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Wednesday, January 4, 2017

"Elation" and "EHR" -- a word and an acronym not typically found together

First, some setup context, excerpted from a September 2016 Wall Street Journal Op-Ed.
Turn Off the Computer and Listen to the Patient
The practice of medicine is a subtle art. Doctors need to give patients their undivided attention.

Sept. 21, 2016

Of the many problems facing modern medicine, the deterioration of the patient-doctor relationship is one of the most pernicious. Today our health-care system is losing its humanity amid increasingly automated and computer-driven interactions between doctors and patients.

The signs and symptoms of this pathology are everywhere ... Primary-care appointments are now as short as five minutes, and the physician must spend much of that time typing instead of attending to the patient and performing a physical examination. Medical students and residents are spending more time with screens than with patients ... Meanwhile, fewer doctors would like to see their children enter a career in medicine, and escalating health-care costs are crippling families and the economy without improving public health.

The electronic health record (EHR), once a promising new medical technology, is a major cause of this disconnect. Not long ago, doctors dreamed of a time when unwieldy paper charts would be replaced by streamlined computer systems, freeing them up for more direct patient care. But now these computer systems are distracting and burdensome. Senior physicians are retiring early because of the EHR, while young doctors feel the humanity draining from a profession to which many were drawn because of a desire to interact and connect with people.

How did we get here? One cause is the development of third-party health-care financing, which grew out of the Great Depression and eventually led to the ascendance of insurance corporations with the ability to influence the clinical practice of hospitals. Similar economic forces have decimated private medical practice, as physicians become employees of hospitals and larger hospital systems. Medicine has become corporatized.

In 2009, with this stage set, Congress passed the Health Information Technology for Economic and Clinical Health (Hitech) Act. The act was designed to improve the U.S. health-care system by promoting and standardizing the use of computer technology by physicians. It prescribed, in great detail, a set of federal standardized instructions for how doctors must use computers in medical practice, such as what data to collect from patients. It also provides a mechanism by which hospital systems can prompt doctors to make decisions that are more in line with the hospital goals and practices. These instructions, enforced by financial incentives, are collectively called “meaningful use.”

Computer programs and one-size-fits-all rules for medical practice have thus become central to the care process...

...Computer algorithms don’t result in higher quality care because the practice of medicine remains a subtle art. Careful listening and undivided attention are important, and the incessant electronic reminders and check-boxes that divert a doctor’s attention while the patient sits on the examination table are a distraction equivalent to texting while driving, and will end up hurting patients.

The patient also suffers because medical records are now used primarily as management tools for billing compliance and population-data collection ... Meanwhile, growing medical specialization and restrictions on resident work hours have led to more shift changes and transitions of patient care from one doctor to another, moments when clear and efficient communication is most vital...

...Medicine is both losing its humanity ... and buckling under the weight of massive, ill-designed electronic information systems.

The answer isn’t to resist technology. Information systems are central to the future of good doctoring, and industry professionals should continue designing electronic systems to enhance medical care and facilitate the connection between patients and physicians. Meanwhile, however, medical practices should be allowed to turn off the “meaningful use” software prompts and return to the job of taking care of real people. Doctors have an obligation to act as stewards of the medical profession and with humanity toward patients and should insist upon the undivided attention necessary to do so.

Dr. Gardner is a physician and resident at Cambridge Hospital in Massachusetts. Dr. Levinson is a cardiologist at Massachusetts General Hospital and Harvard Medical School.
You don't have to search far at all to find voluminous evidence of clinician dissatisfaction with digital health IT, particularly in conjunction with the now-waning, widely hated federal Meaningful Use initiative (which, recall, was the topic that started this blog in 2010 at the outset of my tenure with the Nevada-Utah REC run by HealthInsight, my now thrice-former employer).

Beyond MU grouchiness specifically and complaints regarding health IT UX shortcomings more broadly, some critics even go so far as to question our fixation on digital health "structured data" per se. See, e.g., my December 2015 post "Are structured data the enemy of health care quality?"

Tangentially, see also my recent post "Clinical workflow, clinical cognition, and The Distracted Mind."

I think the full-featured EHR is here to stay for quite some time yet to come, notwithstanding all the chatter about our "post-EHR/mHealth world." Given the continuing "productivity treadmill" time constraints in the irreducibly high cognitive burden, high stakes, chronically fragmented enterprise that is clinical care delivery, the more workflow-efficient the UX the better.

"Elation EHR"

OK, then.

Saw a THCB post by Health 2.0's Matthew Holt. It spurred this post.
Elation’s Kyna Fong on a new type of EMR company
Jan 3, 2017, by Matthew Holt

There’s so much happening in the Health 2.0 world of new technology in health that it’s hard to keep up. AI, VR, AR, Blockchain–and they’re just the buzzwords keeping the VCs happy. So this year I’ve decided to try to interview more interesting new companies to keep you in the know. We’ll see how long that resolution lasts but first up is Kyna Fong, CEO of ElationHealth. Yes, she left a Stanford tenure-track professorship to start an EMR...

I have yet to personally meet any "elated" EHR users, notwithstanding my more than a decade of work spanning DOQ-IT and then Meaningful Use. But, maybe the bold naming here is appropriate. Dunno. Bears further study.

Cloud-based subscription model per provider (support staff logins included), monthly ($349) w/no contract, or annual prepayment at an 8% discount ($321 x 12 = $3,852). Reduced fee ($175/mo) for non-Rx Mids. What about full panel data migration from a prior EHR?
"If you are interested in having us move all your patient care data from your old system, we offer a Custom Data Import from almost every EHR, including Practice Fusion, Allscripts, Amazing Charts, Spring Charts, NextGen and Care 360 for example. It is a one time, additional fee of $9,995."
That all sounds pretty reasonable. Say you're a busy solo doc who averages 20 pts/day, 48 weeks/yr. That works out to 80 cents per pt encounter -- perhaps ~1% of average reimbursement? (way cheaper than schlepping paper, and probably cheaper than most EHR competition).

Also, say you have an active panel of 2,000 pts. The full migration fee would be around 5 bucks per chart. My former Primary in Las Vegas (also a MU client) spent a year populating his new EncounterPRO EHR with the next day's patient visits every night after office hours (he didn't trust his staff to do it accurately; I still can't believe he did that). Another MU client doc of mine in Reno hired a med student to slowly do his MicroMD chart pre-population transcription.

You simply couldn't do all of that for $5/chart. apropos, see one of my 2014 posts "ROI - Health IT Return On Investment 101."

Matthew's YouTube interview with the CEO:

From Forbes:
Can Kyna Fong's Elation Health Help Save $240 Billion In Healthcare Costs And Improve Patient Care?

A Series of Forbes Insights Profiles of Thought Leaders Changing the Business Landscape:  Kyna Fong, Co-founder and CEO, Elation Health
The Institute of Medicine (IOM) published a report in 2014 estimating that the country loses some $750 billion annually to medical fraud, inefficiencies, and other siphons in the health-care system. That’s about 8% of our $3 trillion annual healthcare spend. Over half of the loses are accounted for by unnecessary services, inefficient care, or the failure to prevent problems that require expensive intervention. Elation Healthundefined, co-founded by its CEO, Kyna Fong, along with her co-founder brother Conan Fong, is out to change that dynamic through its cloud-based patient-physician platform. But that’s only part of the story.

“I started the company with my brother, and our mission is to strengthen the relationship between patients and physicians and really enable phenomenal care for everyone. We do this today through a cloud-based, patient-focused care platform that physicians use in all aspects of patient care. It’s a lightweight tool that not only enables the physician to understand the longitudinal story of the patient’s health, but also allows the physician to collaborate with the broader team of providers in different organizations that also care for the patients,” says Fong.

The typical physician shares patients with over 200 other doctors and patients see a multitude of doctors over their lifetime.  Allowing doctors and patients to collaborate across organizational boundaries and share information is a critical challenge that ends up with billion dollars of wasted health expenditures. This lack of interoperability leads to waste and often poor patient care.

“Our focus from the get go has been to build products that put clinical needs first and bring patients and physicians closer together. We call this our clinical first approach and we think that this is the foundation upon which we need technology to be built in order to actually improve outcomes,” says Fong...
See the 90 second animated Vimeo pitch video from their website ("privacy settings" restricted from iFrame embedding). None of the laments set forth in the short video and audio V/O are exactly news. To the extent that Elation EHR can significantly and cost-effectively mitigate them, it should find a ready market. A couple of scary smart people, these sibling co-founders.
Kyna holds a Bachelor of Arts in Applied Math, summa cum laude, and a Masters of Science in Computer Science, both from Harvard University, as well as a PhD in Economics from Stanford University's Graduate School of Business. Previously, she was a professor at Stanford University's Department of Economics.

Conan holds a Bachelor of Science with distinction in Microbiology & Immunology with double minors in Management and Economics from McGill University, as well as a Masters of Health Sciences in Health Finance & Management from Johns Hopkins University's Bloomberg School of Public Health.
All very interesting. I have a number of questions for them. I've also apprised Dr. Carter of about this company. Stay tuned.

Kyna Fong reported on at Health System Management:
Kyna Fong, PhD, co-founder and CEO of Elation Health ... in a keynote address at the 3M Value-based Care Conference in Chicago ... noted that most value-based initiatives focus on plan and incentive design, data analytics and predictive modeling. These things need to strengthen the patient-physician relationship, not undermine it.

She shared five guiding design principles to develop “thoughtful technology that is clinical first, patient-centric and embedded in the physician workflow”:

  1. Engage the physician in their workflow with timely feedback. Physicians have very little time to interact with the technology and it is more important for them to focus on clinical needs and patient relationships. The information must be available at the physician’s fingertips in less than 30 seconds to achieve what Dr. Fong calls “high consistent use.”
  2. Meet reporting needs without adding a burden to PCPs. Technology that automates quality reports makes the PCPs job easier. “It is unsustainable to expect PCPs to spend more time with technology. We should minimize the diligence and effort required to get paid.”
  3. Elevate the patient to an active, engaged member of the care team. “The patient is a powerful potential actor in the value-based care movement, if motivated.” Any solution needs to engage patients and make care quality clear to them. They should be encouraged to track and improve it. Every visit summary should be shared with the patient, as well as their clinical profile and health maintenance schedule. Finally, the data should be portable to other providers. It would save massive amounts of time for physicians and result in better patient awareness and education about their own health.
  4. Accommodate delivery of care by teams across settings. The team needs to be connected by a common patient record. Patient loyalty is to the best care, regardless of the IT system. Patient data needs to be able to follow them through the care system and travel faster.
  5. Make the technology affordable, whether for a multi-million dollar health system or a small physician practice. “Servers are cheaper and upgrade cycles are more frequent. We are past the point that the delivery of care needs to be constrained by technology. We don’t need to put all physicians under the same roof just for the sake of technology.”

Impact on Health Tech Investing in 2017
There's one overriding topic about American health care starting this week, going to January 20 and maybe even beyond--Just how do Trump and the Republican Congress "repeal and replace" the ACA? And of course what does that mean for health technology investment environment? Especially given that 2016 was a record year with Health 2.0 counting more than $5bn raised.

Our sense is that "repeal & replace" becomes "amend & defund." So what will that mean for health tech, for insurance companies, and hospitals? And will emerging markets like China or India start to lead digital health investing?

Want to sort out this muddle for your investing or business strategy in 2017? Health 2.0's Wintertech Conference in San Francisco next Wednesday is the place where all these issues are put into context.
Register today for WinterTech before tickets sell out.

From my Facebook page.


More to come...

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