access to data, but they are often hindered by complex bureaucracy or confusing technology. In general, it still seems that data access is a function of a provider’s willingness to push their EMR vendor to open up. From the small tech company point of view, EMR vendors seem to be under no pressure to integrate and few providers are putting pressure on their EMR vendors. To quote one respondent “Still a lot of talk, obvious value to be had, but limited actual progress.”

And to be fair, we’re not sure small tech companies are helping themselves too much. Since 2017, Health 2.0 & HIMSS have featured the Carin Alliance a bunch, and Aneesh Chopra, Ryan Howells and their gang have been banging the drum on small companies getting access to data, yet when we asked about their work, 80% of small tech company respondents said “Who is the Carin Alliance?”

But third party application integration is becoming a bigger deal (thanks, Redox!)

Whether or not sentiment is mixed, the data about what’s actually happening is clear. Many more small tech companies had actually completed integrations with big EMR vendors, although the complexity of those integrations were perhaps less than what was being done before 2016 (most just read & write and fewer are trying to manipulate data within the EMR). And 85% of these integrations were started after early 2016 (when the previous survey was in the field).

As you’d expect given its market dominance, more vendors have integrated with Epic (64%), followed by Allscripts (54%) and Athenahealth (53%), with Cerner at 45% befitting its later start at getting the API religion. How they accessed the data shows that 3rd party integration vendors (Redox, Sansoro and a few more) are becoming important. Most got to Athenahealth and Allscripts data via their APIs, but using 3rd party integrators is becoming more important especially for Epic and even Allscripts.

But don’t think it’s easy. One respondent wrote, “For many vendors, it is a combination of ways to get all the workflows we need (other than Allscripts and Athenahealth). Epic still requires a mix of API, HL7, direct message and batches. Others are HL7 and direct.”

Now the good news: EMR vendors are becoming better partners

In 2016, most small companies thought that few of the major EMR vendors were generally supportive about their integration efforts. The two big exceptions then were Athenahealth and Allscripts. In 2018, most everyone is doing better, with Cerner making the biggest strides (61% now saying Cerner is supportive vs 31% in 2016)—that’s consistent with what we see from them both in the market and at our conference. eClinicalWorks, Epic, Meditech and GE are still below 50% but are all getting slightly higher marks.

Epic, though, is still its own animal. 83% of the respondents say a large provider client is necessary to get them into a conversation about accessing data. Cerner wasn’t much better (69%), while for Athenahealth, Allscripts and McKesson (which is now mostly under ChangeHealthcare), a large provider client was not needed.

There was also a large minority (40%) who found the contract terms of the vendors, e.g around intellectual property, troubling.

When it comes to actual partnership programs, things are looking up. In terms of the small health tech companies finding a partner program that exists and is easy to use, Allscripts (63% v 43% in 2018) and Athenahealth (72% v 43%) are doing much better and even Epic has gone from 52% saying the partnership program was non-existent in 2016 to only 23% in 2018.

What about those App Stores?  Programs are taking off despite high costs

Probably the biggest change since 2016 has been the creation of iOS and Android-like app stores by many vendors. Plenty of smaller companies are taking part. 50% of respondents are in the Athenahealth MDP marketplace, 39% have taken part in Allscripts Developer Program and 33% are in the Epic App Orchard. But there’s lots of whining—especially about the cost. As one respondent wrote, “As an earlier stage start up, having to pay 20% revenue share for a client clicking through to us from a marketplace with virtually no sales support is high but necessary evil.”

Additionally, we heard a lot not only about the cost, but also about the terms for Epic’s App Orchard. This included Epic wanting to know the details of their technology, being unfriendly to partner vendors and not open to any negotiation of terms.

Since we took this survey (but before we published it), this message seems to have got through, with Epic promising last month to reduce the costs of their App Orchard program.

You got the partnerships and permissions set up? Now integrate!

When asked about specific vendors’ support for their actual integration efforts (i.e. the bit after the partnership puffery), things haven’t changed that much. In general Athenahealth (89%) and Allscripts (78%) are helpful, Cerner in the middle (52% in 2018 v 48% in 2016) and everyone else regarding as more hindering than helping.

But since our 2016 survey, API quality from the big guys has generally improved. Now we’re not getting too carried away, most still feel EMR vendors’ APIs are “not great but workable” and only EMR vendor looking really good was Athenahealth (85% saying “APIs were of high technical quality”).

Most of the time (in an increase from 2016) EMR vendors charged a fee for API access but these are mostly now settling on a percentage of revenue share and was less than $25,000. We think that indicates that the app store model is taking hold.

Conclusion

At Health 2.0 we’ve been trying to shine a light on this topic for some time, and the good folks at SMART on FHIR (the Mandel/Mandl twins, Zak Kohane et al) and the Argonaut/FHIR/CARIN crowd (Graeme Grieve, Aneesh Chopra & a cast of hundreds), have all been banging the drum as well as laying down great work for several years. And yet it’s health tech, so slow incremental progress is probably what we should expect. The state of play is that the big vendors are all now awake to the issue, but there’s lots to sort out before access to data and integration into APIs becomes as automatic as we see outside of health care. Patients with complex diseases still have multiple portals often into multiple version of Epic, and leading journalists are still writing stories about having to have tests redone because they can’t get the images or data to cross the street. But I get the sense that the levee is sprouting leaks. Cerner and Allscripts are moving most on-site installations to public and private cloud, AWS and Google Cloud are sniffing around as data storage providers and starting their own partnership programs. Epic remains Epic, but has an app store and is reacting to some of the criticism.

I’m also hoping that this type of a survey will soon become irrelevant because the topic about access to data and ability to integrate applications will soon become one of those things that we wake up one day and realize aren’t problems anymore. We’ll check back in a couple of years and see how close that day is.

Matthew Holt is Co-Chair of Health 2.0 conferences (now owned by HIMSS), publisher of The Health Care Blog, Co-Chair of Catalyst @ Health 2.0 & President of SMACK.health. Olivia Dunn is an associate at Healthy Communities Institute and Kim Krueger is a Venture Associate at Plug and Play. We are grateful to the California Health Care Foundation for supporting this work.

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Saying No to the Drug Crisis

By BRIAN KLEPPER

In a recent essay, VIVIO Health’s CEO Pramod John guides us through four sensible drug policy changes and supporting rationales that could make drug pricing much fairer. Reading through it, one is struck by the magnitude of the drug manufacturing industry’s influence over policy, profoundly benefiting that sector at the deep expense of American purchasers. As Mr. John points out, the U.S. has the world’s only unregulated market for drug pricing. We have created a safe harbor provision that allows and protects unnecessary intermediaries like pharmacy benefit managers. We have created mechanisms that use taxpayer dollars to fund drug discovery, but then funnel the financial benefit exclusively to commercial interests. And we have tolerated distorted definitions of value – defined in terms that most benefit the drug manufacturers – that now dominate our pricing discussions.

The power of this maneuvering is clear in statistics on health industry revenues and earnings. An Axios analysis of financial documents from 112 publicly traded health care companies during the 3rd quarter of 2018 showed global profits of $50 billion on revenues of $636 billion. Half of that profit was controlled by 10 companies, 9 of which were pharmaceutical firms. Drug companies collected 23% of the total revenues during that quarter, but retained an astounding 63% of the profits, meaning that the drug sector accounts for nearly two-thirds of the entire health care industry’s profitability. Said another way, the drug industry reaps twice the profits of the rest of the industry combined.

Pfizer, the top performing publicly traded company in Q3, generated $4.1 billion in profits on $13.3 billion in revenue, for a 31% quarterly margin and a 45% increase in profitability over Q3 2017. (By comparison, the 2nd and 3rd top performers, Johnson & Johnson and United Health Group, seemed meek, with Q3 2018 margins of 19.3% and 5.6%, respectively.) Convinced that significantly more can be extracted from the market, last week the organization thumbed its nose at the American people and announced another price increase, this time 5-9% on 41 drugs or 10% of its product portfolio, starting January 15, 2019. This action, of course, gave cover to other manufacturers wanting to do the same thing.

The drug industry has, in the main, been too smart to perpetrate this kind of price gouging over the short term. Instead, they’ve preferred to slowly ‘boil the frog,’ with relentless and predictable increases two to three times per year. While complaints abound, nobody has yet refused to pay. These increases have been reliably absorbed by U.S. taxpayers, employers and unions, conveying that there’s probably room for higher pricing still.

These bold business and profit-taking behaviors have been lubricated by a steady stream of pharma lobbying dollars to both parties of Congress – $280 million in 2017 alone, as reported by Open Secrets – which has been directly complicit in creating this economic albatross hung around the necks of the American people. Worse, we’ve come to consider this situation as acceptable and business as usual.

One question now is whether Congress can rise above simply being bought off and take actions for the common good rather than the industry’s financial interests. There’s some reason for optimism, with drug price management proposals from both sides of the aisle. In a Washington Post piece this month, Zeke Emanuel, one of the Obama Administration’s key architects of the Affordable Care Act, wrote:

… the Republican plan demonstrates that even conservatives are feeling pressure to regulate drug prices. The ideological challenge is how to regulate them. It is going to be difficult for Republicans to repudiate their president and stonewall on the issue over the next few years. Perhaps, with more than 90 percent of Democratic and Republican voters supporting regulation, a bipartisan compromise might emerge.

 Let’s hope he’s right, but until our lawmakers stop taking money from pharma, let’s not hold our breath.

One thing is clear. The actions of Pfizer and other powerful drug industry players have repeatedly demonstrated a willingness to test the limits of what captured regulation and a dominated market will bear, as well as a blatant disregard for the larger societal implications of those actions. This is also true for other health industry sectors, but because the numbers are so much higher within pharma, the ramifications are much more serious. Congress’ continued avoidance of meaningful remedies effectively abets an open threat to our national economic security.

While we hope that Congress comes through, so far that’s been a pipe dream. The drug industry is playing a game of chicken with America’s taxpayers, but also with its employers and unions, daring them to take the heat that would come from saying no. What we need is for America’s largest firms to collectively come together, refuse to pay exorbitant drug prices, and demand changes to the drug companies’ business models.

Our paralysis, our refusal to respond to the predatory forces within our borders, is the irony. If and when the reckoning comes, pharma can retort that its actions were transparent, and that we did it to ourselves by not saying no.

Brian Klepper is a health care analyst and the EVP of the Validation Institute.

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Health Care-Related Public-Private Partnerships Will Likely Become the Norm in 2019

By MARY SCOTT NABERS 

The United States ranks number one in the world for health care spending as a percentage of GDP. That sounds great… but, for instance, Texas ranks only 11th worldwide when it comes to performance. That’s because of access to care.

The country’s health care rankings are likely to get worse as 673 rural hospitals in the U.S. are at risk of closing. Here’s what has happened: the need for care greatly outpaces available funding, especially for public hospitals. Something must be done.

If public funding is no longer available, alternative funding can be secured in numerous ways. The simplest way to access alternative funding is through a public-private partnership (P3) engagement. However, alternative funding for public hospitals, health care clinics and university medical centers can be found from other sources as well. Finding funding is not a problem when private-sector investors, large equity funds, pension programs, asset recycling and EB5 programs all stand ready to invest in public-sector projects.

Moving to a P3 health care model would allow hospitals to secure immediate funding and utilize private-sector expertise and best practices while transferring all risks. The launch of health care P3s would also ensure new construction, new jobs and hundreds of additional health care options for people.

In 2017, there were 5,564 registered hospitals in the U.S. and 956 of them were owned by state and local governments. The 80 rural U.S. hospitals that closed during the last six years left many families without health care options. Those people were forced to seek treatment elsewhere or go without health care services.

Some rural health advocates are pushing for a new type of partnership – one that combines emergency and primary care in one facility. They believe that consolidating those services would reduce costs significantly. Chances are that other innovative changes are in the winds as well.

In October, the Aberdeen City Council in Maryland approved preliminary site plans for a new $75 million combined medical center and behavioral health facility. A week later, the University of Maryland’s Upper Chesapeake Health approved plans to replace its aging buildings and services. Its new campus will be located less than 10 miles from the Aberdeen hospital and will house a psychiatric facility and a heliport. The new construction is expected to cost $118 million. Both projects will be launched in 2019.

This summer, Metro Health, located in Cleveland, Ohio, unveiled plans for a new 11-story health care facility. The building will be located on a 52-acre main campus, which is currently home to a number of other buildings and parking garages. The campus will be updated with green space, a new 1,500-space garage and a central utility plant. The system plans to break ground later this year and anticipates completion in 2022. Part of the project will be covered by $767 million from 2017 bond sales, but since the funding fails to cover the entire project, alternative funding is a strong probability.

UConn Health in Connecticut is exploring the possibility of partnering with a private firm for all or a portion of its clinical enterprise. In October, the health system released a solicitation of interest for a private health partner. The objective was to test the possibility of having a private partner assume responsibility for supervision of the $203 million, 300,000-square-foot outpatient facility and the $318 million, 169-bed inpatient facility. The deadline for submitting proposals is Dec. 3.

Earlier this year, Penn State Health announced plans to build a new health care facility in Cumberland County, which is the fastest-growing county in Pennsylvania. The project is planned as a 300,000-square-foot, three-story building with construction to begin in early 2019. This facility will have a 108-bed acute care hospital.

Collaborative joint ventures are becoming the norm and health care P3s are likely to become common throughout the U.S.

Mary Scott Nabers is president and CEO of Strategic Partnerships Inc., a business development company specializing in government contracting and procurement consulting throughout the U.S.

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Young People Need To Turn Out For Their Health

By MERCEDES CARNETHON 

Last week, we saw historic turnout at the polls for midterm elections with over 114 million ballots cast.  One noteworthy observation regarding voter turnout is record rates of participation by younger voters aged between 18 to 29 years old.  Around 31 percent of people aged 18 to 29 voted in the midterms this year, an increase from 21 percent in 2014, according to a day-after exit poll by Tufts University.

Surely their political engagement counters the criticism that millennials are disengaged and disconnected with society and demonstrates that millennials are fully engaged when issues are relevant to them, their friends, and their families. Why, then, do we not see the same level of passion, engagement and commitment when young adults are asked to consider their health and well-being?

I have had the privilege of being a member of the National Heart, Lung and Blood Institute-funded Coronary Artery Risk Development in Young Adults (CARDIA) study research team. In over 5,000 black and white adults who were initially enrolled when they were 18 to 30 years old and have now been followed for nearly 35 years, we have described the decades-long process by which heart disease develops. We were able to do this because, in the 1980s when these studies began, young adults could be reached at their home telephone numbers. When a university researcher called claiming to be funded by the government, there was a greater degree of trust.

Unfortunately, that openness and that trust has eroded, particularly in younger adults and those who may feel marginalized from our society for any number of valid reasons. However, the results—unanswered phone calls from researchers, no-shows at the research clinic and the absence of an entire group of adults today from research studies, looks like disengagement. Disengagement is a very real public health crisis with consequences that are as dire as any political crisis.
As a public health researcher who has been documenting trends in obesity and heart disease for nearly two decades, a number of frightening patterns have arisen.  One pattern is that three out of every four adults are now overweight or obese and the average age of onset of obesity-related illnesses such as diabetes is falling.  Heart disease and chronic heart failure are developing in middle-age—a time that compromises financial well-being secondary to missed days of work managing illness. The negative implications for caring for growing families and aging parents are obvious.  A frightening harbinger of our future are the children and adolescents who see and feel the impact of these illnesses, but who don’t know how to prevent them because the research studies that have identified risk factors have little relevance to their lives today.

The reason they do not have these answers is related to the second startling pattern that young adults are even more difficult to engage in medical and public health research than their older counterparts. I have led and been a member of many research teams and we are extremely grateful for the retired grandmothers and the reluctant, but willing, grandfathers who donate their time to answer questions about their health and allow us to poke, prod and test them.

Due to their participation, we have identified the major causes of cardiovascular disease in the population. However, our knowledge about the evolution of obesity and cardiovascular disease in young adults is limited to studies that were formed in the 1980s before our social and cultural landscape was dotted with mobile devices, online communications and concerns about safety and privacy.

Young adults certainly have many competing responsibilities, including finishing their education, starting first jobs and building their own families. To saddle them with another responsibility seems unfair.  However, just as participating in our political system is one of our many rights and responsibilities as citizens, participating in our public health system should be, too. Ultimately, the goals of public health are to protect the health of all citizens and promote wellness. The national fervor and debate about health care demonstrate the passion people have for health. We need for young adults to stand together and show up to participate in their health with the same fervor and passion with which they showed up at the polls.

Mercedes Carnethon is the Mary Harris Thompson Professor of Preventive Medicine and Chief of Epidemiology at the Northwestern University Feinberg School of Medicine and a Public Voices Fellow with The OpEd Project.

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Health in 2 Point 00, Episode 59

Today on Health in 2 Point 00, Jess interviews me all the way from London. In this episode, she asks me about Google, who hired Geisinger CEO David Feinberg to lead its health care initiatives, Driver, a startup which ran out of money just weeks after their launch, and HealthifyMe, which has recently raised $6 million.

Jess also tells me about her recent trip to Berlin for Frontiers Health. Apparently, there’s a lot that the U.S. can learn from European startups, which have mastered regulatory and really understand how to plug what they’ve got right into pharma. Next, we’re headed to Tokyo for Health 2.0 Asia – Japan, so catch us there on December 4-5. –Matthew Holt 

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