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SUMMER 2020 PHYINS.COM

4 Health Tech in 2020 Six Trends Shaping Modern Healthcare

8 How Healthcare Innovation Ecosystems Accelerate Transformation

18 Healthcare’s Digital Revolution How Pop Culture’s Tech Tools Are Impacting Patients and Providers

Technology Trends that are TRANSFORMING HEALTHCARE EDITORIAL STAFF Technology and Partnerships PUBLISHER William Cotter

SENIOR EDITOR Keys to Improving Population Health and Creating David Kinard

MANAGING EDITORS a System That Works for Providers and Patients Catherine Kunkel Kirstin Williams Over the past decades, clinical The implications of continuous, real- CONTRIBUTING WRITERS science and medicine have brought an time data for patients are profound. Anne Bryant explosion of knowledge, unprecedented Understanding a patient’s baseline Malia Jacobson Cindy Lin, MD ability to diagnose and predict certain metrics could allow us to diagnose Maura Little diseases, improved management diseases better, track trends, monitor Shwetak Patel, PhD Robin Roenker of previously fatal conditions, and costs unobtrusively over time, and CONTRIBUTING EDITOR groundbreaking innovation in precision even personalize therapeutics. Today’s James Carpenter CONTRIBUTING EDITORS—LEGAL therapies and surgeries. Despite these procedural treatments—in which patients Melissa Cunningham, JD advances, healthcare is challenged are instructed to follow a generic set of Nancy Pugh ART DIRECTOR in such basic dimensions as quality rules—will be replaced by declarative Jerry Kopec, Mortise+Tenon and outcomes, cost, scalability, and treatments, in which intended outcomes equity. COVID-19 has transformed are specified and the system dynamically EXECUTIVE MANAGEMENT healthcare by forcing the rapid adoption adjusts to achieve them. Medications and PRESIDENT AND CHIEF EXECUTIVE OFFICER William Cotter of telemedicine and boosting the need monitoring devices will be inextricably VICE PRESIDENT, CLAIMS for technology—for both providers linked; treatments will be more holistic Kari Adams and patients. The pandemic and its and fluid. Wearable technology and ASSOCIATE VICE PRESIDENT, DEPUTY GENERAL COUNSEL Melissa Cunningham, JD associated mortality have cast light on mobile phones have introduced the idea SENIOR VICE PRESIDENT, STRATEGY socioeconomic and racial inequities already; however, the additional data will Christina Galicia in healthcare. The current system is be daunting to many physicians unless SENIOR VICE PRESIDENT, CHIEF FINANCIAL OFFICER AND TREASURER unsustainable, and we must innovate AI and machine-learning algorithms can Kristin Kenny to improve it. support its adoption. SENIOR VICE PRESIDENT, BUSINESS DEVELOPMENT David Kinard

SENIOR VICE PRESIDENT, GENERAL COUNSEL A fundamental bottleneck in our system As research and development continues, Mark Lewington, JD is the assumption that healthcare is it will be critical to foster collaboration SENIOR VICE PRESIDENT AND CHIEF INFORMATION OFFICER performed by clinicians face-to-face between stakeholders so physicians and Leslie Mallonee in a facility, in short bursts centered health systems alike will be supportive of SENIOR VICE PRESIDENT, UNDERWRITING around specific problems. Telemedicine our solutions. Our guiding principle should Stella Moeller SENIOR VICE PRESIDENT, has given many physicians their first be investing in technology solutions and HUMAN RESOURCES AND ADMINISTRATION glimpse into patients’ lives, bringing back building partnerships that will strengthen Alison Talbot virtually the lost art of the home visit; in our ability to improve population health giving doctors a sense of patients’ level and change the social determinants of BOARD OF DIRECTORS of family support and home safety, video health, so we can build a healthcare David Carlson, DO, Chairman visits transform the medical history into system that works for everyone. William Cotter a richer picture of the whole person. Lloyd David Joseph Deng, MD The pandemic has also highlighted ways Jordana Gaumond, MD in which the lack of exam data hinders Jennifer Hanscom Chi-Dooh "Skip" Li, JD telemedicine. Empowering patients Shane Macaulay, MD to self-care, and encouraging self- John Pasqualetto Ralph Rossi, MD monitoring and remote monitoring as a Walter Skowronski lifelong process, shifts healthcare toward Cindy Lin, MD, Shwetak Patel, READ PHYSICIANS REPORT ONLINE phyins.com/magazine a partnership between clinician and FACSM, Clinical PhD, Washington patient, while creating new potential for Associate Professor, Research Foundation CONTACT PHYSICIANS REPORT [email protected] Sports & Spine Endowed Professor, population-health management. Medicine, UW Dept. UW, Allen School of HOME OFFICE: of Rehabilitation Computer Science & Seattle, WA Copyright 2020 Medicine Engineering Physicians Insurance A Mutual Company A PHYSICIANS INSURANCE PUBLICATION

FEATURES

8 How Healthcare Innovation Ecosystems Accelerate Transformation

14 Medical Advances THEN… and NOW

18 Healthcare’s Digital RevolutionHeart Monitors 4 Health Tech in 2020 How Pop Culture’s Tech Tools Are Six Trends Shaping Modern Healthcare Impacting Patients and Providers

ADDITIONAL FEATURES REGULAR FEATURES

12 Virtual Risk 34 Government Relations— How to Manage Risk and Update Reducing the Professional Liability When Threat of Liability for Our Adopting New Technology Providers and Facilities as They Fight COVID-19 20 Cyber Attacks on the Rise Practices and Hospitals Face 38 Trial Results Increasing Threat 40 Dr. Nola Moore Obituary 22 Are Electronic Health Records Causing Practitioner Overload? 24 Paving the Path for Greater EHR Interoperability 26 Reflections from Frontline Heroes 30 Claims Severity and Pressures on Premiums SEND FEEDBACK Tell us more about what you would like to see in upcoming issues. E-mail us at [email protected]. 4

Health Tech in 2020 Six Trends Shaping Modern Healthcare The challenges facing healthcare in 2020 are as vast as they are complex. How can healthcare providers and organizations care for growing numbers of patients, increase efficiencies, improve quality and safety, retain and nurture a skilled workforce, and predict and respond to evolving crises like the coronavirus pandemic? 5 THE PHYSICIANS REPORT | SUMMER 2020

s healthcare transforms to 5G NETWORKS meet these challenges, technology More people than ever are visiting Awill play a critical role. Technology healthcare providers in 2020. General helps eliminate barriers to effective medical-care visits are expected to reach collaboration—factors like distance, 200 million this year, up from original knowledge, and access—resulting forecasts of just 36 million visits. But Without adequate in improved operations, enhanced here’s the catch: all these people aren’t communication across silos, and a broad visiting in person. bandwidth, framework for data-driven decision- making. By enabling providers to capture, As providers and patients adapt providers will have analyze, and integrate data across to COVID-19 and social-distancing different geographic regions, practice recommendations, more and more of limited access to specialties, and modalities of care, those visits will take place remotely. data on mobile technology promises to improve outcomes Prior to COVID-19, telemedicine was for both organizations and patients. already projected to grow 16.5 percent devices, and AI and by 2023, according to a report by Tools like artificial intelligence Market Research Future consultants. predictive-analytics and machine learning are helping The global pandemic has accelerated organizations manage and use growing this growth: in March 2020, telehealth capabilities will piles of patient data, while drone delivery, visits surged by 50 percent, according machine vision, 5G, and 3D printing to research from consultants with Frost be stunted. are making healthcare faster, more and Sullivan. accessible, and more effective. Here’s how these six tech trends in particular are All this remote care and monitoring shaping the ongoing revolution. can put a strain on the networks of healthcare organizations, increasing broadband and wireless internet access congestion and slowing speeds. When across underserved parts of the U.S. jammed networks are hampered by lags and delays, communication suffers, care Ultra-reliable, high-bandwidth networks is less efficient, and capacity is limited. are required to enable healthcare to use technology to improve patient Large files generated by PET scans, outcomes, and 5G networks are MRIs, and other types of imaging providing the answer. By providing technology may not send successfully; near-instantaneous access to data and videos used during telesurgeries are lightning-fast transmission of large files, bound to be less precise; and fewer 5G networks improve quality, efficiency, patients will be able to use cost-saving and outcomes. technology like remote monitoring. Without adequate bandwidth, providers Earlier this year, the Veterans will have limited access to data on Administration launched one of the mobile devices, and AI and predictive- nation’s first 5G hospitals in California, analytics capabilities will be stunted. joining Chicago’s Rush University Medical Center and Barcelona’s San High-speed connectivity has become Raffaele hospital in ushering in so central to effective patient care, an era of blazing-fast connectivity that advocates now argue that connectivity is will improve patient experience and a public-health concern. Lack of access reduce the cost of care. to high-speed internet has hampered access to care in rural areas, prompting AI AND MACHINE LEARNING the American Medical Association to Medical data doubles in volume every adopt a policy advocating for expanded 73 days—and technology experts

(Continued on page 6) 6 (Six Trends Shaping Modern Healthcare, continued from page 5)

say that’s good news for healthcare One barrier to implementation of AI, organizations. According to business Pugh says, is a fear of data-driven and economics-research engine the performance metrics for providers. McKinsey Global Institute, pairing this “When we talk about AI in medicine, big data with the AI and machine- the huge elephant in the room is that learning tools needed to analyze it could when you mention tracking workflow result in $100 billion in annual savings “The irony is that, and motion, providers fear that this for healthcare organizations. data will be used against them, with respect to either in performance evaluation or By facilitating decision support, video and its in the courtroom,” she says. “The information exchange, and improved irony is that, with respect to video workflow for surgeons and surgical discoverability and its discoverability from a legal teams, AI holds enormous promise and malpractice standpoint, many for healthcare, particularly in the from a legal studies show that when this type of operating room. Using motion tracking information is used in a courtroom it to gather data on how surgeons carry out and malpractice ends up helping the physician.” (See complex procedures can inform robust “Virtual Risk: How to Manage Risk and algorithms that allow surgeons to share standpoint, many Professional Liability When Adopting best practices across specialty teams, New Technology,” page 12.) ultimately creating cost savings in studies show that operating rooms, says Carla Pugh, MD, The potential for AI in healthcare Ph.D., professor of surgery at Stanford when this type of is limited by the data informing its University School of Medicine and information is used algorithms: widespread buy-in allows the director of its Technology Enabled for more robust algorithms that yield Clinical Improvement (T.E.C.I.) Center. in a courtroom more actionable decision support. Ultimately, Pugh says, this will be a Motion-tracking data is gathered by it ends up helping symbiotic relationship. “The more we evaluating the location, speed, and can integrate AI into our workflow, movements of surgical instruments the physician.” the better it will get at calculating, during a procedure, and has been benchmarking, and providing the shown to be an effective means of CARLA PUGH, MD, PH.D., information we need,” she says. evaluating surgical skill. Compared to DIRECTOR, TECHNOLOGY video data alone, motion-tracking data ENABLED CLINICAL COMPUTER AND MACHINE VISION combined with video data provides a IMPROVEMENT (T.E.C.I.) The same technology that allows an CENTER, STANFORD more comprehensive data set for training iPhone to recognize the face of its UNIVERSITY SCHOOL and evaluation. Using this data to create OF MEDICINE owner and self-driving cars to navigate more effective algorithms for training roadways can also augment the skills and decision support represents an of surgeons and improve patient exciting application for AI, Pugh says. care. Machine vision, a global market Using AI, healthcare organizations can expected to reach $14.7 billion by “Motion-tracking technology adds a more easily share this data, putting data- 2025, involves the use of specialized three-dimensional layer of data that driven decision support at surgeons’ cameras and algorithms to gather and enhances our ability to understand fingertips anywhere in the world. Even interpret visual information in real time. the video data,” she says. “It has the with AI-augmented decision support, During surgery, machine vision allows potential to streamline the AI analysis Pugh notes, a trained surgeon is still the surgeons to see through a patient’s process, because video and motion data decision-maker. But if a surgeon can anatomy and orient their tools in space. combined are easier to work with than quickly and easily access data about the video data alone. We get real data how others have navigated complicated Machine vision represents the next on how surgeons adapt to the variety of presentations in the operating room, it stage of advancement for digital surgery, ways disease presents itself.” can improve outcomes and save time. according to a news release from Anthony Fernando, CEO of TransEnterix, 7 THE PHYSICIANS REPORT | SUMMER 2020 a company that added a machine- lifesaving organs reach their recipients broaden the lifesaving impact of drone vision feature to its robotic-surgery quickly and safely. organ delivery, more medical drones system earlier this year. The technology will need to be produced, and trained enhances the sensing capabilities of Each of the more than 30,000 organs technicians capable of “piloting” them computer-assisted surgery, automatically transplanted each year must reach its will need to be integrated into the organ- moving the camera during a procedure recipient swiftly to remain viable. Per delivery process at more hospitals and and even responding to commands the United Network for Organ Sharing, medical centers. within the surgical field. hundreds of donated organs don’t make it to their intended destinations 3D PRINTING Like other recent advancements in each year, and thousands are delayed The expansion of 3D printing is rapidly surgery, including the growth of robotic by two or more hours. Compared to impacting industries like aerospace, and digital surgeries, machine vision commercial flights, drones could manufacturing, and education. Although has the potential to improve patient deliver organs in a fraction of the time, 3D printing is already widely used in care. But its adoption may exacerbate at a much lower cost, and without healthcare, experts say the impact of existing disparities in the technological unpredictable delays that could result this emerging technology on medical skillsets of surgeons and decrease the in the loss of a viable organ. and surgical care is just beginning. The already dwindling number of providers journal Radiographics reports that the who excel at open surgery. Already, many In 2018, the Federal Aviation field of radiology in particular will see newly graduated surgeons may not be Administration began changing its confident in performing the open version strict regulations on commercial (Continued on page 33) of some surgeries, while their more drone usage, paving the way for more seasoned counterparts may have little widespread medical use of drone to no experience with robotic surgeries, technology. The following year, the says Jordana Gaumond, MD, FACS, first drone-delivered kidney was general surgeon at The Oregon Clinic.

Surgical groups should also consider what share of their procedures require digital augmentation before investing in any new technology, including this one. “For some procedures—like prostate surgery, deep pelvic surgery, or complex hernia repair—robotics allows surgeons to do things that are unimaginably awesome,” says Dr. Gaumond. “For others, we don’t need to add that level of successfully transplanted technical difficulty. Whatever procedure into a patient at the is being performed, ultimately it’s the University of Maryland surgeon who needs to have the skill and Medical Center, the culmination judgment to choose the best approach.” of years of UMMC research on drone organ delivery. The drone DRONE DELIVERY flight between hospitals delivered OF TRANSPLANT TISSUE the organ in under 10 minutes. Modern drones—unmanned robotic aircraft that fly autonomously using Drone delivery of viable organs onboard sensors and GPS-informed flight has been proven successful, but plans embedded in their systems—have challenges remain. Federal, state, been buzzing through the air since and local governments need to 2001, when they were first used for change regulations to allow military missions. Soon drones may be medical-delivery drones to fly deployed for a new mission: helping more than a few miles. To 8 How Healthcare Innovation Ecosystems Accelerate

TransformationBy Maura Little

A few months ago, the world we lived in looked different—and it continues to change, literally by the minute. The COVID-19 virus has disrupted our lives in more ways than we can count.

You, our country’s physicians, and other healthcare providers failures in our landscape to drive impactful innovation. Startups know this better than most, as you have been working on are pivoting to solve problems that are not quite understood. the frontlines of this global pandemic. If you are unable to The lack of information sharing and technical capabilities read any more than this first paragraph, please know that we has inhibited efforts to act in a more data-driven, scientific thank you for your work. Your service and sacrifice have saved manner. Physicians and staff are being laid off due to payment countless lives, and we thank you for everything you do and structures that rely on the now “old” way of caring for patients. have done to protect our communities and loved ones. The global pandemic has exposed cracks we’ve known to exist in the healthcare system for decades—the only thing that’s Hunkered down in our homes during quarantine, the team at changed is our sense of urgency. Cambia Grove, a healthcare innovation hub, has been focused on the most promising, impactful solutions, how they’re being FOUNDATIONS FOR CHANGE used, the pros and cons of their use, and what to anticipate To some, innovation is looked down on as something to fear. in the near and longer term. The 21st Century Cures Act and To us, innovation simply means positive change. We bring COVID-19 have drastically shifted trendlines in just the first changemakers together to advance innovations that support a few months of 2020. For example, who could have predicted more person-focused and economically sustainable healthcare the skyrocketing pace of telemedicine adoption? Or the system. The healthcare sector’s collective knowledge and impact of the Defense Production Act on medical suppliers, experience is astronomical and, when combined across as hospitals compete with one another to fill an increased silos, leaves us able to advance innovative solutions to our need for PPE and other supplies? As we think through these toughest challenges. We’ve met changemakers throughout changes, what has not changed are the key components and the healthcare ecosystem, across the startup community 9 THE PHYSICIANS REPORT | SUMMER 2020

The global pandemic has exposed cracks we’ve known to exist in the healthcare system for decades—the only thing that’s changed is our sense of urgency.

and at what we call the 5 Points of The key to transforming our healthcare incentives across stakeholders, must Healthcare™: Patients, Providers, system to better serve individuals and be in place for sustained change. Purchasers, Payers, and Policymakers. communities is found when we evaluate Cambia Grove’s ethos is that an and optimize these ecosystem elements • Culture: These include the innovative solution—whether a new to support innovation. predominant beliefs and norms that technology, policy, procedure, device, or define and drive behavior in the something else not yet imagined—can • Infrastructure: These include formal ecosystem. There must be an open be championed by anyone passionate or informal arrangements and key and inclusive culture to ensure that about transforming healthcare. Through resources needed to enable innovators the solutions being created match the constant discussion with our innovator to implement their work and execute existing problems. community, we’re able to listen to their their strategies, as well as the right roadblocks and help break down the technical and physical systems to To put these ecosystem elements into barriers to their solutions. connect solutions with end users. perspective, let’s explore their relevance to the COVID-19 response thus far, as Barriers like misaligned incentives and • Incentives: These include both carrots the healthcare system looks to advance missing technical capabilities impact (e.g., financial and non-financial telemedicine services across the country. multiple stakeholders in the healthcare rewards, recognition, and positive ecosystem. Cambia Grove sees these impact), and sticks (e.g., fines and Before the COVID-19 pandemic, barriers within three ecosystem elements: penalties) to drive behavior. The right telemedicine services were offered infrastructure, incentives, and culture. incentives, as well as alignment of to some patients seeking care.

(Continued on page 10) 10

(Healthcare Innovation Ecosystems, continued from page 9)

Discussions were in progress about INFRASTRUCTURE question are financial. Who pays, and the potential benefits of telemedicine, While some organizations are having how much do they pay, for telemedicine but telemedicine was still, for success implementing telemedicine, services? Before COVID-19, payment most healthcare professionals, an there are still huge barriers to parity was an issue. Now, in response afterthought. For those seeking care in expanding these services nationwide. to COVID-19, the Centers for Medicare rural parts of the country, or for those One critical element is the technical and Medicaid Services (CMS) have who found it difficult to physically see a infrastructure available to connect broadened the list of telemedicine doctor, telemedicine was an interesting patients to internet-based telemedicine services available for Medicare option. But overall, it was still looking services. The American Recovery and reimbursement. These 85 telehealth for its place to enter the headlines Reinvestment Act of 2009 included codes are currently temporary, but and secure its value proposition as funding to advance broadband access as they are battle-tested, Medicare the healthcare community looked to to individuals across the country. As a may begin to see an increasing value transform the system. former congressional staffer, I worked in remote visits. Additionally, as we to implement these efforts with our hear of more offices looking to close In Cambia Grove’s last virtual technology partners in Washington their doors because of a lack of in- telehealth panel, providers reported State. Unfortunately, 11 years person visits, it may be asked: are that within a one-month timeframe, after that bill passed, we still have telemedicine services a way to keep their telemedicine usage had spiked. coverage gaps in both rural and urban doctors’ practices afloat? There are too Providers offering telemedicine before environments. While there is no exact many questions without answers around the pandemic saw an increase from 10 count, it is estimated that 41 to 162 incentives for us to give a clear answer to 80 percent, and I expect those rates million Americans are without access at the moment, but as we look to to hold strong. This demand to offer to broadband services. Many of these advance telemedicine, incentives must telehealth services has prompted many people are also in rural communities, be addressed to adequately implement organizations, including the American with limited physical options for these services for the safety of patients Medical Association, to develop accessing care. For us to fully realize and physicians. telehealth implementation guides for the benefit of telemedicine services, administrators, physicians, and patients. advancing a technical infrastructure CULTURE Startups working in this space have been must be part of the equation. Finally, advancing telemedicine will inundated with calls and requests for require a cultural shift. Typically, services to help patients get the care INCENTIVES cultural shifts are the most arduous. they need. You could argue that this was Another part of the equation to advance They take time and trust. As we what the telemedicine industry needed telemedicine services is the incentives. have responded to the pandemic, to show its value and viability. Right now, the largest incentives in the initial cultural shift has been 11 THE PHYSICIANS REPORT | SUMMER 2020

“The crisis has been an unforeseen pressure test that’s unleashed a tremendous urgency to advance telemedicine services.”

MAURA LITTLE, EXECUTIVE DIRECTOR, CAMBIA GROVE

made in record time, as the need has unleashed a tremendous urgency to a state of flux. The COVID-19 crisis outweighed the risk. As we look to advance telemedicine services. It also has shone a light on some of the ways discover how telemedicine will continue proves that if there's a will, there's a our healthcare system is broken, as to be used in the long run, we must way. Healthcare organizations have well as the need to build up a better be sure to establish trust in these been making rapid decisions that foundation in transforming that system. services throughout the Five Points of show that they aren’t as inflexible as As we move forward, it is my hope that Healthcare to continue building out they purport to be, and the system’s we can all work together to support services for those who need them. The problem-solving efficiency in pursuit you and your work to help individuals more we use telemedicine services, of a common goal—to advance and communities through the global the more we will trust this new type telemedicine—has been pursued at a pandemic and beyond. Thank you of interaction. It will also take honest rapid pace. again for your commitment to serve. feedback between all parties involved to We at Cambia Grove invite you to identify the problems we need to solve. The solutions seeing success during the share your thoughts with us—as we My second-grader son taught me that in COVID-19 crisis have been driven by an listen silently—to help transform the order to “listen” you must be “silent” outsized need to support physicians and healthcare system into one that is (the two words contain the same patients in a physically distant world. more person-focused and economically letters!), and it will be important for Certain ecosystem elements must be sustainable for PRall. PR us to listen silently to make sure that addressed to help advance innovations innovations in the telemedicine space like telemedicine to ensure that we Join us in that conversation on Twitter remain focused on what is needed have the technical infrastructure to @CambiaGrove, or learn more at most for the patients and physicians reach those in need, the financial cambiagrove.com. involved. While infrastructure and incentives to pay for healthcare, and incentives are tactically focused, the trust in the new technology to help Maura Little is executive culture shifts are human-focused and ensure its viability and use. Regardless director of Cambia typically lack linear progression. of whether you think telemedicine Grove, a healthcare is a useful innovation, without these hub focused on NO CONSTANT BUT CHANGE ecosystem elements in place, we risk advancing innovation Impactful healthcare innovation doesn’t falling behind on innovations that may in healthcare. Through strategic initiatives happen in a vacuum; it happens in be useful in supporting better health. and community response to a need. We have seen programming, Cambia Grove breaks down the need to connect physicians and As we look back on our original systemic barriers to model sustainable patients in a new way because of the question in seeking to describe the innovation in healthcare. You can find Maura COVID-19 crisis. The crisis has been healthcare landscape, the best answer on Twitter @MauraLittle or email her at an unforeseen pressure test that’s seems to be that the landscape is in [email protected]. 12

Virtual Risk How to Manage Risk and Professional Liability When Adopting New Technology

Healthcare applications for emerging technologies like artificial intelligence, predictive analytics, and wearable monitors represent an exciting new era filled with promise. These technologies have been shown to improve quality and safety for patients and increase capacity for providers, yielding better outcomes at a reduced cost. But their impact on medical liability is less certain.

In a civil tort involving professional liability, a physician’s Since artificial intelligence is new and not yet well understood duty and standard of care would be measured against what a by the general public, Shope says, it’s too early to know reasonable and prudent physician would do under the same how technologies like AI will impact medical liability. “The circumstances. When AI is involved, measuring against an intersection of AI with professional liability lawsuits really established best practice may be more challenging. “We don’t hasn’t been tested in our courts,” she says. “We just haven’t have a lot of history using these technologies for liability, seen enough litigation to understand how AI will impact the which makes it difficult to establish a best practice,” says medical legal system.” risk-management expert Denise Shope, RN. Shope is a team leader with RCM&D Insurance, an independent insurance- That doesn’t mean that organizations can’t manage the risk advisory firm based in Baltimore, Maryland. associated with emerging technologies. As medicine advances 13 THE PHYSICIANS REPORT | SUMMER 2020 into virtually uncharted territory, Shope Using new technology in a clinical we teach them, and who is responsible says that organizations and practitioners setting means spending extra time for teaching them?” need to use a new framework for educating patients and obtaining understanding and managing risk. consent, says Shope. “Anytime you’re DOMAIN 2: LEGAL AND using any type of remote monitoring, REGULATORY CONSIDERATIONS How should healthcare organizations the patient needs to understand what When evaluating the legal risks involved manage the risk that comes with this means and what their role is, and in adopting AI or other emerging adopting new technologies? Carefully, the patient has to consent,” she says. technologies, considerations include thoughtfully, and proactively, according whether the application in question is to Shope. “I think about professional FDA-approved, who owns the data, how liability and medical malpractice in risks will be shared contractually, and terms of components or domains of whether those risks are insurable. risk,” she notes. “I suggest taking an enterprise-wide risk-management Although the medical-liability approach. Consider all the possible implications for AI are still emerging, risks by domains or components, then physicians can rest assured that some determine whether risk controls are in things remain unchanged, Shope place for each identified risk.” “The intersection says. “The plaintiff’s attorney may go after the large healthcare organization Using an enterprise-wide risk- of AI with professional or mega-group practice for vicarious management framework, organizations liability or other actions, knowing that should consider each of the following liability lawsuits really additional buckets of insurance are “domains of risk” when adopting AI available,” she says. “But the burden or any emerging technology. hasn’t been tested in our of proof is still with the plaintiff.”

DOMAIN 1: CLINICAL AND PATIENT- courts. We just haven’t Providers should also know that the use SAFETY CONSIDERATIONS of AI doesn’t change their obligation to Ultimately, advances in medical seen enough litigation view patients as individuals, she notes. technology are designed to improve Though AI offers valuable decision- patient care. So it makes sense to to understand how AI making support to providers, they are begin a risk-management evaluation by the decision-makers in collaboration considering patient safety. Considerations will impact the medical with patients. “AI uses big data to guide in this domain include patient consent decisions, but providers still need to look and understanding, patient selection, legal system.” at patients as individuals,” says Shope. scientific evidence and best practices, “Anytime a physician uses AI in making and the technical competency of a differential diagnosis, it doesn’t DENISE SHOPE, RN, providers and support staff. RISK-MANAGEMENT CONSULTANT, absolve the physician from liability.” AND INSURANCE PROFESSIONAL, Questions to answer may include: RCM&D, BALTIMORE, MD DOMAIN 3: HAZARD CONSIDERATIONS Before adopting any new technology, • What systems or processes need to organizations need to assess how be in place to ensure that patients new systems will perform in extreme understand and consent to remote Finally, organizations need to circumstances, from weather-related monitoring? consider how providers will learn the disasters to power outages to global • How will we safely select the new technology, and how technical pandemics. Planning for a system patients best suited to the use competency will be assessed failure allows for a more comprehensive of this technology? immediately and in the long term. picture of the risks involved in • What does science say about “Another consideration is the technical adopting new technologies and enables the best practices involving the competency of providers, nurses, and organizations to begin developing use of this technology? support staff,” says Shope. “What do contingency plans alongside the rollout they need to be competent in, how do of those technologies.

(Continued on page 29) 14

Medical Advances Then… Healthcare is being transformed by the latest technology to meet the challenges of the 21st century. There’s no doubt healthcare must adapt and evolve to meet the needs of our increasingly high-tech, digitally connected world, but it’s valuable to acknowledge how things used to be done and how far they have come since. This visual chronology highlights some iconic advances in medicine.

Then Now

MERCURY THERMOMETERS INFRARED THERMOMETERS Evolved from principles first used in the thermoscope Modern non-contact and low-contact infrared thermometers— designed by Galileo Galilei in 1593, the mercury thermometer including forehead and ear thermometers and handheld was developed by Daniel Gabriel Fahrenheit in 1714. Credit thermal scanners—allow medical professionals to assess for the first practical medical thermometer goes to English a patient’s temperature in mere seconds. physician Sir Thomas Clifford Allbutt (1836–1925), whose six-inch-long version, introduced in 1867, could record a reading in five minutes.

Then Now

INVASIVE SURGERY LAPAROSCOPIC SURGERY Traditional surgical methods can involve invasive procedures, The use of camera-aided technology via laparoscope has large incisions, and long recovery times for patients. led to advances in surgical procedures—including lap cholecystectomy, lap splenectomy, lap inguinal hernia repair, and more—that have changed peri-operative recovery time and post-operative morbidity, according to Dr. Jordana Gaumond. 15 and Now

Then Now

IRON LUNG MODERN VENTILATORS AND ECMO Developed in 1927 by Harvard researchers to treat polio More compact, modern positive-pressure ventilators—first patients with chest paralysis, an iron lung used a negative developed to supply oxygen to WWII fighter pilots at high pressure ventilator, which—while effective—made treating altitudes—were introduced to medicine in the 1950s. The patients’ other symptoms difficult, due to addition of microprocessors in the 1980s made ventilators its bulky design. even more responsive to individual patient symptoms. On the cutting edge today: extracorporeal membrane oxygenation (ECMO), which, according to ECMO specialist Joseph Deng, MD, can oxygenate the blood outside the body, keeping patients alive for days or weeks while their heart and lungs recover from traumatic injury.

Then Now EARLY CRASH CARTS MODERN CRASH CARTS First developed in the mid-1960s, early “crisis carts” Modern crash carts are more high-tech, with everything were simple wooden carts on wheels stocked with a clipboard, nurses and physicians need to respond to a coding patient— items needed for intubation, and a few essential lifesaving including a defibrillator, IV fluids and tubing, manual medications. resuscitators, an oxygen tank, a CPR board, and lifesaving medications like Narcan, Epinephrine, and nitroglycerin. [NOTE: There seem to be discrepancies about whether the cart was invented by Anita Dorr, RN, or John J. Nobel, MD. See: https://en.wikipedia.org/wiki/Crash_cart, but also https:// www.workingnurse.com/articles/Anita-Dorr-Inventor-of-the- Crash-Cart.] 16

Medical Advances Then…

Then Now

THEN: STETHOSCOPE NOW: HANDHELD ULTRASOUND DEVICES Invented by Parisian physician René Laennec in 1816, the While stethoscopes still allow medical-care personnel to better stethoscope has played a foundational role in the development hear patients’ heartbeats and assess their lung function, new of modern medicine over the past two centuries, and has even handheld ultrasound technology lets doctors “see” not only come to symbolize the profession itself. the heart, but also the lungs and other organs immediately, advancing their diagnostic capability. While the cost of this technology is still high, medical schools are already training new students in how to adopt it in their practices.

Then Now

THEN: EARLY PROSTHETICS NOW: 3D-PRINTED PROSTHETICS The first confirmed use of a prothesis dates to 3000 B.C., with Thanks to 3D printing advances, modern prosthetics are an elegant prosthetic wooden toe found on a mummy buried becoming cheaper and easier to make. These lightweight, near Luxor, Egypt. By the early 1500s, refined iron arms—like advanced prosthetics—which can be made in a range of colors the one owned by Götz von Berlichingen—had been developed. and styles—have been a particular boon to pediatric patients, The design of modern prosthetics was spurred by increased since they can be easily replaced as children’s limbs grow. need following both the Civil War and World War II, though pre- 1970s limbs were often made of heavy plastics and involved leather straps that were hard to fit and maintain. 17 and Now

Then Now THEN: NURSES ON HORSEBACK NOW: TELEMEDICINE Championed by the likes of Mary Breckinridge—founder of the Today, patients have immediate access to healthcare providers Appalachians-based Frontier Nursing Service in 1925—rural from across an array of disciplines—from primary care to healthcare once required medical professionals to ride on specialists and mental-health counselors—in the comfort horseback to remote areas of the country. of their own homes, no matter where they live, thanks to advances in telemedicine and the increased availability of apps, texts, and face-to-face calling technology.

Sources: https://frontier.edu/about-frontier/history/ https://en.wikipedia.org/wiki/Medical_thermometer https://www.rivier.edu/academics/blog-posts/5- https://en.wikipedia.org/wiki/Frontier_Nursing_Service medical-innovators-who-changed-nursing/ https://en.wikipedia.org/wiki/Medical_thermometer https://en.wikipedia.org/wiki/Stethoscope https://onlinelibrary.wiley.com/doi/pdf/10.1197/ https://academic.oup.com/qjmed/ aemj.10.7.798 https://www.tmc.edu/news/2018/04/solutions-could- article/95/4/251/1562440 a-handheld-ultrasound-replace-the-stethoscope/ https://www.aclsmedicaltraining.com/crash-carts/ https://www.rcpe.ac.uk/sites/default/files/ https://learningenglish.voanews.com/a/will-new- vol28_1.1_7.pdf https://www.youtube.com/watch?v=Xf_O9RaUs0E devices-replace-the-stethoscope-/5137681.html https://www.tegam.com/advantages-of-contact- https://www.huffpost.com/entry/stethoscope-replaced- https://en.wikipedia.org/wiki/Prosthesis ultrasound-devices_n_4658869 thermometers-over-non-contactinfrared- http://unyq.com/the-history-of-prosthetics/ thermometers/ https://interestingengineering.com/10-medical- inventions-of-all-time-that-changed-the-world https://interestingengineering.com/3000-year-old- https://www.ncbi.nlm.nih.gov/books/NBK263237/ wooden-toe-worlds-oldest-prosthetic https://www.youtube.com/watch?v=Xf_O9RaUs0E https://www.thoughtco.com/history-of-the-iron-lung- https://share.upmc.com/2015/03/timeline-prosthetic- respirator-1992009 https://www.workingnurse.com/articles/Anita-Dorr- limbs-years/ Inventor-of-the-Crash-Cart http://broughttolife.sciencemuseum.org.uk/ https://www.amputee-coalition.org/3d-printed- broughttolife/techniques/mechanicalventilators https://www.jenonline.org/article/S0099- prosthetics-kids/ 1767(00)90010-2/abstract https://www.ncbi.nlm.nih.gov/pmc/articles/ [Dr. Jordana Gaumond correspondence by email] PMC5467868/ https://www.workingnurse.com/articles/Anita-Dorr- https://commons.wikimedia.org/ https://nypost.com/2020/04/01/advancements-in- Inventor-of-the-Crash-Cart breathing-devices-for-wwii-fighter-pilots-paved-way- https://www.acls.net/acls-crash-cart.htm for-modern-ventilator/ https://www.herkentucky.com/blog1/mary-breckinridge [Dr. Joseph Deng interview] 18

HEALTHCARE’S DIGITAL REVOLUTION How Pop Culture’s Tech Tools Are Impacting Patients and Providers A decade ago, patients with a suspected Instead of presenting patients with their health data, providers are now fielding questions about health data that patients bring sleep problem had to spend a night in a in with them. “Patients are increasingly bringing in their health data from apps and wearable devices,” says sleep specialist and sleep lab, then wait to visit their physician psychiatrist Alex Dimitriu, MD, founder of Menlo Park Psychiatry & Sleep Medicine in Menlo Park, California. “I discuss electronic to review a readout of their sleep stages, health data with patients every day.”

night awakenings, and snoring patterns. And poor sleepers aren’t the only ones using personal health- Today, patients can wake up, roll over, tracking technology. These days, most pregnant women have at least one pregnancy app on their phone offering health tracking, and open a sleep-tracking app on their education, and support. “I would say most of my patients use a pregnancy-tracking app, and often a couple of apps at once,” phone to pore over sleep metrics. says Kathleen Pizzolatto, CNM, ARNP, of CHI Franciscan Health in Tacoma, Washington. 19 THE PHYSICIANS REPORT | SUMMER 2020

“In 2009, blogs were fairly new, and the prevailing view in healthcare was, ‘No, don’t look on the internet for health questions, come to see your physician.' That was a completely errant view that devalued patient experience and patient education, and presumed that the only way to get information was from your own physician.”

WENDY SUE SWANSON, MD, CHIEF MEDICAL OFFICER, BEFORE BRANDS

Many people have more access to of the Quantified Self (QS) movement, she says. “That was a completely errant health data than ever before, thanks says Wendy Sue Swanson, MD, chief view that devalued patient experience to sophisticated sensors embedded in medical officer for Before Brands and patient education, and presumed everything from smartwatches to socks. (maker of Spoonful One), a company that the only way to get information was Per a 2019 Gallup poll, about one in dedicated to the prevention of from your own physician.” three Americans reports tracking their childhood food allergies. Founded in health data using a phone or tablet app. 2007 by Gary Wolf and Kevin Kelly, As patients sought and used more of What does this mean for providers as the QS movement supported individual their own health data, healthcare had they manage their patients’ questions access to health and personal data. to change. “We saw that people were and expectations, debunk myths, and getting information online anyway, help patients navigate the complexities In 2009, Swanson began the nation’s from their friends and from companies of our digital world? first hospital-based health blog as Seattle marketing to them,” says Swanson. Mama Doc, a role she held through “Widespread misinformation about QUANTIFYING PERSONAL- 2019. “In 2009, blogs were fairly new, vaccine safety is one example. Parents HEALTH DATA and the prevailing view in healthcare was, were learning about vaccines online from The explosion of interest in personal ‘No, don’t look on the internet for health their friends, not from their doctors.” health-tracking represents the growth questions, come to see your physician,’” (Continued on page 36) 20

Cyber Attacks on the Rise Practices and Hospitals Face Increasing Threat

As our world becomes increasingly high-tech and digitized, the threat of cybercrime within healthcare grows. Health records remain a top target for criminals.

Yet many practices, clinics, hospitals, CASE #1 CASE #2 and health systems still aren’t Employees of a hospital discovered A medical group experienced a Ryuk adequately prepared or covered for that their email accounts were ransomware event. Ryuk is a type of medical-professional liability, or even for not accessible. The hospital’s IT crypto-ransomware that uses encryption product liability such as that which is department investigated and discovered to block access to a system, device, used with emerging technologies. that a ransomware attack had infected or file until a ransom is paid. Ryuk is 70 servers and 600 workstations. The often dropped on a system by other Throughout 2019, NAS (now known hospital had to close operations for malware, or gains access to a system as Tokio Marine HCC—Cyber and two business days and suffered various by remote desktop services. The event Professional Lines Group) found that losses due to the event. resulted in the shutdown/compromise of cyberattacks continued to be of primary the medical center’s computer system, concern to business leaders in all The hospital’s cyber-liability insurance which included multiple desktops and sectors. The increased sophistication covered: servers as well as backup systems. The of cyber criminals, a growing base of • IT forensic consultants—Consultants malicious actor made a ransom demand connected devices (a.k.a., “the attack were retained to immediately address of more than $1.2 million. Attorneys surface”), and human vulnerability all the ransomware attack, secure data, for the insured attempted to negotiate contribute to a business environment rife investigate whether any patient- the ransom down, but the hacker wasn’t with cyber-security risk that continues to health information was compromised, willing to negotiate. be exploited by criminal actors. and rebuild the hospital’s network. • Business interruption and income Additionally, legal counsel confirmed In 2019, they saw that the activity loss—Several surgeries had to be that the medical group’s system could (and expense!) of cyberattacks on cancelled, resulting in loss of income. not be restored from the encrypted their policyholders continued to shift • Data recovery—Several employees backup servers. The medical group, from “data breach” to “cybercrime.” had to work overtime to re-create lost therefore, paid the $1.2 million While phishing attacks, fraud, and data from backup. ransom, but was reimbursed under its ransomware are all on the rise, there • Ransom amount—The hospital Cyber Extortion coverage. After paying was a decline in data breaches, paid the ransom demand to restore the ransom, the insured received the exposure of personal information, and system access. decryption key and was able to regain related notification expenses. access to its systems and data. Total expenses: $570,000 21 THE PHYSICIANS REPORT | SUMMER 2020 COVID-19 Relief Packages If there were a theme for 2019 cyber 2. Train Employees claims, as told by Tokio Marine HCC— Employee training is another key part Trigger Uptick In Scams Cyber and Professional Lines Group, it of achieving HIPAA compliance and would be the growth of phishing attacks mitigating associated privacy and Congress recently passed a number on small-to-midsized businesses. security risks. HIPAA rules require that of relief packages, and criminals Ransomware and financial-fraud claims an organization’s workforce be properly are trying to scam victims out of were up from 2018 across the board, trained on the HIPAA Privacy, Security, their relief funds. Criminals use and largely initiated in response to and Breach Notification Rules. email, SMS text, and robocalls to phishing attacks. Though the larger contact victims. Log onto our cyber cyber incidents at Facebook, Citrix, and 3. Implement Policies and Procedures center at https://bit.Ly/3dqwmbp Capital One grab the headlines, the HIPAA’s Privacy and Security Rules to learn more about COVID-19 rampant attacks on small and midsized require healthcare organizations to have scams and prevention, COVID-19, businesses are devastating, as most data-security policies and procedures and HIPAA: get tips on how to use SMBs don’t have sufficient resources to addressing a multitude of risks. Zoom securely; view webinars on prepare or defend themselves. A recent Inadequate policies and procedures protecting your cyber security in Fundera study reports that “three out are a frequent violation cited in HIPAA uncertain times; and more. of four small businesses don’t have the enforcement actions. personnel to address IT security.” • Do not immediately rebuild your 4. Manage Vendors Appropriately system (you might destroy important Whether through wire transfers, Vendor risks have become one of forensic evidence). fraudulent payments, or unauthorized the top data-security concerns for • Regularly back up all critical data, access to financial accounts, cybercrime healthcare organizations. As OCR and store it offsite. activities were up significantly on all holds business associates and sectors of business in 2019. covered entities liable for HIPAA WHAT TO LOOK FOR WHEN compliance when it comes to vendor CONSIDERING CYBER- relationships, it’s important for LIABILITY INSURANCE HEALTHCARE healthcare organizations to have a Not all insurance programs are CYBERCRIME ACTIVITIES vendor-management program in place created equal, so it’s important to +254% to maintain control of their business compare policies. You are at risk from associates processing PHI. simple negligence, rogue employees, unencrypted data, and outsourced 5. Prepare an Incident Response Plan information technology. And that The best way to handle a cyberattack means you need to protect all of your is to be prepared well in advance. billing information, such as credit card When responding to a cyber incident, numbers, addresses, bank information, 2018 2019 critical decisions must be made within insurance information, Social Security a condensed timeframe. Notification numbers, employee information, and PROTECTING YOUR ORGANIZATION deadlines—the most notable of which basically everything in your medical 1. Conduct a Risk Assessment is the 60-day notification deadline to records. Physicians Insurance includes Risk assessments and analysis are the OCR and affected individuals—apply a basic level of coverage as part of its foundation to mitigating the above to all healthcare organizations. standard physician and clinic policies. risks and preventing an unpleasant Higher limits for increased protection experience with the U.S. Department Any mistakes can be costly and are also available. of Health and Human Services Office have a lasting impact. for Civil Rights (“OCR”). Failure to If you have questions about cyber conduct a risk analysis is the most If you suspect ransomware… security or other risk-mitigation common HIPAA violation found during • Isolate the infected computer(s) from resources, log onto our website at the OCR’s investigations. Analyzing your all networks (by unplugging network phyins.com and go to the Cyber Center organization’s risks is the starting point cable and/or turning off Wi-Fi). portal. To report a cyber breach or to determining a proper information- • Take a picture of the ransomware suspected breach, contact our Claims security program and appropriate risk- message (if possible). Department at 800-962-1399.PR PR mitigation measures. 22

Are Electronic Health Records Causing Practitioner Information Overload? When the Health Information Technology In the years since, the shift from manila folder–based patient records to cloud-based EHRs has been sweeping. for Economic and Clinical Health By 2017, nine out of 10 office-based physicians had adopted (HITECH) Act was signed into law in 2009, an EHR platform, as had 99 percent of large hospitals (defined as those hospitals with more than 300 beds)—plus 93 percent of small and rural hospitals—across the U.S., according to the stimulus package’s key goal was the Office of the National Coordinator for Health Information encouraging healthcare providers to trade Technology. [statistic link: https://bit.ly/3d5vvlZ] The many advantages of EHRs, according to proponents, in their pen-and-paper notes in favor of include storage ease, streamlined sharing among a patient’s various medical providers, the ability to send e-prescriptions, online Electronic Health Records (EHRs). and increased access for patients to their own health records. 23 THE PHYSICIANS REPORT | SUMMER 2020

However, a growing number of national “Sorting through all that to find the surveys suggest that not all physicians notes that summarize the patient’s are pleased with the usability of their “Sorting through history is very time-consuming and current EHR platform. somewhat difficult, because you never all that to find the know where the meat of the matter will The Harris Poll conducted a 2018 notes that summarize occur,” McClellan says. survey of more than 500 primary-care physicians (PCPs) on behalf of Stanford the patient’s history Further, he says, at times the EHRs Medicine and found that while the is very time-consuming may present patient health status as majority of respondents felt EHRs had a jumble of line-item entries, without generally improved their patient care, 40 and somewhat “true prioritization of key information,” percent of participating PCPs saw more meaning that pertinent patient challenges than benefits to EHRs. difficult, because information—such as the results of a you never know where stress test four months prior—may get Further, 59 percent of survey lost in the shuffle. respondents—including many physicians the meat of the matter who acknowledged the overall value Even distilling from among legitimate of EHRs—voiced a concern that the will occur.” health details in EHRs in order to platforms are in need of a “complete identify data that pertain to the overhaul” to improve their ease of use. DAVID MCCLELLAN, MD, patient’s immediate medical situation FACEP, EMERGENCY-MEDICINE can be tricky, especially in a fast-paced PHYSICIAN, PROVIDENCE This sentiment was echoed in a Yale- ED environment. SACRED HEART led study published in the March 2020 MEDICAL CENTER, Mayo Clinic Proceedings, which found SPOKANE, WASHINGTON “If somebody comes in for abdominal that a cross-sectional survey of U.S. pain, I don’t really need to know physicians—representing all specialty about their neurologic history or their disciplines—gave EHRs a system- musculoskeletal history,” McClellan usability scale (SUS) grade of “F.” This says. In that situation, “I only was in contrast to higher SUS scores must be made quickly, as is typically the predominantly need to know what for other modern technology platforms, case in the emergency department. their previous cardiac history and including Google (score of “A”); Amazon gastrointestinal history is, along (“B”); and Microsoft Word, DVRs, and “One of the banes of our existence in with a general sense of whether GPS (“C”). emergency medicine is that electronic they’re somebody who comes in medical records have a huge capability frequently or somebody who hardly The study’s authors found a statistically for historic information,” McClellan ever goes to see the doctor.” significant link between poor EHR says. “But the information I need to usability and physician burnout, noting take care of a patient well—balancing A TIERED APPROACH TO that previous studies have shown that the need for expeditious decision- INFORMATION GATHERING physicians now spend an average of one making and expeditious interventions— Essentially, McClellan adopts a three- to two hours on EHRs for every hour can be very difficult to pull out of the tier approach to health-information spent in direct contact with patients. electronic medical record, because gathering. The primary data source, there is so much in it.” in his thinking, should usually be the INFORMATION OVERLOAD patients themselves. By asking key David McClellan, MD, FACEP, an McClellan observes that a given patient’s face-to-face questions about patients’ emergency-medicine physician at EHR may have pages upon pages of medical history and what’s brought them Providence Sacred Heart Medical entries in the “Notes” tab for a single in to the ED, McClellan gets quick and Center in Spokane, Washington, agreed calendar year alone. Often, he says, important insights into their presenting that navigating a patient’s full medical these describe past status updates, such medical condition. history via an EHR can be challenging— as “returned patient’s call,” which aren’t especially when treatment decisions essential information for treating their Rather than trying to navigate through current health situation. a patient’s potentially dense full EHR,

(Continued on page 32) 24

PAVING THE PATH FOR GREATER EHR INTEROPERABILITY To some degree, you could liken aspects of the existing health IT landscape to a railway without connections.

While healthcare providers and hospitals have widely embraced and executives. “Due to several factors, we didn’t achieve the electronic health records (EHRs) and other online information level of interoperability between systems that many had hoped portals over the last decade, communication between for. It’s almost like everybody bought a rail car, but the rail providers—and at times, with patients—remains a challenge. connections weren’t in place.”

“We had practices going out and buying their own technology, NEW RULES BRING HISTORIC CHANGES and many of us thought that would solve a lot of the problems,” In March, the U.S. Department of Health and Human Services says Robert M. Tennant, director of the health information (HHS) issued two groundbreaking final rules that will reshape technology policy at Medical Group Management Association, a how healthcare data is organized and maintained. The goal: leading industry organization for medical-practice administrators to address lingering, troublesome barriers to interoperability 25 THE PHYSICIANS REPORT | SUMMER 2020 in healthcare IT while at the same time demographic information, insurance giving patients easier access to their information, allergies, chronic illnesses, own healthcare information. medications, and other critical healthcare data. As a continued effort to implement the 21st Century Cures Act, the By streamlining this essential two rules “mark the most extensive information into what Tennant calls healthcare data-sharing policies the a standardized “USCDI snapshot,” federal government has implemented,” healthcare providers can easily according to an HHS statement. “Unfortunately, data assess the most significant aspects The rules will be enforced beginning of a patient’s record without being sometime in 2021, though the silos continue to burdened with “an 800-page full-record COVID-19 pandemic could potentially PDF, which is of almost no use to a push back the timeline. fragment care, burden provider,” he says. (See “Information Overload,” page 22.) Taken together, the “ONC’s Cures Act patients and providers, Final Rule,” issued by the HHS Office and drive up costs “The USCDI represents the minimum of the National Coordinator for Health that the provider has to share to Information Technology (ONC), and the through repeat tests. avoid being charged with information “Interoperability and Patient Access blocking,” Tennant adds. “It’s the Final Rule,” issued by the Centers for The days of patients baseline for the first 24 months. I think Medicare & Medicaid Services (CMS), it’s an important step forward, because provide patients with more control being kept in the dark now everybody knows what to expect. over their own health records and The IT vendors know how to incorporate establish new rules to prevent so-called are over.” it as standardized data, and it should “information blocking” practices within make care coordination much easier.” healthcare systems. SEEMA VERMA, CMS ADMINISTRATOR APPS GIVE PATIENTS CONTROL “The information-blocking rule The move to streamline data and basically outlaws the blocking of data improve EHR information-sharing while outlining a number of permitted across providers is key. But Tennant exceptions,” explains Tennant. health information—including allergies, feels that the real “game-changer “Providers are no longer permitted to current medications, and other crucial in healthcare” will be in the hands keep their healthcare data in a silo. If a clinical data—are presented. The goal: of patients themselves—via their patient requests it, or another provider easing operability and legibility across smartphones. requests it, then by law they must now various EHR vendors and healthcare share that data. That’s a big change.” information exchanges. Application programming interface (API) technology—the tech behind “Unfortunately, data silos continue to The ruling requires that EHRs provide popular apps like Expedia or Uber— fragment care, burden patients and critical patient-care information has revolutionized the consumer providers, and drive up costs through using standardized data classes as world, Tennant says, and the current repeat tests,” CMS administrator Seema outlined by the U.S. Core Data for thinking is that it can likely do the Verma said in a release announcing the Interoperability (USCDI). The goal is to same for healthcare. new rules. “The days of patients being ensure that critical patient information kept in the dark are over.” is understood and made accessible to As a result, the new rules will require providers across many care settings. that ONC-certified EHR vendors make STANDARDIZING patient-health information available via INFORMATION-SHARING Essentially, the new rules help API technology. This means that patients One feature of the ONC Final Rule codify and standardize reporting will eventually be able to have their aims to standardize and streamline the protocols for the key elements in a information sent to their smartphones ways that critical facets of patients’ patient’s medical record—including via the app of their choice.

(Continued on page 39) 26 Reflections from Frontline Heroes

At this unprecedented time of challenge and crisis in The following are reflections from a few of our frontline healthcare, we recognize all our members and other healthcare heroes on their experience, and specifically—knowing that professionals serving on the frontlines of the pandemic, for the next pandemic is a matter of “when” rather than “if”— their immense sacrifice and undaunted dedication. We thank what lessons they’ve learned during the pandemic that you for your good clinical judgment, and your consistent they will carry forward. prioritization of patient health and safety above other concerns.

Tim Silbaugh, MD (Center), Emergency Medicine, AK Emergency Medicine Associates, Providence Alaska Medical Center, Anchorage, Alaska

As an emergency-medicine physician working through could be if our country embraced world-class excellence in the COVID-19 pandemic, I more fully value the outstanding medical care. Even with dedicated physicians, abundant cooperative spirit of our frontline medical providers. Nurses, financial resources, and the most advanced medical doctors, paramedics, and techs work extra shifts, providing technology, the U.S. has underperformed most nations in direct care in stifling masks, gowns, and respirator hoods. our response to COVID-19, with more cases and deaths than The local and national hospital administrators apply lessons any other nation. To be prepared for the next pandemic, learned in the hot zones of infection to rapidly create new the United States needs universal healthcare, accessible isolated treatment zones and care protocols. I am equally to all Americans, and national leadership that respects, aware how much better our healthcare in the United States understands, and supports the medical sciences. 27 THE PHYSICIANS REPORT | SUMMER 2020

Alexander R. Sellman, RN, Emergency Department, Providence Alaska Medical Center, Anchorage, Alaska

I never thought that I would be qualified for next pandemic, breakout, or mass-casualty incident was right emergency nursing. Then I realized that it was not my around the corner. When the COVID-19 pandemic hit, I knew clinical understanding or experience that prepared me for that the key was constant readiness and confidence in my the emergency room, but my heart. I knew I would likely ability to serve. My training gave me the confidence to address encounter great tragedy and uncertainty on the frontlines the many changes that came our way. For future pandemics or of healthcare, but I was all in. I am here for one thing—to surges, our greatest challenge may be addressing the fear and help. I prepared with our Highly Infectious Treatment Team uncertainty that COVID-19 has created in patients, families, here at Providence Alaska Medical Center knowing that the and healthcare workers.

As a regional treatment center for emerging special pathogens, we conduct quarterly training exercises. We saw the results of this training in our preparation for COVID-19. Understanding surge planning, PPE donning and doffing, and clinical workflows for a respiratory pathogen was extremely valuable in our response and allowed us to adjust our plan as needed, based on the specifics of the COVID-19 pandemic. Knowing the value of that training and translating it into a state of preparedness will shape our approach moving forward. It has been a privilege to take part in the interdisciplinary teamwork and commitment that has been so evident in our COVID unit. Watching some of our Christa Arguinchona, RN, Special Pathogens patients walk out of the hospital and be Unit (SPU) manager, Providence Sacred Heart reunited with their families, knowing how ill they were, has been highly Medical Center, Spokane, Washington rewarding and a tribute to the sacrifice and commitment of our amazing team.

(Continued on page 28) 28

(Frontline Heroes, continued from page 27)

Luke Parr, MD, Critical Care, Legacy Medical Group—Emanuel, Portland, Oregon

I work for Oregon Anesthesiology Group (OAG) and and are on the path to recovery. From top to bottom, Legacy’s serve on one of Legacy Health’s Critical Care and ECMO clinical staff, nonclinical staff, and leadership, as well as my (Extracorporeal Membrane Oxygenation) teams. ECMO is colleagues at OAG, have been incredibly brave. They choose an external heart-lung bypass machine for people who are to show up at work every day, knowing they’re risking their likely to die even on conventional life-support systems, such own health and that of their families, to take care of patients as mechanical ventilators, and provides a last-line form of with COVID-19. But this has been hardest for the patients’ therapy. During this pandemic, I’ve traveled to hospitals in families, with visitation severely restricted. Still, in the a multistate area to care for COVID-19 patients as young as hardest of times, the families I’ve worked with have responded 19 and as old as 61, many of whom have come off ECMO with understanding and compassion.

Photo by Beth Nakamura/The Oregonian

Jason Wells, MD, Pulmonary Critical Care, The Oregon Clinic, Portland, Oregon

My biggest lesson has been the importance of impressed with the whole healthcare system, from the people preparedness and planning for pandemics ahead of time so who clean the rooms to the hospital administrators. Everyone that we’re not creating protocols from scratch. If there is a has put in extraordinary effort; it’s very heartening to see bright spot to come out of this, it’s that we are now better people put themselves on the line in order to care for patients. prepared to handle surges, and have plans in place for future Until something like this happens, you don’t really know how pandemics or any new COVID-19 surges we may experience the system will react, and the response of our healthcare this fall and winter. Throughout this experience I’ve been teams has been remarkable to see. 29 THE PHYSICIANS REPORT

“There’s a risk inherent to adopting a technology that doesn’t have a strong business case, because you’re using limited resources for something that doesn’t have a strong ROI.”

DENISE SHOPE, RN, RISK-MANAGEMENT CONSULTANT, AND INSURANCE PROFESSIONAL, RCM&D, BALTIMORE, MD

(Virtual Risk, continued from page 13) Considerations in this domain include exciting, to be sure. But organizations A proactive risk assessment helps environment support, maintenance should be wary of adopting it without healthcare organizations of any size agreements, capacity management, first considering how it aligns with determine whether adopting a new and contingency plans for business their business strategy, says Shope. technology is a safe, smart financial interruptions. Organizations need to go Managing the risk associated with investment. “Providers in small group through scenario-based risk assessment adopting new technology requires practices should consider whether to anticipate or predict uncertainty, careful consideration of the they have the resources to help with a says Shope. “Basically, this means organization’s strategic priorities. proactive risk assessment,” says Shope. anticipating scenarios like pandemics,” “If they don’t, providers can check with she says. “What happens if we have a Before taking on new tech, Shope says, their insurance broker, who can do that surge in demand? Technology is great organizations should understand how sort of risk assessment for them.” when it works, but organizations need the new technology aligns with their risk to have a multidisciplinary team to help appetite. Smaller group practices may Another consideration in this domain predict where the failures will be.” have a lower tolerance for risk than larger that Shope points out is insurance groups or hospitals with deeper pockets, coverage: providers should work with DOMAIN 4: TECHNICAL for example. And in some cases, the insurance professionals who understand CONSIDERATIONS potential ROI of a new technology may the risk involved in adopting new Before integrating new technology into warrant greater risk. technology. “Physicians and their clinical settings, organizations need to insurance brokers must work together think outside the exam room to include Evaluating how a particular technology in managing the new risks involving non-clinical staff and technological fits into an organization’s approach to risk the use of AI,” she says. “Insurance support. Who will support and maintain helps manage vulnerabilities, says Shope. professionals need to understand the the technology, repair it when it “There’s a risk inherent to adopting a risk. No one wants to be left uninsured fails, ensure interoperability between technology that doesn’t have a strong because of insurance-contract language systems, and safeguard the privacy and business case, because you’re using or exclusions in the insurance policy, so security of patient data? limited resources for something that coverage is critical.”PR PR doesn’t have a strong ROI,” she notes.

Another consideration is whether Denise Shope, RN, adopting new technology leaves the DOMAIN 6: FINANCIAL MHSA, ARM, CPHRM, organization vulnerable to cyberattacks. CONSIDERATIONS can be reached at Organizations need to have a plan in Finally, a risk assessment should [email protected]. place for maintaining cyber hygiene include a close look at the Shope is a risk- to minimize interruptions to patient organization’s financial strengths, management consultant care in the event of a data breach or weaknesses, and goals. Does the with RCM&D who began cybercrime, says Shope. (See "Cyber organization have the financial her 25-year career Attacks on the Rise," pg. 20). resources to invest not only in the in healthcare as a registered staff nurse at Geisinger Medical Center in Pennsylvania. new technology, but in the training, She is past president of the American Society DOMAIN 5: STRATEGIC technology support, and contingency for Health Care Risk Management (ASHRM), planning it will require? CONSIDERATIONS and she received ASHRM’s Distinguished Emerging technology like AI is Fellow Award in 2018. 30 Claims Severity and Pressures on Premiums

In 2014, a 16-year-old woman For the last several years, the medical severity of claims beginning in 2016. In professional liability (MPL) industry has the four years between 2016 and 2020, who was 25 weeks pregnant was been experiencing increased financial the number of claims settling for more hospitalized with severe preeclampsia, pressure in response to the changing than $1 million and $2 million jumped a serious complication characterized healthcare system and social inflation. 100% and 300% respectively. One key by high blood pressure. Her physicians In fact, since 2013 there have been a contributor to this marked increase is contended that they advised her to total of eight medical malpractice cases social inflation. undergo an emergency C-section, which exceeding $100 million, including she refused. The patient claimed that the aforementioned case; six of these The term “social inflation” is a catchall doctors told her that the baby would cases have been in the last two years phrase utilized in the insurance industry, die or suffer brain damage if she had a alone. This increase in the frequency but in general, it refers to the increase C-section. Whichever the case, when the and severity of claims, along with in loss costs due to shifts in distrust of baby was delivered vaginally days later, it an extended period of downward corporations, juror compositions, and suffered severe damage. The mother filed competitive pressure on premiums, is effective plaintiff-attorney strategies. a lawsuit, and in June of 2019, the case prompting needed adjustments across went to trial. After the parties rested, the the entire industry. The recent wave of distrust of jury came back in just two and a half corporations makes it easier for a jury hours with a staggering verdict in the Locally, in the Pacific Northwest, to believe that a faceless corporation amount of more than $229 million in Physicians Insurance’s experience during with ample assets or insurance should favor of the plaintiff—the largest medical- 2001 to 2019 also shows an increase in be held responsible. Plaintiff attorneys malpractice verdict ever recorded. Claims Activity Impacting Rates and Premiums—Increasing Frequency of Severity—PI Data Paid Indemnity in Closed Year 9.0% 2.7%

8.0% 2.4%

7.0% 2.1%

6.0% 1.8%

5.0% 1.5%

4.0% 1.2%

3.0% 0.9%

2.0% 0.6%

1.0% 0.3%

0.0% 0.0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 5 Years Ending Source: Physicians Insurance Company— PI1007 Claims Report Claims >=$1M Claims >=$2M 31

Peer Comparison Underwriting Expense Ratio THE PHYSICIANS REPORT | SUMMER 2020 26% 25% 25% 24% 24% use this distrust in corporations to alter 24% 23% 21% 21% how they file pleadings in malpractice 20% 20% 21% 19% 19% cases, purposely naming only the 18% 16% 17% 17% healthcare entity as the defendant 15% 15% instead of individual providers responsible for the care.

Social inflation is also amplified by a new composition of juries. As the Millennial generation become jurors, 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 their experience and mindset differs MPL Composite Physicians from those of prior generations. Plaintiff attorneys who want the jury to “send a harm, to claim damages if they had the The healthcare and medical professional message” will appeal to this generation’s chance of a better outcome and the liability industries have gone through broad mistrust in authority and paint provider’s negligence eliminated that significant changes in the past five experts as “authority figures,” hoping chance. Oregon also has a cap which years. Well before the advent of the jurors will reject their testimony on has been heavily contested over the COVID-19 pandemic, the MPL industry prejudicial grounds. last few years. Since 1987 the cap for was experiencing economic shifts and wrongful death and bodily injury has healthcare was reshaping itself through Another factor contributing to overall been heavily contested in the courts consolidation and employment models. increases in claims is the cost to defend and in the legislature, with the plaintiff While PI has kept base rates flat as them. The cost to defend a claim in the trial bar aggressively seeking to increase long as possible by closely managing Pacific Northwest increased by nearly or eliminate the cap for both wrongful expenses and trying to offset increases 60% since 2007. This means that not death and bodily injury. through other means, claim costs only are claims resolving for more and continue to rise due to influences like more indemnity (the sum of money paid Ever since Physicians Insurance wrote social inflation and plaintiff-attorney out in the claim), but it is also costing its first policy in 1982, its focus has tactics. As a mutual company owned more to defend them. always been on protecting its members. by and operated for the benefit of our As a result, Physicians Insurance members, we plan to continue insuring, And while there are many factors that regularly takes cases to court. Our defending, and supporting our members cause the value of cases to go up, the defense verdicts at trial show that this well into the future. This will likely result legislative and judicial environments strategy, though more expensive than in rate adjustments in the future, but within the Pacific Northwest also have just settling a case, is a consistently they will always be made in keeping with a significant impact. Meaningful winning one for members. And, though our commitment to keep administrative liability reform has eroded over the PI may outspend its composite peer and operating costs in line with our years; last year saw the introduction of set in defending claims, the company historic low levels.PR PR a new class of beneficiaries in wrongful- consistently underspends its peers in death cases in Washington, allowing administration and operating costs. the parents and siblings of deceased Peer Comparison Loss and LAE Ratio parties to bring suit even if they don’t 85% 84% live in the U.S. and aren’t financially 83% 80% 82% 82% 81% 81% dependent on the deceased. 74% 75% 75% 71% 70% 69% 66% 66% 66% 60% 60% In Oregon, as a result of a recent 58% Supreme Court case, there is now a new cause of action in malpractice claims allowing plaintiffs to claim the theoretical “loss of chance of a better outcome” as an injury. These claims are unique in that they allow patients, instead of claiming actual physical 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Composite Physicians 32

“At the end of the day, the overriding principle and focus has to be on giving good patient care.”

MIRANDA AYE, JD, PARTNER, JOHNSON, GRAFFE, KEAY, MONIZ & WICK LAW FIRM, SEATTLE, WA

(Electronic Health Records, continued from page 23) generally speaking, be reason enough to find an EM physician guilty of medical McClellan generally then scans his fast-paced nature of their practice—in malpractice. patients’ summation document— the unenviable position of experiencing typically a two-page printout that information overload. When doctors face a potential medical- provides key details about the reason negligence claim, their actions for their visit, their current medications When asked whether he feels that the and inactions are weighed in legal and known allergies, a brief medical advantages of EHRs outweigh their proceedings against “what a reasonably and surgical history, and current vital challenges, McClellan says, “I’m probably prudent physician in that same field signs. This document serves as a second in the minority on this, but I would come would do in the same or similar line of information, able to verify and down on the slight negative side.” circumstances, with what was known expand on the patient’s self-reporting. at that time,” according to Aye. Finally—when necessary—McClellan LIABILITY CONSIDERATIONS refers to the full EHR to find pertinent But what are the legal ramifications—if Thus, the standard of care for reviewing lab results, specialist's-visit notes, or any—of an EM physician admitting a patient’s EHR in emergency other information relevant to potential that, when seconds matter, it may be medicine may be different from what’s ED interventions he may order. impossible to scan a patient’s complete expected of a primary-care physician or EHR before devising a treatment plan? specialist, both of whom work in less Complicating the entire process, time-sensitive environments. McClellan says, is the fact that EHRs When it comes to liability, “It really is across various providers and platforms a matter of what the standard of care is To illustrate, Aye shares an anecdote don’t always interface well. Furthermore, in that physician’s profession, in terms about an EM physician she defended, different providers tend to categorize of what they should be looking at in who was named as part of a wrongful- information differently within the the EHR,” explains Miranda Aye, JD, a death case for prescribing Naproxen to record—sometimes key information may partner with Seattle law firm Johnson, an elderly patient who had come to the be found in the patient’s “Notes” section, Graffe, Keay, Moniz & Wick, who focuses ED after a fall—failing to note from her while other records might instead put on medical-malpractice defense cases. full EHR that the patient had chronic similar information under “Imaging” or kidney disease. Patients with decreased “Cardiology,” as appropriate. “EM doctors typically wouldn’t be going kidney function are typically advised back into all the primary-care notes to avoid high doses of NSAIDs like This lack of standardization can and looking at extensive records,” Aye Naproxen; the patient, who had signed significantly impede efficient EHR says. “That wouldn’t typically be part a do-not resuscitate order, experienced navigation, placing Emergency Medicine of their practice.” Therefore, failing acute kidney failure after taking the pain (EM) doctors in particular—thanks to the to review the entire EHR would not, reliever, and later died.

(Continued on page 38) 33 THE PHYSICIANS REPORT | SUMMER 2020

To effectively use field of RNA biology, or the study and bioprinting technology, sequencing of ribonucleic acid, and the organizations must invest development of “molecular stethoscope” in training, management, applications, providing less-invasive materials, and equipment. Another testing for cancer, pathogens, and challenge is managing the security chromosomal abnormalities, are also and privacy of Digital Imaging and expanding the potential for genomics. Communications in Medicine (DICOM) files used in bioprinting. Exchanging Emerging challenges in the field and storing DICOM files requires include increasingly narrow candidate establishing protocols for the safe, secure pools for clinical trials of ever-more transmission of patient data. specialized gene therapies and the need for integration of siloed genomic GENOMICS data to inform large-scale projects like (Six Trends Shaping Modern Over the last three decades, the 1000 Genomes Project and the Healthcare, continued from page 7) breakthroughs in genotyping Cancer Genome Atlas. More robust and gene-expression profiling datasets will help further unlock genetic have transformed the field diversity and uncover more biomarkers exponential growth in the number of of genomics, allowing researchers to for disease, paving the way for future 3D models used for planning medical investigate more of the human genome breakthroughs.PR PR interventions and creating implants. while dramatically driving down costs. In 2003, the first human genome was Sources: The field of surgery is also being sequenced at a cost of $3 billion. Today, Carla Pugh, MD, PhD, shaped by 3D printing. By using well next-generation sequencing (NGS) has is Professor of Surgery known, widely available bioprinting brought the cost down to below $1,000 at Stanford University hardware, practitioners can create per human genome. School of Medicine custom implants, surgical guides, and and director of the Technology Enabled anatomical models on demand for In 2020 and beyond, NGS will Clinical Improvement surgeries in nearly every domain, from continue to shape genomics with (T.E.C.I.) Center. She is orthopedics to spinal, maxillofacial, and further cost reductions, per health- the first surgeon in the United States to obtain cranial surgery. sciences consulting firm L.E.K. a PhD in education. Her research involves the Innovations in instruments, sample use of simulation and advanced engineering The benefits of 3D printing are well preparation, and bioinformatics— technologies to develop new approaches for supported by research, per a study in healthcare-computing applications and assessing and defining competency in clinical Biomedical Engineering Online. Their tools—will streamline workflow and procedural skills. systematic review of literature found that make genomics more cost-effective for Jordana Gaumond, 3D-printed parts can improve surgical organizations large and small. MD, FACS, is a general outcomes for patients by increasing surgeon at The Oregon efficiencies, reducing surgical time, and Most genomics research involves Clinic, where she decreasing radiation exposure. analysis of DNA across different specializes in acute- populations in a sample. Now, care surgery, the Adopting 3D printing presents advancements in technology that treatment of breast challenges, particularly for small group allow researchers to study individual disease, and minimally practices that must balance the cost of cells are creating more individualized invasive gastrointestinal procedures. She is a a 3D-printing laboratory with its clinical applications for genomics research. This Fellow of the American College of Surgeons, benefits, according toRadiographics . “single-cell biology” enables researchers board-certified by the American Board of Startup costs are significant, and the to compare genetic expression and Surgery, certified by the American Society of costs of printing and additional scans study cellular heterogeneity between Transplant Surgeons, and a member of the Physicians Insurance Board of Directors. can increase the overall cost of the cell populations, providing new insights procedure, according to the journal for oncology, reproductive health, Biomedical Engineering Online. and genetics. Advancements in the 34 GOVT. AFFAIRS

GOVERNMENT RELATIONS—UPDATE REDUCING THE THREAT OF LIABILITY FOR OUR PROVIDERS AND FACILITIES AS THEY FIGHT COVID-19

Physicians Insurance has been engaged in a wide range of • Inadequate or delayed COVID-19 testing is leading government-relations activity concerning healthcare providers to flawed and/or delayed diagnosis. and facilities during the coronavirus outbreak, at both the federal and state level. We are working with our national and • Non-COVID-19 patients with other healthcare issues are strategic partners in states where we do business to reduce having to wait for substantial periods of time to receive the threat of liability for healthcare providers and facilities treatment, resulting in the delay of treatment and a who are leading the fight against COVID-19. reduced chance of positive healthcare outcomes.

AREAS OF LIABILITY CONCERN • Concerns have been raised relating to telemedicine and/or Liability concerns include, but are not limited to, these areas: patients being released from hospitals early to free up beds for COVID-19 patients, reducing patient safety and quality • Physicians and other healthcare professionals, to meet healthcare measures. increasing demand, are being asked to provide treatments or care outside their general practice areas, and for which FEDERAL MPL AND HPL PROTECTIONS they may not be familiar. To date, federal efforts have fallen short of what is truly needed to reduce the threat of liability for all healthcare • Healthcare professionals and facilities have inadequate providers and facilities engaged in fighting the national safety equipment that could result in the transmission of COVID-19 pandemic. the virus from patient to provider and then to additional patients, or directly from one patient to another. On March 20, 2020, President Trump signed into law H.R. 748: Coronavirus Aid, Relief, and Economics Security Act • Healthcare facilities facing shortages of equipment such (CARES Act), which extends liability protections to volunteer as ventilators are being forced to ration care, resulting in healthcare professionals during national declared emergencies patients not receiving the care they need. or disasters. The Good Samaritan provisions in Section 3215 provide immunity for healthcare given by a volunteer in good • Elective surgeries and procedures are being delayed faith and within the scope of the volunteer’s licensure—but for months to provide additional capacity to treat they do not include protections for facilities. We are working COVID-19 patients. with our national partners to promote necessary amendments 35 THE PHYSICIANS REPORT | SUMMER 2020 that would include Crisis Standard of healthcare community, requesting that CALIFORNIA NON-ECONOMIC- Care language to provide additional he extend the Uniform Emergency DAMAGE CAP protections for healthcare facilities. Volunteer Health Practitioners Act We received good news out of California to Washington practitioners. Current on the challenge to the non-economic- Congress has shifted its focus from state law favors out-of-state workers damage cap. The campaign behind healthcare-provider and facility liability over Washington practitioners, so the the ballot initiative to increase the to employer liability. The conversations letter calls on the governor to provide California medical non-economic- surrounding the fourth coronavirus-relief the same protections to Washington damages cap has decided to aim for package promote employer liability providers as are provided for workers the 2022 ballot, due to the pandemic. protection—as the nation determines who arrive from other states. The $250,000 non-economic-damage how to safely reopen for business— cap was put in place in 1975; the along with healthcare-provider and On April 23, 2020, the governor 2020 ballot measure, if passed, would facility protections. Working with our responded unfavorably to the request, have adjusted the non-economic- partners, the MPL Association and the stating that he does not believe the damage cap for inflation, increasing Health Coalition on Liability and Access, current circumstances or projections the cap to $1.2 million for 2021. we have drafted federal language to represent an immediate need for Proponents for the ballot initiative extend the provider liability protections liability waivers. The governor has could not get enough signatures to in the CARES Act beyond volunteers expressed interest in tracking qualify amid the COVID-19 pandemic. to all healthcare providers. The draft COVID-19 claims data for further In addition, they recognized that language is similar to the bipartisan- consideration; however, he is not the environment is not favorable for approved language in the first stimulus convinced that blanket immunity overturning the cap and attacking package. We are working to secure broad is the answer. We will continue to healthcare providers and facilities bipartisan support, including support work with the governor and share currently battling the pandemic. from Congresswoman Dr. Schrier from appropriate COVID-19 claims data Washington, who signed on early to with all members of the Legislature As a legislator once said, “Politics is the Good Samaritan language in the in preparation for 2021 legislative- the art of postponing decisions until CARES Act. We hope to insert both session opportunities. they are no longer relevant.” Physicians healthcare-provider and facility liability Insurance will continue to serve as a language and employer liability language OREGON EXECUTIVE- trusted, reliable resource of information in the next coronavirus-relief package. ORDER REQUEST for our insureds and lawmakers. More importantly, we hope to educate On April 3, 2020, a letter was sent Advocacy is crucial to ensuring that Congress on the immediate need for to Governor Brown on behalf of the the concerns of our members and their national reforms to protect against healthcare and facility community, patients are heard by lawmakers at both future pandemics and national disasters. requesting that the governor follow the the state and national level, and we New York gubernatorial executive order are well positioned to work as a leading WASHINGTON AND OREGON that limited liability for healthcare advocate on initiatives that impact MPL AND HPL PROTECTIONS providers and facilities. healthcare now and for the 2021 We are working with the Washington session and the next Congress.PR PR and Oregon State Medical Associations, Like Governor Inslee, Governor Brown hospital associations, and liability- has expressed interest in tracking reform coalitions to make requests COVID-19 claims data before making More to both governors to protect healthcare any decisions on blanket immunity for providers and facilities if Congress healthcare providers and facilities. We Information fails to implement adequate have been told she has a plan ready For more information about our protections during this national and to activate if a professional or facility Government Relations Program, state-declared emergency. liability crisis should occur. We have please contact Anne E. Bryant, engaged in a robust grassroots campaign Senior Director of Government WASHINGTON EXECUTIVE- in Oregon and will share appropriate Relations, at [email protected] ORDER REQUEST information with all members of the or 206-343-7300, extension On April 2, 2020, a letter was sent Legislature in preparation for 2021 6612. You can also visit our to Governor Inslee on behalf of the legislation-session opportunities. webpage at phyins.com/gov. 36

(Healthcare's Digital Revolution, continued from page 19)

In the 11 years since Swanson began blogging, consumers have demanded increasing access to personal health data, with young parents leading the charge. Health-tracking is most popular among young, affluent women, per the Gallup poll. “There’s a whole revolution of gadgetry in pediatrics allowing OPINION parents to track their baby’s data,” Swanson says. From Lumi, the Proctor & Gamble smart-diaper baby monitor Why Alexa’s that shows sleeping, feeding, and diaper activity—which Swanson helped Bedside Manner is develop—to the Dr. Mom otoscope that allows parents to spot ear infections at home, to the Kinsa QuickCare Smart Bad for Healthcare Stick digital thermometer, devices let parents track their baby’s every By Elisabeth Rosenthal | Kaiser Health News moment, movement, and milestone Amazon has opened a new healthcare In April, at Fortune’s Brainstorm without setting foot in a doctor’s office. frontier: now Alexa can be used Health conference in San Diego, to transmit patient data. Using this Bruce Broussard, CEO of health EMPOWERED PATIENTS, new feature—which Amazon has insurer Humana, said he believes IMPROVED OUTCOMES labeled as a “skill”—a company technology will help patients As new consumer products compete named Livongo will allow diabetes receive help during medical crises, to provide users with ever-increasing patients—which it calls “members”— and cited the benefits of home amounts of health data, providers may to use the device to “query their last monitoring and the possibility of spend more time helping patients sort blood-sugar reading and blood-sugar doctors’ visits being conducted by out whether the data is useful, or even measurement trends, and receive videoconference. accurate. Personal sleep-tracking data insights and Health Nudges that from smartwatches is one example, are personalized to them.” But when I returned from says Dimitriu. While smartwatches may Brainstorm Health, I was confronted provide basic information about some Private-equity and venture-capital by an alternative reality of virtual aspects of sleep, the technology is still firms are in love with a legion of medicine: a $235 medical bill for a evolving. Users may not know that the companies and startups touting telehealth visit resulting from one of sleep-stage readings from a wrist-worn the ability of virtual doctors’ visits my kids calling a longtime doctor’s device are nowhere near as accurate as and telemedicine to revolutionize office. The bill was for a five-minute the data from a lab-based sleep study healthcare, investing almost $10 phone call answering a question that tracks brain waves. billion in 2018, a record for the about a possible infection. sector. A startup called Kinetxx will When Dimitriu talks technology with provide patients with virtual physical Virtual communications have patients, he often educates them therapy, along with messaging streamlined life and transformed on the limitations of personal sleep- and exercise logging, without ever many of our relationships for the tracking gadgets. “Sleep tracking is still requiring them to step into a gym or better. There is no longer much emerging,” he says. “It’s now where a clinic. And Maven Clinic (which need to sit across the desk from a health tracking was 10 years ago.” is not actually a physical location) tax accountant or travel agent, or to offers online medical guidance stand in a queue for a bank teller. This type of technology is still in and personal advice focusing on its infancy, agrees Swanson, but it women’s health needs. presents opportunities for providers to (Continued at https://bit.ly/2BvJAMl) 37 THE PHYSICIANS REPORT | SUMMER 2020

“When patients are monitoring their own health, I think they’re more active participants in their own healthcare.”

KATHLEEN PIZZOLATTO, CNM, ARNP, CHI FRANCISCAN HEALTH, TACOMA, WASHINGTON

address some of healthcare’s pressing And sometimes, home-based health healthcare, says Swanson. “23andMe problems, like how to care for growing technology is more about reassurance is a beautiful example of this,” she patient panels and spend more than actionable data. “If a patient wants says. “[Founder] Anne Wojcicki was meaningful time with each patient. to use a fetal Doppler monitor at home trying to emancipate personalized data. to hear their baby’s heartbeat, and it It doesn’t need to live in your health For example, digital tools can help makes them feel better about their record. We can give it to you and help providers scale messaging to create pregnancy, that’s fine with me,” says you understand it over time.”PR PR much-needed efficiencies in clinical Pizzolatto. “But they still need to learn settings. “Does a pediatrician need to about doing a fetal-kick count to monitor Alex Dimitriu, MD, is dual board-certified tell each patient the same thing over and the baby’s movement, because that’s the and founded Menlo over in every appointment?” Swanson information their provider needs.” Park Psychiatry & asks. “Using digital tools, we could Sleep Medicine. He send certain health messages specific But, Pizzolatto points out, self- treats patients with a to that appointment, or that child’s monitoring and the learning that comes wide variety of mental developmental stage, to a parent an hour with it can empower patients to make health–related issues before an appointment, and the parent positive changes. “When patients are such as anxiety, PTSD, depression, bipolar could ask questions if needed. This has monitoring their own health, I think disorder, ADHD, and sleep disorders. been a huge miss in the digital space.” they’re more active participants in their Kathleen Pizzolatto, own healthcare,” she notes. “And when CNM, ARNP, is an Health-tracking technology can also patients work with their provider to advanced-practice help bridge language, knowledge, develop a plan, we know they’re more provider with CHI and communication barriers between likely to follow it, which leads to more Franciscan. She providers and patients, says Dimitriu. positive outcomes.” provides care for women “Many of my patients use the Dalyio app from adolescence to track moods, and it’s helpful because Ultimately, personal health-tracking through menopause, everyone’s version of ‘having a bad day’ is paving the way for providers to spot with a focus on gynecology and care for or ‘a bad night’s sleep’ is different,” he trends in patient populations that could women during pregnancy and childbirth. says. “These devices also benefit users track viral illness and speed pandemic Wendy Sue Swanson, MD, by adding awareness and granularity.” response, says Swanson. “Patients like served as founder the shiny new app on their phone, but and chief of digital When a patient tracks their own the potential for the back-end data is innovation at Seattle heartrate via a wrist-worn fitness huge,” she says. “If a physician tracks Children’s Hospital monitor, they can reference a data point 1,000 patients and can see trends in before joining Before that helps inform decision-making, temperature, they’d be able to spot Brands as CMO. She says Pizzolatto. “That gives a provider abnormalities and patterns too.” leads communication something more solid to go on than to clinicians and parents around the when a patient calls and says, ‘I feel Helping patients understand their own development of early food allergies, and like my heart is racing,’” she says. health data is central to the future of champions digital health, prevention, and healthcare advocacy. 38

Trial (Electronic Health Records, continued from page 32)

Results Though the EM physician spoke with both the elderly patient and her daughter The following summaries are Physicians during her visit, neither mentioned the Insurance cases that have gone to trial patient’s pre-existing kidney condition. and are public record. In reporting The EM physician failed to see an alert these legal results, it is our goal to about the condition in the patient’s inform members about issues that EHR, because it was under a tab named impact healthcare professionals. While “Problem List” that is sometimes used by primary-care physicians, but is we share information we think may be typically not comprehensively reviewed— informative, we choose not to disclose depending on presenting complaint—in the names of plaintiffs or defendants emergency medicine. when reporting these results. “The problem was, this EM physician didn’t even know where to find the Problem List in that particular EHR,” IMPROPER REPAIR OF THIRD- IMPROPERLY PERFORMED Aye says. “It’s a tool that primary- DEGREE TEAR FOLLOWING C-SECTION RESULTING IN care doctors typically use. EM doctors VAGINAL BIRTH EMOTIONAL INJURY would usually review the Past Medical SPECIALTY: General Surgery SPECIALTY: OB/GYN Information. The information wasn’t in ALLEGATION: 36-year-old female presented both places, in this case.” to the hospital in active labor with her ALLEGATION: 36-year-old female second baby. The patient gave birth to presented to Labor and Delivery for a The physician won the case and was a healthy baby boy but suffered a third- scheduled C-section of her second baby. exonerated, thanks in part to the degree vaginal tear during delivery. Due to The patient alleges that the obstetrician testimony of other EM physicians the complexity of the laceration and repair, proceeded with the incision in spite of brought in as defense witnesses. They a general surgeon was called in to assist. the patient yelling that she could feel agreed that the “Problem List” tab is not Plaintiffs argued that the general surgeon everything and was in pain. something they would typically consult failed to identify the anatomy/structures in an EHR, particularly one they were involved in the repair and performed The patient claimed she suffered PTSD, not used to. Further, they agreed that it the repair incorrectly, and as a result, anxiety, and depression, and was unable was beyond the scope of an EM standard the patient experienced significant anal to return to work as a result. of care to expect a physician to discern incontinence. a patient’s kidney condition on the The defense argued that the repair failed in the PLAINTIFF ATTORNEY: David Williams basis of other historical lab data not in absence of any negligence resulting in injury. (Bellevue, WA) evidence with the visit. PLAINTIFF ATTORNEYS: James Holman and Colleen Durkin Peterson, Holman Law PLAINTIFF EXPERTS: Andrew Lin, Still, Aye advises that her clients not (Tacoma, WA) MD, OB/GYN, Robert Ertner, MD, make avoiding litigation the driving Anesthesiology factor behind how they practice PLAINTIFF EXPERTS: Juan Vargas, MD, medicine—when it comes to how best to OB/GYN (Oakland, CA), Marianna Alperin, DEFENSE ATTORNEYS: Elizabeth review patient EHRs, or anything else. MD, OB/GYN (La Jolla, CA) Leedom and Jenny Churas, Bennett Bigelow and Leedom (Seattle, WA) “At the end of the day, the overriding DEFENSE ATTORNEYS: Jennifer Crisera principle and focus has to be on giving and Sarah Silverman, Bennett Bigelow and DEFENSE EXPERTS: Katherine Van good patient care,” she says.PR PR Leedom (Seattle, WA) Kessell, MD, OB/GYN, David Hepner, DEFENSE EXPERT: Kelly Clinch, MD, MD, Anesthesiology General Surgery (Kirkland, WA)

RESULT: Defense Verdict, Pierce County RESULT: Defense Verdict, Pierce County 39 THE PHYSICIANS REPORT | SUMMER 2020

“They will be able to walk into the emergency department, potentially, hold their phone up, and have their health information flow from their phone, perhaps via a QR code, into the hospital’s EHR.”

ROBERT M. TENNANT, DIRECTOR, HEALTH INFORMATION TECHNOLOGY POLICY, MEDICAL GROUP MANAGEMENT ASSOCIATION

(EHR Interoperability, continued from page 25) discharge, or transfer (ADT) status “The vision for many people, and both providers and patients—allowing to their primary-care provider or especially for the government, is that patients to see, in real time, their appropriate specialist, so that follow-up the patient will be in control of their potential out-of-pocket rates for various care can be provided. health data, and patients will also be lab and testing services. in control of interoperability,” Tennant “If a patient, say, has diabetes, and says. “They will be able to walk into “Let’s say you go to the doctor, and a negative event lands them in the the emergency department, potentially, the doctor feels you need to get an hospital, if they’re discharged and hold their phone up, and have their MRI,” he says. “Using API technology, there’s no clinical follow-up, they could health information flow from their patients could quickly get a list of local likely end up back in the hospital,” phone, perhaps via a QR code, into the MRI providers and their out-of-pocket Tennant explains. hospital’s EHR.” expense for each one. With the out-of- pocket cost potentially being less at As the ADT messaging becomes more “Right now, online health information an insurance plan’s preferred testing streamlined and standardized, the hope portals are great, but it’s still a bit of a facility, I see it as an opportunity for is that primary-care physicians will hassle to sign in,” Tennant adds. “They plans to control costs and for patients to then reach out proactively to patients to don’t always offer the complete record, decrease their out-of-pocket expenses.” encourage them to make an appointment and often the information presented to prevent future hospital stays. is not in a patient-friendly format. If EMPOWERING COORDINATED CARE accessing your healthcare information on Increased information access and “If the practice is in a value-based your phone could be curated and made potential cost savings may be the contract, then they have every incentive easier by third-party apps, it could be biggest advantages for patients. to get on the phone and talk with that a tremendous asset to the healthcare- For providers, the new rules’ most patient, because that way they can keep delivery process. It would be a way to significant impact may be enhanced their costs low while providing improved increase interoperability, and could lead value-based care. care,” Tennant says. to enhanced price transparency.” As part of the CMS Final Rule, a new In doing so, we hope to see railways Tennant predicts that as app-based Condition of Participation mandates without connections replaced by the systems become widely available, that all hospitals send electronic smooth flow of information and improved they will become cost-saving tools for notifications of a patient’s admittance, care coordination.PR PR PRSRT STD US POSTAGE PAID SEATTLE, WA PO Box 91220 PERMIT NO. 794 Seattle, WA 98111

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THE PHYSICIANS REPORT | SUMMER 2020

Dr. Moore earned a BS, MD, and MS in pulmonary physiology from the University of Wisconsin at Madison. She practiced for 30 years in partnership with her late husband, James H. Dahlen, MD.

Dr. Moore served for nine years on the Nola M. Moore, MD, Physicians Insurance board of directors and for nine years on the board at NORDIC (a A Founder of Physicians dental liability company), and served terms Insurance, Passes Away as president of the King County Medical Society and King County Academy of Family WELCOME Nola M. Moore, MD, of Shoreline, WA, Practice, from which she received the King a founding director of Washington State County Academy Community Service Award. TO OUR NEW Physicians Insurance Association (which MEMBERS! later became Physicians Insurance), died She is survived by her sister Mavis, April 17, due to complications from the daughter Dee Dee (husband Bob, children MEDICAL-PROFESSIONAL LIABILITY novel coronavirus. Annaliese, Morgan "Mo," and Marielle Ada West Dermatology "Leo"), son Eric (wife Darci, daughter Meridian, ID Dr. Moore was one of the early physician Lucy), and son Kerry (wife Katie, leaders who extended personal credit to daughters Zoe and Mattie Mae). Edmonds Medical Clinic capitalize the company, and who worked Edmonds, WA with the Washington State Medical In lieu of flowers, remembrance HOSPITAL EXCESS Association to gain statewide support for the contributions can made to Helen Chu’s Seattle Children’s Hospital young company. Dr. Moore was an energetic lab at the University of Washington Seattle, WA champion of patient and physician rights, Department of Medicine, Division of was tireless in her compassionate service of Allergy and Infectious Disease. Virginia Mason Health System others, and remained active in the medical See Dr. Chu’s contact info at: Seattle, WA community until just a few years ago. https://bit.ly/36YPalV