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Real Interoperability and Other Micro-moments From #PCCSummit18

Posted on November 7, 2018 I Written By

Colin Hung is the co-founder of the #hcldr (healthcare leadership) tweetchat one of the most popular and active healthcare social media communities on Twitter. Colin speaks, tweets and blogs regularly about healthcare, technology, marketing and leadership. He is currently an independent marketing consultant working with leading healthIT companies. Colin is a member of #TheWalkingGallery. His Twitter handle is: @Colin_Hung.

I love attending user group conferences. They are THE BEST way to get a true sense of what is on the minds of healthcare professionals. I find that people at user meetings are very open and candid. I don’t know why this happens, but I’m grateful it does.

This week, I had the privilege of attending PointClickCare’s annual #PCCSummit18 in Nashville, TN. PointClickCare is the leading EHR provider to the Long-Term and Post-Acute Care (LTPAC) space. Their customers are Skilled Nursing Facilities (SNFs), Senior Living organizations and Home Care providers.

I learned so much about the challenges facing LTPAC providers and I had so much fun connecting with PointClickCare staff as well as their customers. These are some of the memorable/notable moments from the event.

Real Interoperability happening between Hospitals and LTPAC

Interoperability wasn’t just talked about at #PCCSummit18, you could actually see it in action. PointClickCare’s partnership with Redox and their upcoming release of the Harmony interoperability module. More on this in a future article.

Investing in LTPAC Innovation Paying Off

For years PointClickCare has poured millions of dollars into R&D – researching, building, testing and in some cases acquiring new products for the LTPAC market. That investment in innovation continues to pay dividends as end-users and partners applauded each of the new modules/features unveiled at #PCCSummit18.

We’re still talking about faxes?!

The most eye-opening data point shared at #PCCSummit18 came via a real-time audience survey in one of the breakout sessions on LTPAC process optimization. The presenters asked the audience to text back their answer to the following question:

In the past 12 months, which (patient) transitions improvement projects, or remote patient reporting projects have you been a part of?

  1. Improved paper/fax processes
  2. Direct Messaging
  3. 3rd party tools
  4. None

You can see the surprising result. The majority of the audience had either not worked on any such transition improvement project or had been part of one that improved a paper/fax process. Yikes! We have a lot of work to do in #HealthIT.

Using storytelling to make data memorable

My favorite breakout session was by Doug Landis, a professionally trained actor who went onto become the chief storyteller at Box and who is now a venture capitalist. Landis’s presentation was full of useful tips and tactics on how to present data in a memorable way through the power of stories.

No single path to success

On the theme of storytelling, 4 Nashville songwriters presented their stories as the keynote session on Day 3. Each of musicians came to Nashville wanting to become the next breakout star. What happened instead is that each became a songwriter who created a piece that helped a rising star hit it big on the music charts – Carrie Underwood, Lady Antebellom and Miranda Lambert to name just a few. Their stories are proof positive that there are many roads to success and sometimes your own success can be found by helping other succeed.

Everyone leaving happy

Every attendee that I spoke with had nothing but praise for PointClickCare. They felt well taken care of, they thought the venue was fantastic, they thought the social events were incredible and they loved the food. It’s fun to be part of a conference where everyone leaves happy.


What’s the Real Cause of Hospital Readmissions?

Posted on February 24, 2014 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

To a person, I’m sure that every hospital has a detailed understanding of their hospital readmission number. Reimbursement depends on it and so every one or them knows that number well. However, how many of them really know the cause of their hospital readmissions?

As I consider the various companies working to reduce hospital readmissions, the vast majority (possibly all) of the ones I’ve seen and heard have focused on home health technologies. In theory, the idea makes sense. Someone is discharged from a hospital and so we need to provide them better home health technologies that can prevent them from returning to the hospital. This is the promise of home health technology and the media loves to cover it.

However, in a recent pre-HIMSS Google+ video briefing I did with Capsule, Stuart Long, their Chief Marketing and Sales Officer, made a comment about hospital readmissions that I’d never heard before. He said that the majority of readmits were coming from long term care and skilled nursing facilities and not from the home.

I found this to be a fascinating finding and one that made a lot of sense. However, I pressed him to know where he got the data for it. Since it was done from an internal survey, he offered me the following explanation of the finding:

Recently, Capsule surveyed the market to assess the level of financial pain that hospitals were feeling due to the Medicare penalties associated with 30 day readmissions coming from the patient’s home. We found that technology, although market buzz suggests otherwise, was not the main driver for hospitals mitigating the risk of penalty expenses associated with readmissions. To our surprise our survey of hospital CFO’s revealed that to date it has been the improvement of existing and newly deployed care processes that has had the most significant impact on the management of – in some cases even the reduction of – patient readmissions.

However, a consistent theme that was discovered across our survey was that the hospital readmission issues are not primarily coming from the home, but from long-term care (LTC) facilities and skilled nursing facilities (SNFs). Key points discovered include:

  • 60%-80% of readmits come from LTC & SNF
    • Mostly due to high co-morbidity (High number of simultaneous chronic diseases).
    • Discharges can vary to location based upon relationships with LTC’s and SNF. As high as 33% of patients to SNF, LTC and Home Health to “in network partners” where they have control through people and process.
      • 66% of discharges, however are “outside the network” to LTC and SNF where they have no insight to the patient.

This survey data supports the need for healthcare facilities to have a Remote Patient Monitoring (RPM) System & Clinical Decision Support solution for this population due to Accountable Care Organizations (ACO) and capitated reimbursement. To be able to effectively reduce readmissions and provide the best treatment of patients, much better care coordination is needed. For starters,

  • Data MUST be communicated to the primary physician. There is a driving need to send data to multiple caregivers.
  • There is a need to notify the primary physician or responsible caregiver in the event the patient show’s early signs of deterioration.

The additional challenge with the home is how to manage patient compliance. The current trend is to send an RN, Nurse Assistant, Case Manager or other outside company to the home for care.

Further to this point, a paper published by the Department of Health and Human Services OFFICE OF INSPECTOR GENERAL; “MEDICARE NURSING HOME RESIDENT HOSPITALIZATION RATES MERIT ADDITIONAL MONITORING” November, 2013 can be found here. This paper substantiates the problem with a specific disease condition that contributes to the high readmission rates from LTC and SNF’s.

In FY 2011, nursing homes transferred one quarter of their Medicare residents to hospitals for inpatient admissions, and Medicare spent an astonishing $14.3 billion on these hospitalizations. Nursing home residents went to hospitals for a wide range of conditions, with septicemia the most common.

I think this is a really important finding and I’d love to have it validated by readers of this site who have data from their hospital. Do you see the same thing happening with your hospital readmissions or something else?

If we assume that this finding is true, then the solution to the problem of hospital readmissions is very different than I previously thought. I think Capsule sees it as a tremendous opportunity for them to leverage their skills with connected devices in places like long term care and skilled nursing facilities.

As part of this strategy, Capsule just announced at HIMSS 2014 a new medical device information system that they’re developing. At first this sounded more like a device tracking system for medical devices. Is the device working properly? Where is the device? etc. Certainly it will have those features, but Capsule is looking at this medical device information system from a much larger perspective. They want the system to Connect, Monitor, Analyze, and Act. Connecting is what they’ve always done. Monitoring is the medical device management piece. However, Analyzing and Acting on the data those devices collects puts Capsule in a very new space.

I’ll be interested to see how deep Capsule goes with this and who they choose to partner with to put together the intelligence behind the “Analyze” and “Act” components. This will take some work and many will argue that this type of stuff should be done in the EHR. However, you have to remember that long term care and skilled nursing facilities were left out of the EHR incentive money and are way behind the rest of healthcare in IT adoption. Could these post-acute facilities put in a medical device information system from Capsule as a way to reduce hospital readmissions? Seems like an interesting and reasonable strategy to me. Plus, the hospital would be happy to pay for it if will indeed reduce their hospital readmissions.

Group Develops EMR-Less HIE Technology

Posted on August 22, 2012 I Written By

Anne Zieger is veteran healthcare branding and communications expert with more than 25 years of industry experience. and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also worked extensively healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or

A pair of major tech players and a group led by Geisinger have come together to create tools making health information exchanges accessible to providers who don’t have an EMR in place. The tools are aimed at skilled nursing facilities, but from what I can see, the approach would work for other providers too.

Federal standards already require SNFs to submit MDSs — which are electronic patient assessments — to both the Medicare and Medicaid programs. The thing is, MDS data doesn’t conform to the Continuity of Care standard, so it can’t be shared amongst various providers across an HIE.

What’s happening is that Geisinger’s Keystone Beacon Community and GE-Microsoft joint venture Caradigm have created a MDS (minimum data set)-to-CCD transformer which turns patient care data into a Continuity of Care Document.  Providers can then take their CCD document and transfer it to  an HIE.

The Keystone Beacon Community, which is part of an HHS-backed program established in 2009, was launched to speed up the ability of health IT to transform local healthcare systems.  Keystone includes a network of 17 central Pennsylvania providers, including medical practices, hospitals, long-term care communities and others.

I’m not surprised to see Geisinger driving this train, as it’s been ahead of the EMR curve for many years. Geisinger is also large enough to conduct a real test of new technologies, as its network single-handedly serves more than 2.6 million residents of 42 area counties.

Still, I’ve got to wonder whether efforts like the Direct Project aren’t a better place to invest energy at the moment. It seems to me that Direct Project technologies are far simpler to deal with and still get a great deal done. But then again, maybe I’m just being a party pooper.  Nonetheless, I can’t help feeling that in this situation, less (complicated technology) is more.