Physician Ratings on System Usability Usability System on Ratings Physician Yellow Cyan Black Magenta

PAGE 68 XCLUSIVE E Roadmap to interoperability

ONCÕs KarenONCÕs DeSalvo

will boost your efﬁ ciency will boost efﬁ your

Why your patient portal

WORK SMARTER WORK PAGE 91

ES503041_ME101014_cv1.pgs 09.22.2014 23:25 ADV

Clinical support Quality of care

PAGE 22

building betterbuilding systems 4 ways vendors are

YOUR FUTURE EHR YOUR PAGE 74

Patient portals Technical supportTechnical

Meaningful Use Meaningful

CORECARD EHR

OCTOBER 2014 10, VOL. 91 NO. 19 S Physician ratings on system usability usability system on ratings Physician yellow cyan black magenta

Medical Economics OCTOBER 10, 2014 2014 EHR SCORECARD ■ TOP 50 EHRS ■ KAREN DESALVO ON INTEROPERABILITYRABILITY Advertisement not available for this issue Advertisementof the not digital available edition for this issue of the digital edition

www.medicaleconomics.com/resourcecenterindex MedicalEconomics.com Facebook Twitter www.MedicalEconomics.com/HIMSS2012www.MedicalEconomics.com/ACA MedicalEconomics.com Facebook Twitter See medicaleconomics.modernmedicine.com/himss2012resource centers related to our Business of Health series You’ve gotYou've questions got technology about the Affordablequestions. Care Act. as well as topics such as Patient-Centered Medical Homes, accountable We’ve got answers. care organizations, and ourWe've EHR got Best answers. Practices Study at the above link.

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Referenced in MedLine®

Volume 91 OCTOBER 10, 2014 Issue 19

IN DEPTH COLUMNS

PAGE EHR 91 16 AMA ISSUES EHR CALL TO ACTION SCORECARD 8 ways physicians say EHR vendors Gail Levy, MA should improve their systems. STARTS Five ways your patient portal ON PAGE 22 24 PHYSICIAN EHR can boost productivity SATISFACTION GROWS Exclusive results from a survey of physicians on their attititudes toward their EHR systems.

38 TOP 50 EHRS An evaluation of the f nancial viability of the top EHR vendors. 46 EHR CAPABILITY CHECKLIST A guide for physicians on evaluating what EHR systems of er. 68 ONC’S STARTS ON PAGE 38 INTEROPERABILITY ACTION PLAN An exclusive interview with ONC’s 9 EDITORIAL BOARD Karen DeSalvo on interoperability. 10 ME ONLINE COVER STORY | TECHNOLOGY 74 YOUR FUTURE EHR 12 FROM THE TRENCHES 4 ways vendors are improving the Exclusive physician ratings on 16 VITALS functions and usability of their 98 ADVERTISER INDEX systems. EHR system usability 99 THE LAST WORD 81 THE MOBILE HEALTH A new study says online REVOLUTION starts on page 22 communication remains elusive for primary care physicians. How physicians can meet patient demand for more connected care. ❚ Top EHR systems scored in 87 OPEN NEW AVENUES OF MISSION STATEMENT PATIENT COMMUNICATION 5 key areas Medical Economics is the leading business resource for of ce-based physicians, How technology is helping bridge ❚ gaps between doctors and patients. Physician perspectives providing the expert advice and shared examined on EHR usability experiences doctors need to successfully meet 91 THE PORTAL-OPTIMIZED today’s challenges in practice management, PRACTICE ❚ Analysis of EHR use trends patient relations, malpractice, electronic 5 ways your patient portal can boost health records, career, and personal f nance. productivity. Medical Economics provides the nonclinical education doctors didn’t get in medical school.

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ken sylvia Vice President, Group Publisher Twitter Talk 732-346-3017 / [email protected] david a. depinho Publisher/Group Editor Other people and 732-346-3053 / [email protected] organizations tweeting Publishing & salEs Editorial Monique Michowski george g. ellis Jr., Md, Facp national Account Manager Chief Medical Adviser about issues that 732-346-3098 / [email protected] JeFFrey bendix, Ma matter to you ana santiso Senior Editor national Account Manager 440-891-2684 / [email protected] 732-346-3032 / [email protected] riCHArD VAuGHn MD chris Mazzolini, Ms Content Manager @rvaughnmd Margie Jaxel Director of Business Development, 440-891-2797 / [email protected] Good read. “smallest independent Healthcare technology Sales 732-346-3003 / [email protected] donna Marbury, Ms primary care practices, physician Content Specialist tod Mccloskey 440-891-2607 / [email protected] owned, provide better care at lower Account Manager, alison ritchie overall cost” http://bit.ly/1qNNnm0 Display/Classified & Healthcare technology 440-891-2739 / [email protected] Content Associate 440-891-2601/[email protected] Mount SinAi HoSPitAL Joanna shippoli Account Manager, recruitment Advertising ken terry @mountSInaInYC 440-891-2615 / [email protected] gail garFinkel weiss Contributing Editors #Obesity is one of the most important don berMan risk factors for #cancer, second Business Director, eMedia art 212-951-6745 / [email protected] robert Mcgarr to tobacco” - Dr. Paolo Boffetta @ Group Art Director Meg benson 440-891-2628 / [email protected] TischCancer http://bit.ly/1uOrM3i Special Projects Director 732-346-3039 / [email protected] Production karen lenzen StEPHEn SCHiMPff, MD gail kaye Senior Production Manager @drSChImpff Director of Marketing & research Services Physician frustration is rampant but 732-346-3042 / [email protected] audiEncE dEvEloPmEnt hannah curis Joy puzzo Corporate Director lets reframe the resolution question Sales Support http://bit.ly/1s1rcyk #primarycare christine shappell Director renée schuster Joe Martin Manager List Account Executive A. PAtriCk JonAS, MD 440-891-2613 / [email protected] @apjonaS Maureen cannon rEPrintS Report: Recruiters have trouble filling Permissions 877-652-5295 ext. 121 / [email protected] 440-891-2742 / [email protected] Outside US, UK, direct dial: 281-419-5725. Ext. 121 primary care openings http://sbne.ws/r/q85a #FMREVOLUTION chris deMoulin dave esola Executive Vice President Vice President, General Manager Joe loggia rebecca evangelou Pharm/Science Group Chief Executive Officer Executive Vice President, Michael bernstein toM ehardt Business Systems Vice President, Legal Executive Vice President, Julie Molleston Francis heid Chief Administrative Officer Executive Vice President, Vice President, Media Operations & Chief Financial Officer Human Resources adele hartwick georgiann decenzo tracy harris Vice President, Treasurer & Controller Executive Vice President Senior Vice President

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8 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES502545_ME101014_008.pgs 09.22.2014 20:23 ADV The board members and consultants contribute expertise and analysis that help shape the content of Medical Economics. the Advisers

PAGE 91 EDITORIAL CONSULTANTS If your patients resist the PRACTICE MANAGEMENT use of a well-designed Judy Bee www.ppgconsulting.com portal, the problem may be in La Jolla, CA Keith Borglum, CHBC Professional Management and Marketing your practice’s process.” Santa Rosa, CA Kenneth Bowden, CHBC —Gail Levy, MA CONSULTANT Berkshire Professional Management Pittsf eld, MA Michael D. Brown, CHBC Health Care Economics Indianapolis, IN Frank Cohen, MPA EDITORIAL BOARD www.frankcohengroup.com Clearwater, FL Virginia Martin, CMA, CPC, CHCO, CHBC Healthcare Consulting Associates Mary Ann Bauman, MD Elizabeth A. Pector, MD of N.W. Ohio Inc. Waterville, OH Internal Medicine Family Medicine Rosemarie Nelson Oklahoma City, OK Naperville, IL MGMA Healthcare Consultant Syracuse, NY Mark D. Scroggins, CPA, CHBC Clayton L. Scroggins Associates Inc. Cincinnati, OH Gray Tuttle Jr., CHBC The Rehmann Group Lansing, MI John L. Bender, MD Patricia J. Roy, DO Michael J. Wiley, CHBC Family Medicine Family Medicine Healthcare Management Ft. Collins, CO Muskegon, MI and Consulting Services Bay Shore, NY H. Christopher Zaenger, CHBC Z Management Group Barrington, IL Karen Zupko Karen Zupko & Associates Chicago, IL

Maria Y. Chandler, MD, MBA Joseph E. Scherger, MD TAXES & PERSONAL FINANCE Business of Medicine, Pediatrics Family Medicine Lewis J. Altfest, CFP, CPA Irvine, CA La Quinta, CA Altfest Personal Wealth Management New York City Robert G. Baldassari, CPA Matthews, Carter and Boyce Fairfax, VA Todd D. Bramson, CFP North Star Resource Group Madison, WI George G. Ellis Jr., MD Salvatore S. Volpe, MD Glenn S. Daily, CFP Internal Medicine Internal Medicine-Pediatrics Insurance consultant New York City Youngstown, OH Staten Island, NY Barry Oliver, CPA, PFS Thomas, Wirig, Doll & Co. Capital Performance Advisors Walnut Creek, CA Gary H. Schatsky, JD IFC Personal Money Managers New York City David C. Judge, MD Craig M. Wax, DO David J. Schiller, JD Internal Medicine Family Medicine Schiller Law Associates Norristown, PA Cambridge, MA Mullica Hill, NJ Edward A. Slott, CPA E. Slott & Co. Rockville Centre, NY

HEALTH LAW & MALPRACTICE Barry B. Cepelewicz, MD, JD Jeffrey M. Kagan, MD Garfunkel Wild, PC Stamford, CT John M. Fitzpatrick, JD Internal Medicine Wheeler Trigg Kennedy, LLP Denver, CO Newington, CT Alice G. Gosﬁ eld, JD Alice G. Gosf eld and Associates Philadelphia, PA James Lewis Grifﬁ th Sr., JD Fox Rothschild Philadelphia, PA Lee J. Johnson, JD Mount Kisco, NY ask us Lawrence W. Vernaglia, JD, MPH Foley & Lardner, LLP Boston, MA Have a question for our advisers? Email your question to [email protected].

MedicalEconomics.com MEDICAL ECONOMICS ❚ OCTOBER 10, 2014 9

magentablackcyanyellow ES502305_ME101014_009.pgs 09.20.2014 01:48 ADV MedicaleconoMics.coM Smarter BuSineSS. Better Patient Care. exCluSive online Content and newS. online

online exclusive physicians abandoning independent practice Physicians are feeling increasingly stressed and Twitter Talk overworked, and are leaving private practice for Follow us on Twitter hospital employment in ever-greater numbers, to receive the latest news and participate in the according to The Physicians Foundation. Only discussion. 35% of respondents to the foundation’s latest narrow networks workforce survey are in private practice, compared A new study shows narrow networks offer ﬁnancial beneﬁts for patients. with 49% in 2012, with 81% saying they are http://ow.ly/BF6jU eliqua

“overextended.” Read more survey results at health insurance exchanges MedicalEconomics.com/TPFsurvey GAO says #Healthcare.gov needs security upgrades http://ow.ly/BF5M1 #ACA #HIT

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Now @MEonline end of life care Expert opinion is still needed to determine healthcare.gov security #prescribing appropriateness for most issues examined drugs used at the #endoﬂife A government report http://ow.ly/BDJVv finds improvements, but problems remain. Read more at incentive programs Me app. download free today. MedicalEconomics.com/websecurity Physicians not participating in meaningful Get access to all the benefts Medical Economics use, PQRS should prepare for ﬁnancial hits ofers at your fngertips. The Medical Economics app #2 uninsured numbers http://ow.ly/BzNXp #EHR #HIT for iPad and iPhone is now available for free in the shrink in 2014 thanks to aca obesity treatment iTunes store. But 41 million still lack coverage, a MedicalEconomics.com/app study finds. See details at FDA approval given for new drug to treat MedicalEconomics.com/uninsured #obesity http://ow.ly/BvPfV

affordable care act #3 meaningful use Paying for the #ACA: Understand the participation rates up immunization resource Medicare and net-investment tax center More than half of respondents in http://ow.ly/BrjcH Stay up-to-date with the latest developments Deloitte survey have reached MU2. in immunization and vaccination therapies at Find more information at MedicalEconomics.com/MUrates MedicalEconomics.com/immunization join us online part of the facebook.com/MedicalEconomics Medical Economics is part of the ModernMedicine Network, a Web-based portal for health professionals ofering best-in-class content and tools in a rewarding and easy-to-use environment for knowledge-sharing among members of our community. twitter.com/MedEconomics

10 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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magentablackcyanyellow ES502857_ME101014_011_FP.pgs 09.22.2014 22:42 ADV from the Trenches

During my many years of solo pediatric practice, I was the medical home for all of my patients. I and my pediatric peers saw our patients in the offce, at night (if necessary for acute illness), and in the hospital when we admitted them. We referred them to specialists...and guided and oversaw all their medical care.”

Horst D. Weinberg, MD, Sacramento, california

government intrusion doctors can take back dilutes pcmh concept control of medicine Regarding your article “PMCH: How to It would appear that physicians have no re- make care coordination work” (May 25, course over how their careers are managed 2014): Isn’t it interesting...What ‘goes around except by some non-physician entities. How- comes around.’ Something new? Isn’t that ever, I have searched and there does not exist what we in primary care used to do, and any federal or state laws over who physicians some still do, for oh so many years without are required to treat except in the ER [emer- needing articles in Medical Economics to gency room.] guide us? In the ER, every presenting patient is re- During my many years of solo pediatric quired by federal law to undergo a medical practice, I was the medical home for all of my screening exam. Other than that, physicians patients. I and my pediatric peers saw our can pick and choose who they will treat. If patients in the ofce, at night (if necessary physicians as a group want to make an im- for acute illness), and in the hospital when pact and take back control over the practice we admitted them. We referred them to of medicine, then we should stop treating specialists when necessary, and guided and members of the House of Representatives, oversaw ALL their medical care. Congress, the administration and all em- It is only with the advent of intrusive ployees of Medicare, Medicaid and insurance government regulations, mandates of vari- companies except in cases of emergencies. ous insurance plans causing patient shifting We would not be breaking any laws, but from plan to plan and so from doctor to doc- the point of our concerns would be loud and tor that the PMCH [patient-centered medi- clear. I cannot believe that with the level of cal home] has been diluted and in most cases skill and education they we as a group pos- lost. sess, have allowed these non-physician I seriously doubt that articles on how to groups dictate to us the manner that medi- make PCMH work will change much in the cal care will be applied. ICD-10, [Internation- present-day medical milieu. I feel sorry for al Classifcation of Diseases-10th revision], the present day primary physician.... us ‘old MOC [maintenance of certifcation], mid- timers,’ we truly lived and practiced in the levels, tests/procedures/medications being golden age of medicine. denied, all forced upon us, would seem to Horst D. Weinberg, MD be restriction of trade by people Sacramento, california who are not medically trained. 14

12 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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magentablackcyanyellow ES502858_ME101014_013_FP.pgs 09.22.2014 22:42 ADV from the Trenches

I think that advanced practice nurses will have to be recruited to help solve the [primary care shortage.] They are already independently licensed in at least 20 states. Either working along or in collaboration, they hold great promise to provide the projected need of primary care services that is soon to appear.”

Edward Volpintesta, MD, BetHel, connecticUt

TELL US 12 We can stop this by not see- It takes about 11 years to train a primary [email protected] ing these groups who negatively care doctor. I don’t think that the system can impact the delivery of medical care. It would train enough of them over the next several Or mail to: not take long. T ree months and the federal/ years (taking into account the added inf ux Letters Editor, state governments would realize that when from the Aff ordable Care Act) to adequately Medical Economics, their employees from the bottom to the top supply the future need. 24950 Country Club are not receiving medical care, then things I think that advanced nurse practitioners Boulevard, Suite 200, North would change. We cannot organize or strike, [APRNs] will have to be recruited to help Olmsted, Ohio 44070. but in a passive way we can take back control solve the problem. T ey are already indepen- Include your address and to practice medicine in the interests of our dently licensed in at least 20 states. Either daytime phone number. patients. working alone or in collaboration they hold I agree that granting a medical license to great promise to provide the projected need Letters may be edited for length and those who are not properly trained is not in of primary care services that is soon to ap- style. Unless you specify otherwise, we’ll the best interest of the public. Albeit a medi- pear. assume your letter is for publication. cal student has more knowledge than a mid- Ideally direct pay is a good idea but ironi- Submission of a letter or e-mail level, that is not an adequate argument for cally it will only worsen the shortage because constitutes permission for Medical turning them loose on the public. T is con- most patients will balk at the idea of paying Economics, its licensees, and its assignees stant degrading of the practice of medicine yearly membership fees in addition to insur- to use it in the journal’s various print and has to stop. It is dangerous and not in the in- ance premiums. electronic publications and in collections, terest of patients. Finally, being available 24/7 will require revisions, and any other form of media. What has happened to common sense? herculean energy and stamina and the sac- rif ce of personal time. Primary care doctors Lawrence Voesack, MD are already overstressed and either burned oDeSSa, teXaS out or approaching it. T e availability that Dr. Schimpff desires will only accelerate burnout use aprns to solve and leave little time for personal develop- primarY care shortage ment. In his timely article, “Solving the crisis in pri- T e conclusion? Use the APRNs to help mary care” in the August 25 issue, Stephen C. solve the primary care crisis. It may not be Schimpff , MD, off ers several ways to resolve the complete answer but it is a big part of the the def ciencies of the primary care system: answer. too few primary care doctors and not enough time to see patients and build a trusting rela- Edward Volpintesta, MD tionship being the most pressing issues. BetHel, connecticUt

14 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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magentablackcyanyellow ES501193_ME101014_015_FP.pgs 09.18.2014 01:55 ADV Examining the News Affecting theVitals the Business of Medicine

PHYSICIAN SURVEY: EHRS WASTE 48 MINUTES aMa: 8 WaYs Ehr VEndors DAILY MUsT iMProVE sYsTEM UsaBiliTY

Physicians in a recent The American Medical Association (AMA) is calling on survey reported losing an average of electronic health record (EHR) vendors to drastically improve 48 minutes a day due the design and functionality of their systems, which have to electronic health been a source of frustration for many of its members. records (EHRs). “Physicians have long embraced new technology quickly and regularly, and they see Survey results value that EHRs can deliver,” says Steven Stack, MD, president-elect of the AMA and published in September chair of its Advisory Committee on Physician EHR Usability. “We do not want to go by the American back to paper records. But today’s current EHR products are immature, costly, and are College of Physicians not well-designed to improve clinical care.” (ACP) found that every In fact, a survey recently published in the Journal of the American Medical respondent reported Association Internal Medicine found that physicians lose an average of 48 minutes per losing some time each day to EHR data entry. day because of EHR “We have to check, click, double-click and scroll incessantly just to get through use. The mean loss for simple tasks. It is inordinately ineﬃ cient to do that,” says Stack. “T ere is a crying attending physicians need to make it much more like the experience people have on most commonly was 48 minutes, and the available smartphones, where it’s intuitive, ef ortless, and timesaving rather than time mean loss for trainees diminishing.” was 18 minutes. T e AMA says it is working closely with vendors to improve in the eight areas The ACP queried 845 identif ed. In early 2015, the AMA plans to release modules developed by physicians on physicians in December purchasing, implementing and optimizing EHRs. 2012 and received responses from 411 who used EHRs. Among all 8 ways to enhance EHR usability respondents, 89.8% reported that at least enhance physicians’ ability to provide high-quality patient care one data management 1 function was slower after EHR adoption; 63.9% 2 support team-based care reported that note writing took longer; 33.9% said 3 promote care coordination it took longer to f nd and review medical data; and 4 offer product modularity and conﬁ guration 32.2% said it took more time to read electronic reduce cognitive workload notes. 5 The authors note that ambulatory practices may 6 promote data liquidity benef t from the use of scribes, standing orders, 7 facilitate digital and mobile patient engagement and talking instead of email to recapture time 8 expedite user input into product design and post-implementation feedback lost to EHRs. T e Vitals continued on page 18

16 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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magentablackcyanyellow ES502885_ME101014_B17_FP.pgs 09.22.2014 22:44 ADV theVitals

ACA leAds to drop in UninsUred Study: Narrow networks AmeriCAns lead to rise in primary In the frst three months of 2014, the number of uninsured Americans care appointments dropped to 41 million, down from 48.6 million  EnrollEEs in a “Overall, the fndings limited network plans are in 2010, according to an narrow network plan suggest that the switch saving money by directing Early Release of Estimates in Massachusetts who to limited network plans care towards primary report from the Centers kept their primary care reduced spending without care and away from for Disease Control and physicians (PCPs) ended harming access to downstream spending,” Prevention. up going to emergency primary care or inducing the authors say. Te The report, culled departments (EDs) less shifts to more expensive report adds that there is from data from the often and saw their tertiary care,” said the no evidence that patients National Health PCP more, which was are using lower quality Interview Survey, covers the opposite of what hospitals, or of harmful January to March 2014. researchers in a new efects for chronically It estimates that 3.7 study expected to fnd. “The ﬁndings suggest ill patients. million people obtained Massachusetts state that the switch to Te authors note coverage through employees were ofered that the savings the Afordable Care a three-month premium limited network plans are concentrated Act (ACA) insurance holiday in 2012 if they reduced spending among individuals exchanges. The Obama switched to a narrow without harming access who retained their administration, which network that would save primary care physician tracked ACA enrollment the state money. An to primary care or while moving to their through April, put analysis of the ofer and inducing shifts to more current insurer’s the total number of its efect on spending expensive tertiary narrow network plan enrollees at eight and savings was or another insurer’s million. Other fndings: published as a working care.” narrowed network plan. paper by the National Tat fnding suggests, Bureau of Economic “networks that are Research. particularly restrictive % Te study analyzed a on primary care access 61.8 complete set of claims data study. It notes that the may fare less well than for the years 2009 through increase in PCP visits those that impose only of Americans under age 65 were covered by private health 2012. It found that the and spending is “more stronger downstream insurance plans. premium incentive caused than ofset by a decrease restrictions.” 10% of employees to switch in specialist visits and Narrow networks have to the narrow network. sp e n di n g .” come under scrutiny in the Municipal employees Concern about past year, and the Centers % with the same insurance enrollees not being able for Medicare and Medicaid 18.4 provider were not ofered to fnd a doctor was not Services announced in the incentive. refected in the study’s March that it would be of adults aged 18-64 were Te insurer, fndings, which found reviewing such plans uninsured. Massachusetts Group that “distance traveled to to see if they meet the Insurance Commission providers falls for primary standard of “reasonable (GIC), realized a 4.2% care physicians, but rises access.” Te standard % reduction in spending for specialists and in includes benchmarks because of the switch, says particular hospitals.” for the number of PCPs, 17.1 the study, while individuals “Te basic results specialists and hospitals had public health plan coverage. realized a savings of 36% on hold even for the sickest that need to be available to healthcare spending. patients, suggesting that enrollees.

18 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES502306_ME101014_018.pgs 09.20.2014 01:48 ADV theVitals

meAningfUl Hepatitis C drugs could Use pAyments sUrpAss increase Medicare Part D $24.8 Billion, spending by 11% in 2015 Cms sAys The Centers for Medicare and Medicaid Services  ThE fEdEral U.S., this issue has caught Milliman’s analysis (CMS) has paid more government’s cost for the attention [...] due to its measured the impact of than $24.8 billion in Medicare Part D will sheer magnitude.” these new drugs on the meaningful use incentive increase between $2.9 According to Medicare Part D program; payments to providers billion and $5.8 billion if Kaczmarek, a majority of the study did not include and hospitals, according 15% to 30% of hepatitis the cost will be from the the efect of the drug to a recent report. C (HCV)-infected federal reinsurance subsidy, therapy on other medical CMS ofcial benefciaries receive which is the mechanism costs. Elisabeth Myers treatment in 2015 and the used to cover the cost “Te cost of Medicare presented the latest cost of treatment averages of expensive drugs in Part D will increase numbers September 3 $84,000, according to a new Part D. He adds that the signifcantly if the new at the Health IT policy study by Milliman. fndings of the study will drugs [including Sovaldi committee meeting. Tis is equivalent to impact taxpayers and Part and Olysio] are used According to the a 6% to 11% increase in D sponsors more than and the cost remains at report, 90% of eligible federal Part D spending, managed care organization the current level,” said professionals (EPs) or approximately $100 or hospital decision- Kaczmarek. “Formulary have registered for the to $200 per Medicare makers. managers are likely to Medicare or Medicaid Part D benefciary per Te Pharmaceutical use prior authorization electronic health record year. Furthermore, it is Care Management and step edits to control (EHR) incentive program, estimated that the cost Association (PCMA) utilization.” and so far more than of HCV drug therapies retained Milliman to Debate about the 400,000 EPs have will increase total annual analyze the cost impact expensive treatment’s received apayment. individual Medicare Part of the new HCV drug efect on the healthcare The number of D benefciary premiums therapies on the 2015 system was prompted providers who have by $481 million to $965 individual Medicare Part by the groundbreaking attested to meaningful million in 2015. Tis is D program. Tere are Hepatitis C drug sofosbuvir use has seen a sharp equivalent to a 4.3% to an estimated 3.2 million (Sovaldi), which reached increase since CMS’ 8.6% increase over 2014 people in the United States sales of $5.7 billion in the report earlier this year. benefciary premiums or infected with HCV, many of frst six months of 2014 as As of August 25, 2014, an additional $17 to $33 whom are undiagnosed. demand for the drug has 8,024 EPs and 436 per benefciary per year. Of these 3.2 million surged. hospitals have attested “Payers (PDP sponsors) people, approximately Sovaldi, produced by for the 2014 reporting are somewhat concerned 270,000 were enrolled in Gilead Sciences, costs period. Of those about the increase in cost Medicare Part D in 2013. $84,000 for a 12-week reporting, 3,152 EPs and but the government is Terefore, expensive HCV course. But the drug 143 hospitals attested to paying the bulk of [it],” says treatments will have a can cure Hepatitis C in meaningful use stage 2 Steve Kaczmarek, principal signifcant impact on a majority of cases with (MU2). and consulting actuary, individual Medicare Part D minimal side efects. “We expect to see the Milliman. “Although there spending. Curing the disease would numbers continue to go are drugs on the market “We used our pricing mean preventing long up,” Myers said. “You can that have higher costs, they models to determine who hospitalizations and see that these numbers are used to treat conditions will bear the cost of the liver transplants, which are signifcantly that are not as prevalent new drugs by running can cost an average of diferent than what as Hepatitis C. With a pricing scenarios with and $600,000 per patient, we were getting last potential patient base of without the new drugs,” reports the Washington quarter.” 3.2 million patients in the Kaczmarek explained. Post.

MedicalEconomics.com Medical econoMics ❚ OctOber 10, 2014 19

magentablackcyanyellow ES502304_ME101014_019.pgs 09.20.2014 01:48 ADV magentablackcyanyellow ES501204_ME101014_020_FP.pgs 09.18.2014 01:55 ADV HEART FAILURE SHATTERS MILLIONS OF LIVES

HEART FAILURE PATIENTS: “STABLE” OR SILENTLY PROGRESSING? Heart failure is a progressive disease that is characterized by frequent hospital admissions and high mortality rates:

HEART FAILURE OF HEART FAILURE HOSPITALIZATIONS PATIENTS DIE WITHIN OCCUR EVERY YEAR1 1 YEAR OF DIAGNOSIS3,4 and rehospitalization this increases to ~50% continues to be an issue2 within 5 years3,4

The neurohormonal imbalance associated with chronic heart failure is a contributing pathophysiological factor to the progression of the disease. Overactivation of the RAAS and SNS lead to decline in heart function, and cardiac remodeling; and the normal counterregulatory beneﬁcial effects of the natriuretic peptide system (ANP/BNP) are diminished in heart failure.5-7

RAAS=renin-angiotensin-aldosterone system; SNS=sympathetic nervous system; ANP=atrial natriuretic peptide; BNP=brain natriuretic peptide.

References: 1. Go AS, Mozaffarian D, Roger VR, et al. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129(3):e28-e292. 2. Bradley EH, Curry L, Horwitz LI, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6(4):444-450. 3. Levy D, Kenchaiah S, Larson MG, et al. Long-term trends in the incidence of and survival of heart failure. N Eng J Med. 2002;347(18):1397-1402. 4. Roger VL, Weston SA, Redﬁeld MM, et al. Trends in heart failure incidence and survival in a community-based population. JAMA. 2004;292(3):344-350. 5. Fauci AS, Braunwald E, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill; 2008. 6. Boerrigter G, Costello- Boerrigter L, Burnett JC Jr. Alterations in renal function in heart failure. In: Mann DL. Heart Failure: A Companion to Braunwald’s Heart Disease. 2nd ed. St. Louis: Saunders; 2011. 7. McMurray J, Komajda M, Anker S, et al. Heart failure: epidemiology, pathophysiology and diagnosis. In: Camm AJ, Lüscher TF, Serruys PW. ESC Textbook of Cardiovascular Medicine. New York: Oxford University Press; 2009.

magentablackcyanyellow ES501205_ME101014_021_FP.pgs 09.18.2014 01:56 ADV COVER STORY

EHR

tings SCORECARDysician ra usability Ph on system

LIKE A TEENAGER, today’s electronic health record (EHR) systems seem clumsy, f ckle, stubborn, argumentative, crash way too frequently, and force physicians to exercise great patience with a tool born to improve ef ciency. Physicians cite EHR adaptability, interoperability, and their impact on quality of care as areas in need of further development despite a decade of government incentives totaling nearly $24.7 billion through June 2014. Getty Images/iStock/360

22 MEDICAL ECONOMICS ❚ OCTOBER 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES503325_ME101014_022.pgs 09.23.2014 01:38 ADV Yet, as healthcare informa- needs in an era of cataclysmic tion technology (HIT) moves out change. (See story, page 24.) of its adolescence, infrastructure Also highlighted in this issue are INSIDE improvements, software develop- the top 50 EHR companies displayed ment, and interfaces will be nothing alphabetically to of er physicians a short of transformative says Karen predictive metric for a company’s 24 EHR scorecard B. DeSalvo, MD, MPH, MSc, national longevity in the market. Medical coordinator of the Of ce of the Economics explores healthcare’s National Coordinator for Healthcare 10-year vision for technology, and its Information Technology (exclusive challenges and benef ts. interview on page 68)—like the evolution of cell phones to smart phones. Tomorrow’s practice The scorecard is in. Our won’t be conf ned by four walls 25 Quality of care and 15-minute appointment coverage aims to help 26 Meaningful use slots, but will have the ability, for 28 Patient portals the f rst time, to inf uence, guide you better understand 30 and educate patients in real-time Technical support at home or at work. And that 32 Clinical support will forever change the practice EHR system capabilities of medicine and how healthcare and showcase physician teams operate to help patients 34 About the survey improve health. But there is a lot of work left opinions on usability. respondents to fulf ll that vision. In February 2014, Medical Economics unveiled groundbreaking survey results that showed widespread dissatisfac- In the October 25, 2014 edition, tion with EHR systems. A survey we take on a key question about data of approximately 1,000 practicing ownership, especially as it relates to physicians showed that nearly 70% sharing of patient health informa- do not believe the EHR investment tion with specialists, subspecialists, 38 has been worth the ef ort, resources, hospitals and other healthcare Top 50 EHRs and costs. Poor system functional- networks as required by the govern- ity would be the deciding factor to ment’s Meaningful Use 2 incentive switch EHRs for nearly 69% of the program to adopt and use EHR respondents. Cost was cited by 48% technology. of physicians. T e scorecard is in. As you read Because these results were so through this series, remember compelling, Medical Economics that the guiding principles of this conducted a follow-up survey in coverage aim to help you better mid-2014, netting 7,240 physician understand EHR capabilities, and 68 respondents, to further examine showcase a collective opinion about Exclusive interview EHR usability, functionality, techni- usability by physicians. Most impor- with ONC’s Karen cal support, meaningful use attesta- tantly, this coverage explores tech- DeSalvo tion data, clinical decision support nology challenges today and let’s you tools and patient portals to help see tomorrow’s vision to help you physicians and EHR companies succeed in a dynamic and rapidly develop systems that meet patient changing healthcare market.

MedicalEconomics.com MEDICAL ECONOMICS ❚ OCTOBER 10, 2014 23

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SATISFACTION WITH EHR SYSTEMS GROWS AMONG PHYSICIANS

Exclusive survey gathers physician usability ratings of the top EHR systems in ﬁ ve key areas

by KEN TERRY Contributing editor

onsidering the dissatisfaction that many dents had EHRs, and only 11% of those said physicians have expressed about elec- they were planning to replace their system tronic health records (EHRs), you might within the next 12 months. On the other think that most doctors hate these sys- hand, only 55% said they would recommend tems. But, according to an exclusive Medical their EHR to colleagues. T e satisfaction of Economics survey, 55% of physicians are fair- physicians with particular aspects of their ly or very satisf ed with their EHRs, and EHRs varied a great deal, and the market 54% believe they have helped improve leaders were not necessarily the most popu- the quality of care. lar among their customers. Forty-f ve percent of respondents said Since the survey sample was skewed to- that EHRs have had a positive f nancial ward small and medium-sized private prac- impact on their practices. Most of that is tices, this doesn’t surprise Holmes. T e phy- probably related to the Meaningful Use sicians in these practices probably selected incentives from the government, says Mi- the cheap and free products from smaller chelle Holmes, MBA, a Seattle-based princi- vendors, she notes. “T ey’re not using a pal with ECG Management Consultants. “I system that someone else selected on their don’t think it’s the norm for people to say the behalf.” prof tability of their practice is better after Internist Edward Gold, MD, an experi- EHR implementation than before it, from a enced EHR user who practices in a 59-doc- productivity and cost perspective.” tor group based in Emerson, New Jersey, About 80% of Medical Economics’ respon- Continued on page 25 Getty Images/iStock/360 (background) Getty Images/iStock/360

24 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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Continued from page 24 give you the reports you need for the medi- says many physicians prefer the inexpensive cal home, the reports you need to belong to EHRs “because they’re simple, and they’re an ACO. Tey don’t have the interoperability meant to be easy to use. But they don’t ac- or the connectivity that’s required. Tey’ll complish all the things that need to be ac- do for keeping an ofce record, but they just complished for Meaningful Use. Tey don’t Continued on page 26 EHR Quality of care The effect your EHR has on the usability quality of care your practice provides An EHR system can either enhance or hinder the care a physician provides to his or her patients. The promise of EHRs is that they will help physicians and the healthcare system provide high-value Ratings care, but that remains largely unfulfilled. Some systems are closer to this ideal than others. The vendors that focus on helping physicians The performance of an navigate today’s healthcare challenges will thrive.

electronic health record Rank System Base Score (EHR) system can mean 1 SOAPware 24 8.0 the difference between 2 MEDENT 67 7.2 a thriving practice and a struggling one. These 3 Healthfusion 29 6.9 systems impact every 4 e-MDs 156 6.5 aspect of medical care, 5 Epic 986 6.3 from the care physicians 6 Amazing Charts 114 6.3 provide to patients to the 7 Advanced MD 27 6.2 practice’s ability to get 8 Practice Fusion 6.1 paid for the work it does. 255 For this exclusive 9 Modernizing Medicine 42 6.1 EHR Scorecard, Medical 10 athenahealth 221 6.0 Economics asked 11 eClinicalWorks 540 5.8 thousands of physicians 12 Aprima 48 5.7 to rate their systems, on 13 Care360 (Quest) 54 5.6 a scale of 0 to 10, in the key areas that matter 14 McKesson [All systems} 105 5.2 most to them. 15 GE 256 5.1 Demographic 16 Greenway* 227 5.0 information on the 17 Vitera* 108 5.0 survey respondents can 18 Nextech 23 4.9 be found on page 34. 19 Cerner 211 4.6 20 Allscripts [All systems] 552 4.5

*Greenway and Vitera merged in late 2013 to become Greenway Health.

MedicalEconomics.com Medical econoMics ❚ OctOber 10, 2014 25

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Continued from page 25 provide the basics.” Tis coverage highlights fve EHR usability areas important to physicians: Quality of Meaningful Use care, Meaningful Use, patient portals, tech- Percentage achieving Meaningful Use nical support and clinical support. (See EHR system scores on pages 25, 26, 28, 30 and 32.) The ability to attest to the federal government’s Meaningful Use incentive program is the primary reason many physicians purchased AttestAtion tools an EHR. But some systems have tools that make attesting easier Of the respondents who used EHRs, 78% than others. Satisfaction with this function is key, especially for had attested to Meaningful Use in the past meeting the challenges of stage 2. year. Sixty-eight percent said the ability of their EHR to enable them to attest to meaningful use was “good” or “excellent.” Rank System Base MU% Internist Kenneth Kubitschek, MD, a partner in North Carolina Internal Medi- 1 Epic 986 87% cine in Asheville, North Carolina, and Gold both said their EHRs made it fairly easy to 2 Allscripts [All systems] 552 87% attest in Meaningful Use stage 1. But like most doctors, they’re having trouble with 3 Nextech 23 87% some stage 2 requirements for reasons that have little to do with the quality of their 4 GE 256 85% EHRs. Teir challenges include getting patients to use patient portals and exchang- 5 NextGen 399 83% ing care summaries at transitions of care in an environment where interoperability 6 Cerner 211 83% remains limited. 7 eClinicalWorks 540 82% 8 athenahealth 221 82% 30% 9 MEDENT 67 81% of physicians rated their EHR system as excellent 10 Vitera* 108 79% at making attesting to 11 McKesson [All systems] 105 79% meaningful use easy

12 MEDITECH 102 79% One area in which EHRs seem to have 13 Greenway* 227 76% made progress is clinical decision support (CDS). Sixty-eight percent of our respon- 14 Care360 (Quest) 54 76% dents had a positive opinion of their ability to use their EHR to implement at least fve 15 e-MDs 156 75% CDS support tools, which is required for Meaningful Use stage 2. 16 Aprima 48 73% Holmes notes that the CDS tools in current EHRs go well beyond pop-up alerts in 17 Practice Fusion 255 68% electronic prescribers that warn doctors about drug interactions, wrong dosages, 18 SOAPware 24 67% and so forth. CDS is built into the documentation templates of many EHRs, she points 19 Modernizing Medicine 42 60% out. For example, there may be prompts regarding out-of-range information on vital 20 Healthfusion 29 60% signs. Some of the prompts regarding practice *Greenway and Vitera merged in late 2013 to become Greenway Health. Continued on page 28

26 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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magentablackcyanyellow ES502886_ME101014_027_FP.pgs 09.22.2014 22:43 ADV EHR SCORECARD

Continued from page 26 guidelines, such as initial medications suggested for a patient with newly diagnosed Patient portal diabetes, are quite helpful, Kubitschek says. Usability of the patient portal But many care planning prompts, such as from your EHR vendor suggested recommendations to an over- weight patient, are unnecessary, he adds. A functional and intuitive patient portal is key to lessening the Peter Basch, MD, medical director for administrative burdens faced by physicians and improving ambulatory health and health IT policy communication between providers and patients. It leads to more at MedStar Health in Washington, D.C., efficient workflow and boosts practice productivity. Studies have observes that EHRs certifed for Meaning- shown that patients who use a portal to communicate with their ful Use must contain certain types of CDS doctor are healthier and more satisfied. tools. Tese include reminder alerts, he says. But he feels that vendors have much Rank System Base Score further to go in this direction. For one thing, alerts that are fred improperly can lead to 1 MEDENT 67 8.1 alert fatigue. Also, he notes, smart features could be developed to suggest diagnostic 2 Epic 986 7.1 tests for a particular problem and to fnd out whether similar tests had been per- 3 athenahealth 221 7.1 formed earlier. 4 Practice Fusion 255 7.0 ConneCting with pAtients About six in ten respondents gave a “good” 5 SOAPware 24 6.7 or “excellent” rating to the usability of their patient portal and the ease of updating 6 Healthfusion 29 6.6 EHR data on the portal. Tis is important to many practices because of Meaningful Use 7 Amazing Charts 114 6.5 stage 2. Te government incentive program 8 Modernizing Medicine 42 6.3 requires that eligible professionals provide 50% of patients with online access to their 9 eClinicalWorks 540 6.2 records. Tey must also ensure that 5% of their patients view, download or transmit 10 Advanced MD 27 6.1 11 Nextech 23 5.8 % 12 Aprima 48 5.7 49 Fewer than half of 13 Greenway* 227 5.5 physicians said their EHR system is capable of 14 McKesson [All systems] 105 5.5 enabling them to identify patients who are out 15 Vitera* 108 5.3 of bounds on speciﬁc 16 GE 256 5.1 individual measures, such as an elevated A1C. 17 Cerner 211 5.1

18 e-MDs 156 5.0 their health information online. And they have to demonstrate that they can ex- 19 Care360 (Quest) 54 4.9 change secure messages with patients. Te main barrier to achieving these 20 NextGen 399 4.8 goals is not the technology, Holmes notes. “Most portals aren’t difcult for the practice *Greenway and Vitera merged in late 2013 to become Greenway Health. Continued on page 30

28 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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magentablackcyanyellow ES502867_ME101014_029_FP.pgs 09.22.2014 22:43 ADV EHR SCORECARD

Continued from page 28 or the patient to use. Te hurdle is getting people to use them.” Technical support Aside from that, Kubitschek says, his Vendor’s ability to resolve technical patient portal works very well. “When I do problems with your EHR my labs and other stuf, the information up- loads automatically as soon as I sign it. And Is your vendor there when you need them? Glitches and system the patients are getting it, because we’re crashes can derail a physician’s day and harm a practice’s workflow, talking to them. It has their problems, aller- not to mention the aggravation of waiting on the phone instead of gies, medications, and immunizations. We seeing patients. Technical support and training a vendor provides get messages back and forth from the pa- is key when shopping for an EHR system. Nothing leads to buyer’s tients. I’ve been pretty pleased with it.” remorse faster than poor customer support. Another beneft, he adds, is that patient messages come right into an EHR inbox, Rank System Base Score and physicians can decide to whom those should be directed. He has his nurse triage 1 MEDENT 67 8.3 the patient communications. He can then reply directly to a patient message or send it 2 Amazing Charts 114 7.7 back to his nurse, and can choose whether to save it to the chart. 3 SOAPware 24 7.5 Vendor Customer serViCe 4 Modernizing Medicine 42 7.4 About 60% of the respondents rated the quality and amount of EHR training and the 5 Practice Fusion 255 6.8 vendor’s ability to solve technical problems as “good” or “excellent.” Around the same 6 Healthfusion 29 6.7 percentage gave a thumbs-up to the quality of the interface between their EHR and 7 athenahealth 221 6.6 practice management system (PMS), if they 8 Care360 (Quest) 54 6.6 had non-integrated systems. On the other hand, many respondents 9 Nextech 23 6.5 gave their vendors fair or poor scores for their ability to solve technical problems 10 Epic 986 6.4 (30%), the level of support the practice received in confguring the EHR (29%), the 11 Advanced MD 27 6.4 12 e-MDs 156 6.3 % 13 Aprima 48 6.3 53 of physicians say they do 14 eClinicalWorks 540 6.1 not use their EHR vendor for billing or revenue 15 Vitera* 108 5.7 cycle management

16 Greenway* 227 5.6

17 McKesson [All systems] 105 5.2 quality and amount of training (28%), and the ability to customize their EHR (36%). 18 Cerner 211 4.9 Basch believes that increasing transpar- ency and competition have induced ven- 19 GE 256 4.8 dors to ofer packages of software, training and implementation that are better than 20 Allscripts [All systems] 552 4.7 they were. Holmes, in contrast, speculates that many physicians rate their vendors *Greenway and Vitera merged in late 2013 to become Greenway Health. Continued on page 32

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Continued from page 30 highly because they don’t know how much of the support work is being done by their Clinical support organization’s IT staf or by “super-users” in Ability to implement at least ﬁve their own ofces. clinical decision support tools Gold and Kubitschek both give their vendors fairly high marks for training and tech- Most systems can provide alerts and other notifications to help nical support. But Gold notes that training physicians provide better care to their patients, especially those varies greatly among EHR suppliers. “Te suffering from chronic conditions that require constant monitoring. basic problem that most doctors have with Intuitive clinical decision support—including alerts and reminders, EHRs has to do with the inadequacy of clinical guidelines, documentation templates, and focused patient data training. Te lower level EHR vendors will reports—can help doctors improve care and meet quality measures. give you six hours of training online. Te more training you get, the more it costs, and Rank System Base Score doctors don’t like costs. Doctors never invest enough in training,” he says. 1 MEDENT 67 8.4 His own group he adds, is big enough to aford its own IT person, who trains new 2 Amazing Charts 114 8.1 staf and provides ongoing training to the doctors and staf members. “It’s never once 3 Healthfusion 29 8.0 and done,” he points out. “In a higher-end system, there are so many bells and whistles 4 athenahealth 221 7.7 that people are unaware of that could make their lives a lot easier. It’s a continuous pro- 5 Modernizing Medicine 42 7.6 cess of educating people.” 6 Practice Fusion 255 7.5 QuAlity reporting Seventy-nine percent of EHR users said 7 Aprima 48 7.5 their systems could generate quality re- 8 e-MDs 156 7.4 ports. Tat’s about the same percentage of respondents who said they’d attested 9 Epic 986 7.3 10 Care360 (Quest) 54 7.2 % 11 Advanced MD 27 7.1 70 of physician respondents 12 eClinicalWorks 540 6.8 who do not have an EHR system have no plans to 13 SOAPware 24 6.8 purchase one.

14 Vitera* 108 6.5 to Meaningful Use, which requires quality 15 Greenway* 227 6.3 measures. But these statistics obscure the dif- 16 McKesson [All systems] 105 6.3 culties that some users have in using their EHRs to report on quality measures, Gold 17 GE 256 5.7 says. “In some systems, it’s easy to generate reports,” he notes. “Others require the 18 NextGen 399 5.6 involvement of the vendor, which charges the physicians to do this.” Moreover, if doc- 19 Allscripts [All systems] 552 5.5 tors and practice staf aren’t specifcally trained to produce reports, it might be very 20 Cerner 211 5.5 challenging for them. Gold himself fnds it fairly simple, he adds, because his system *Greenway and Vitera merged in late 2013 to become Greenway Health. Continued on page 35

32 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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magentablackcyanyellow ES502883_ME101014_B33_FP.pgs 09.22.2014 22:44 ADV EHR SCORECARD

at a surVey respondents GlaNCE

More than 7,400 primary care physicians and specialists took part in this exclusive Medical Economics survey, conducted by Readex Research. The charts below provide a snapshot of the survey pool’s pertinent information, including practice description, size, and afﬁ liation, and electronic health record (EHR) use and history. ractice size N=7442 ractice description N=7442 P P Physician employment N=7442 Privately held Privately Owned a hospital/health system by system of a government Part Other employed currently Not Family Medicine Family Pediatrics Medicine/Other IM specialtyInternal OB/GYN Other specialtySurgical Multispecialty group Cardiology answer No 1 physician 2-5 physicians 6-10 physicians 11-25 physicians 26-50 physicians 51-100 physicians than 100 physicians More 8% 8% 2% 1% 5% 3% 8% 5% 4% 3% 22% 19% 17% 12% 11% 25% 32% 15% 11% 61% 28%

EHR use Years with current EHR system N=5755 20% 80% 40% NO YES 30%

20% N=7240 10%

Meaningful use attestation in last 12 months <1 year 1-3 years 4-5 years >5 years No answer 2% 20% 78% NO YES Top 10 ambulatory EHR systems, by number of respondents Epic 1004 N=5790 Allscripts 561 eClinicalWorks 551 Planning to replace 405 current EHR system NextGen 261 11% Practice Fusion YES GE 257 89% 230 NO Greenway athenahealth 222 Cerner 214 N=5701 e-MDs 158

34 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES503382_ME101014_034.pgs 09.23.2014 01:45 ADV EHR SCORECARD

Continued from page 32 ever, the challenge is much provides a dashboard for % more immediate. Tey’re too this purpose. 30 busy attesting to Meaningful Fairly high numbers Number of Use stage 2 and getting all of respondents said their physicians who their quality reports right to EHRs could generate clini- worry about using the data cal reports on subgroups said they have for quality improvement, he of patients (63%), identify had their EHR says. patients who were out of system for more bounds on specifc mea- than 5 years. usAbility sures, such as diabetic Nearly two-thirds of respon- patients with elevated dents gave above-average A1c levels (49%), and send scores to their EHRs on two alerts to providers and care managers about markers for usability: ease of ordering tests patient care gaps (45%). Eighty-seven per- and medications, and ease of moving be- cent of EHR users said their systems could tween sections of EHRs. And 53% of respon- do at least one of these tasks. dents rated their vendor’s ability to custom- Do many physicians use this data and ize their EHRs as “good” or “excellent.” the related workfow features to improve Regarding customization, Holmes be- care and manage population health? Basch lieves that most physicians can’t read- doubts it. Te business case for using health ily distinguish between what their own IT IT to improve quality, he says, is still lacking people or other stafers do and what their in most practices. vendor does. But employed physicians have For Kubitschek and his colleagues, how- Continued on page 36

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magentablackcyanyellow ES503386_ME101014_035.pgs 09.23.2014 01:45 ADV EHR SCORECARD

EHR UsabiliTy REPoRT Continued from page 35 vice (ERA) correctly; 53% a more difcult time get- 54% did the same for their ting things changed in system’s ability to provide survey their EHR than do private More than half feedback on coding er- methodology practice doctors, she says, of physician rors. because of the former’s respondents say “I thought those num- The fndings cited in this need for organizational bers should be higher,” approval. So she thinks their EHR has had Holmes says. “If you have report are based on a survey the usability scores refect a positive impact a PMS that can’t post an conducted by Readex Research “the amount of control on the quality ERA correctly, you have a and sponsored by Medical that physicians have over problem. Tat’s core func- Economics of care they provide. . Through the use of their systems in smaller tionality that’s been there an online survey, the purpose practices.” for years.” of this research project was Tat doesn’t explain Some practices are still to better understand use % the popularity of cloud- 11 clinging to old billing sys- and performance regarding based EHRs, which al- tems that are no longer ambulatory electronic low little customization. Number of supported by their ven- health record (EHR) systems Holmes thinks that prac- physicians who dors, she notes. In addi- currently available to medical tices that choose those said they have had tion, a substantial portion professionals. products see other ad- their EHR system of the practice universe Data was collected via vantages in them. Among for less than 1 year. isn’t even using ERA yet, an online survey from June other things, she says, according to a recent re- 10, 2014 to June 27, 2014. they’re generally simpler port. to implement, learn and The survey was closed optimizAtion for tabulation with 7,442 navigate than are more 45% responses. However, a complex client-server pro- Te bulk of responses to majority of the study’s results grams. of physicians questions about the re- are based upon the 5,790 Basch gives credit to reported that spondents’ EHRs ranged employed respondents who EHR vendors for improv- from neutral to slightly ing the usability of their the overall positive. To Holmes, this indicated their practice has an products in some ways. performance indicates that much more ambulatory EHR system. For example, he notes, of their EHR is buried beneath the sur- As with any research, the physicians can order a face of the survey results. results should be interpreted system was test or a prescription any- average to poor. For example, she says, with the potential of non- where in the workfow in she’d like to know how response bias in mind. It is many systems, rather than much IT support the re- unknown how those who having to be at a certain spondents had available responded to the survey may point in the process. to them and how much be diferent from those who Kubitschek, says that the usability of of the EHR’s functionality they’re actually did not respond. In general, EHRs has vastly improved since he start- using. the higher the response rate, ed using one in 1995. While the vendors Basch takes a more optimistic view. the lower the probability of haven’t made much progress in the past Considering all of the difculties doctors estimation errors due to non- three years because of their focus on Mean- encounter in learning how to use an EHR response and thus, the more ingful Use, he says, he’s recently seen some and changing how they work, he says, “I’d stable the results. innovations that have made his EHR more expect people to feel neutral to slightly The margin of error for user-friendly. positive.” percentages based on 5,790 Te determining factor in how an indi- responses is ±1.3 percentage prACtiCe mAnAgement systems vidual physician or a group feels about an points at the 95% confdence Because fnances are the lifeblood of prac- EHR—assuming it has decent functional- level. The margin of error for tices, the practice management system ity—is the degree to which the doctors have percentages based on smaller component of EHRs—or the standalone optimized their system so that it helps them sample sizes will be larger. PMS bolted to an EHR—is vitally impor- become more efcient and deliver better tant. But just 61% of respondents gave good care. Says Basch, “If you take a less than op- or excellent scores to the ability of their timal tool and try to optimize it, you can get system to post electronic remittance ad- better results.”

36 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES503375_ME101014_036.pgs 09.23.2014 01:44 ADV According to a new Wells Fargo Securities report, Aprima ranks among the top five vendors* that physicians choose to replace their previous EHR.

HERE’S JUST A FEW REASONS WHY:

• Aprima ranks #1 in Clinical Decision Support.** We make it easy to switch – on-premise • Aprima also ranks high in these usability or in the cloud, purchase or lease – you and satisfaction categories: decide what works best for your practice.

• Aprima helps you navigate Ability to Achieve Impact on Meaningful Use, CQMs, ICD-10, PQRS, interoperability and more. Meaningful Use Quality of Care Technical Patient Portal • Our customers tell us that they can see Support more patients, enjoy improved financial performance and are able to spend more time with their families.

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*Source: CMS and Wells Fargo Securities, LLC estimates. ** Based on a survey of EHR users in the Medical Economics Top 50 report, October 10, 2014 issue. ©2014 Aprima Medical Software, Inc. All rights reserved. Aprima is a registered trademark of Aprima Medical Software. All other trademarks are the property of their respective owners.

magentablackcyanyellow ES503700_ME101014_037_FP.pgs 09.23.2014 04:11 ADV Top 50 EHRs

Medical Economics is unveiling this exclusive report on the top 50 electronic health record (EHR) vendors in an eﬀ ort to help physicians make purchasing decisions. Companies are listed in alphabetical order.

Public Vendor System Name or Private Company Annual Revenue EHR Annual Revenue Website 4Medica 4medica iEHR Private $6,000,000 $2,000,000 www.4medica.com

AdvancedMD (ADP) AdvancedMD EHR Public $12,000,000,000 www.advancedmd.com

Advanced Data Systems MedicsDocAssistant EHR/EMR Private * www.adsc.com Corp.

Allscripts Healthcare Touchworks EHR, Allscripts Public $1,400,000,000 $870,000,000 www.allscripts.com Solutions, Inc. Professional EHR

Amazing Charts, LLC Amazing Charts Private $8,700,000 $8,700,000 www.amazingcharts.com

Aprima Medical Software Aprima EHR Private ** www.aprima.com

athenahealth athenaClinicals Public $595,000,000 www.athenahealth.com

Benchmark Systems, Inc. Benchmark Clinical Private $10,000,000 $3,000,000 www.benchmark-systems.com

Bizmatics, Inc. PrognoCIS EMR Private $6,000,000 $6,000,000 www.bizmaticsinc.com

CareCloud Corp. CareCloud Charts Private $11,000,000 $11,000,000 www.carecloud.com

Cerner Corp. PowerChart Ambulatory Public $2,900,000,000 www.cerner.com

CompuGroup Medical, Inc. CGM CLINICAL, CGM webEHR, Public $50,000,000 $40,000,000 www.cgmus.com (CGM US) CGM ENTERPRISE EHR

CPSI CPSI Medical Practice EMR Public $200,860,000 www.cpsi.com

*Revenue estimates gathered from Hoovers f nancial reporting. **Revenue withheld at company’s request

INSIdE EHR reference guide ALSO 46 Capability checklist 68 Exclusive interview 56 Meaningful Use 2 with ONC’s Karen DeSalvo 62 Patient portal 63 Revenue cycle management

38 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES503381_ME101014_038.pgs 09.23.2014 01:45 ADV Top 50 EHRs

Public Vendor System Name or Private Company Annual Revenue EHR Annual Revenue Website CureMD CureMD All-in-One EHR Private $91,800,000 $62,200,000 www.curemd.com

Cyfluent Cyfluent Private $5,000,000 $2,000,000 www.cyfluent.com

DocuTAP, Inc. DocuTAP Private ** www.docutap.com

e-MDs , Inc. Solution Series, Private ** www.e-mds.com Cloud Solutions

eClinicalWorks eClinicalWorks Private $280,000,000 $252,000,000 www.eclinicalworks.com

Endosoft EndoVault Private * www.endosoft.com (Utech Products, Inc.)

Epic Systems Corp. EpicCare Ambulatory, Private $1,660,000,000 $1,660,000,000 www.epic.com EpicCare Inpatient

GE Healthcare (GE Corp.) Centricity Practice Solution / Public $146,000,000,000 www.gehealthcare.com Centricity EMR

Glenwood Systems, LLC GlaceEMR Private $7,500,000 $7,500,000 www.glenwoodsystems.com

Greenway Health, LLC PrimeSUITE, Intergy, Private $350,000,000 www.greenwayhealth.com SuccessEHS

HealthFusion, Inc. MediTouch Private $35,000,000 $35,000,000 www.healthfusion.com

Integrated Systems Omni EHR Private * www.omnimd.com Management, Inc.

iPatientCare, Inc. iPatientCare Private $39,000,000 $39,000,000 www.ipatientcare.com

Kareo, Inc. Kareo EHR Private $48,000,000 $48,000,000 www.kareo.com

MacPractice, Inc. MacPractice MD, Private $15,000,000 $15,000,000 www.macpractice.com MacPractice 20/20, MacPractice DC, MacPractice DDS

McKesson Specialty iKnowMed (SM) EHR, iKnowMed Public $122,460,000,000 www.mckesson.com Health (McKesson Corp.) (SM) Generation 2

MD On-Line, Inc. (MDOL) MDOL EMR Private $32,160,000 $3,390,000 www.mdon-line.com

MEDENT MEDENT Private $42,000,000 $30,000,000 www.medent.com

Medical Informatics WebChart EHR Private * www.mieweb.com Engineering, Inc.

MEDITECH MEDITECH Private $597,840,000 www.meditech.com

Meditab Software, Inc. IMS Clinical Private $35,000,000 $20,000,000 www.meditab.com

MicroFour, Inc. PracticeStudioX16 Private $13,650,000 $12,000,000 www.practicestudio.net

Modernizing Electronic Medical Assistant (EMA) Private $17,300,000 $17,300,000 www.modmed.com Medicine, Inc.

MTBC ChartsPro Public * www.mtbc.com

Nextech Nextech Private ** www.nextech.com

*Revenue estimates gathered from Hoovers fnancial reporting. **Revenue withheld at company’s request Continued on page 45

MedicalEconomics.com Medical econoMics ❚ OctOber 10, 2014 39

magentablackcyanyellow ES504753_ME101014_039.pgs 09.24.2014 19:48 ADV Advertisement not available for this issue Advertisementof the not digital available edition for this issue of the digital edition

Top 50 EHRs

Continued from page 39 Public Vendor System Name or Private Company Annual Revenue EHR Annual Revenue Website NextGen Healthcare NextGen Ambulatory EHR Public $444,700,000 $335,000,000 www.nextgen.com Information Systems, LLC

Optum, Inc. Optum Physician Public $37,000,000,000 www.optum.com (UnitedHealth Group) EMR

Platinum Systems PlatinumEMR Private * www.platinumemr.com Specialists, Inc.

Practice Fusion, Inc. Practice Fusion EHR Private * www.practicefusion.com

Practice Velocity, LLC VelociDoc Private $24,500,400 $12,800,000 www.practicevelocity.com

Praxis EMR Praxis EMR v5 Private $38,400,000 $38,400,000 www.praxisemr.com (Infor-Med Medical Information Systems, Inc.)

Prime Clinical Patient Chart Manager Private $10,000,000 www.primeclinical.com Systems, Inc.

Pulse Systems, Inc. Pulse Complete EHR Public $1,200,000,000 $92,300,000 www.pulseinc.com (Cegedim Group)

Quest Diagnostics Care360 EHR Public $7,100,000,000 www.medplus.com

RazorInsights, LLC ONE-Electronic Health Record Private $7,000,000 $7,000,000 www.razorinsights.com

SOAPware, Inc. SOAPware, myHEALTHware Private $5,600,000 $5,600,000 www.soapware.com

Viztek Opal-EHR, Exa Private $72,000,000 www.viztek.net

DownloaD Find the Top 50 list and other EHR reference materials at http://MedicalEconomics.com

*Revenue estimates gathered from Hoovers fnancial reporting. **Revenue withheld at company’s request

ot How we g 1 Companies ofering complete, 4 If editors obtained a revenue range, our data ambulatory EHR systems were given the the low end of the range was used. opportunity to report company data by flling out a Medical Economics survey. Editors 5 Some survey participants evaluated companies based on survey provided Medical Economics with revenue Tis Medical Economics responses and other criteria. data for our internal deliberations only. Those vendors are marked with ** in the project started in spring 2 When available, editors obtained revenue feld. 2014 and concluded on revenue for publicly traded companies from August 28, 2014. Here is published annual reports. 6 The Top 50 is listed in alphabetical order. how the editorial team 3 Editors used revenue estimates from 7 Some companies provided annual EHR approached gathering Hoovers fnancial reporting if vendors revenue while others did not. That feld was company data presented did not complete the survey and if other left blank when not provided. in this report: information, such as published annual reports, was not available. Hoovers estimates are denoted with an * in the revenue feld. Top 50 EHRs continued on page 46

MedicalEconomics.com Medical econoMics ❚ OctOber 10, 2014 45

magentablackcyanyellow ES503380_ME101014_045.pgs 09.23.2014 01:44 ADV EHR capability CHECKLIST

Does your electronic health record (EHR) system have the functionality you need? Choosing an EHR vendor that provides the services your practice requires is a complicated endeavor, and purchasing the wrong system can cut into practice f nances and hamper workf ow for years. T is EHR Capability Checklist was designed by Medical Economics editors to help physicians evaluate their current EHRs or shop for a new one. Is your system up to snuf ? See the checklist below to f nd out.

VENDOR SUPPORT AND TRAINING PATIENT PORTAL

Offers on-site training Offers a patient portal

Provides online resources for training Allows patient to view: purposes, such as tutorials, online chats and downloadable educational Lab results materials Plan of care summary Ability to create customized templates X-ray reports that suit the needs of your practice Other diagnostic testing Responds quickly to technical Consultant reports problems associated with the EHR system Educational materials

Provides guaranteed turnaround times for resolving technical issues Ability to communicate securely through the patient portal Offers ﬂ exible and after-hours technical and staff support Enables patients to schedule and cancel appointments through the patient portal Provides U.S.-based technical support call centers Enables patients to request prescription reﬁ lls through the patient portal

Continued on page 48

46 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES503237_ME101014_046.pgs 09.23.2014 00:39 ADV Kareo helps you get back to your patients. With intuitive software and services from Kareo, you can simplify your ofﬁce administration, get faster, more accurate payments, and take the pain out of your ICD-10 transition. Created just for the private practice, Kareo’s affordable suite of EHR, practice management, and billing solutions helps you run your practice smarter, so you can get back to what’s important. Get back to being a doctor at 866-231-2871 or kareo.com/icd-10.

magentablackcyanyellow ES502856_ME101014_047_FP.pgs 09.22.2014 22:42 ADV Top 50 EHRs

Continued from page 46 INTERFACES MEANINGFUL USE

Provides the following system Capable of attesting to Meaningful interfaces: Use 2 (The system has met 2014 edition criteria of the Ofﬁce of the Reference National Coordinator for Health Hospital Information Technology)

Imaging Ability to exchange care summaries Practice management (PM) system with other providers to attest to Meaningful Use stage 2 Devices Provides veriﬁable Meaningful Use EKG stage 1 and stage 2 attestation rates Spirometry for eligible providers Holter monitor Provides easy-to-use Meaningful Use X-ray platform Ultrasound

Provides customized interfaces POPULATION HEALTH MANAGEMENT to meet your needs Generates reports on subgroups of patients (for example: women over 50 who are due for mammograms.) QUALITY CARE AND REPORTING Creates patient registries that track Produces quality data for Meaningful the preventative and chronic care Use services provided to patients

Generates quality data for Physician Ability to provide patient-care alerts Quality Reporting System Capable of exchanging clinical Enables providers to identify summaries across the spectrum of patients who are not meeting clinical care guidelines for chronic conditions Generates tailored educational Helps physicians improve quality materials for patients metrics

Continued on page 55 Ability to implement at least ﬁve clinical decision support tools (such as drug interaction checkers)

48 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES503240_ME101014_048.pgs 09.23.2014 00:39 ADV New packaging

Smaller carton, more syringes.

10-Pack 6-Pack Carton Dimensions: 114 x 52 x 124 mm. Carton Dimensions: 141 x 134 x 56 mm.

• VAQTA is now available in a 10-pack of single-dose adult formulation preﬁlled syringes • The new carton is 31% smaller than the currently-available 6-pack, which may help you store more syringes in less space The ACIP recommends vaccination for adult patients at increased risk of hepatitis A infection, including international travelers, users of injection or non-injection illicit drugs, and persons who have an occupational risk of infection. ACIP=Advisory Committee on Immunization Practices. About VAQTA VAQTA is indicated for the prevention of disease caused by hepatitis A virus (HAV) in persons 12 months of age and older. The primary dose should be given at least 2 weeks prior to expected exposure to HAV. Select Safety Information Do not administer VAQTA to individuals with a history of immediate and/or severe allergic or hypersensitivity reactions (eg, anaphylaxis) after a previous dose of any hepatitis A vaccine, or to individuals who have had an anaphylactic reaction to any component of VAQTA, including neomycin. The vial stopper and the syringe plunger stopper and tip cap contain dry natural latex rubber that may cause allergic reactions in latex-sensitive individuals. Please see additional select safety information on following page. New packaging

10-Pack 6-Pack Carton Dimensions: 114 x 52 x 124 mm. Carton Dimensions: 141 x 134 x 56 mm.

NDC 0006-4096-02 – carton of 10, 1-mL preﬁlled single-dose Luer-Lok® syringes with tip caps. NDC 0006-4096-09 – carton of 6, 1-mL preﬁlled single-dose Luer-Lok® syringes with tip caps.

To order: • Call the Merck Vaccine Customer Center at 1-877-VAX-MERCK (1-877-829-6372) Monday through Friday, 8:00 am to 7:00 pm, or visit MerckVaccines.com®

Select Safety Information (continued) The most common local adverse reactions and systemic adverse events (≥15%) reported in different clinical trials across different age groups when VAQTA was administered alone or concomitantly were: • Adults 19 years of age and older: injection-site pain, tenderness, or soreness (67.0%), injection-site warmth (18.2%), and headache (16.1%) Immunocompromised persons, including individuals receiving immunosuppressive therapy, may have a diminished immune response to VAQTA and may not be protected against HAV infection after vaccination. The total duration of the protective effect of VAQTA in healthy vaccinees is unknown at present. Vaccination with VAQTA may not result in a protective response in all susceptible vaccinees. Please see the adjacent Brief Summary of the Prescribing Information.

Brands mentioned are the trademarks of their respective owners.

Copyright © 2014 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. VACC-1106515-0000 06/14 VAQTA® (Hepatitis A Vaccine, Inactivated) ADVERSE REACTIONS Suspension for Intramuscular Injection Clinical Trials Experience Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a vaccine cannot Brief Summary of the Prescribing Information be directly compared to rates in the clinical trials of another vaccine and INDICATIONS AND USAGE may not reflect the rates observed in practice. Indications and Use The safety of VAQTA has been evaluated in over 10,000 subjects 1 year VAQTA is indicated for the prevention of disease caused by hepatitis A to 85 years of age. Subjects were given one or two doses of the vaccine. virus (HAV) in persons 12 months of age and older. The primary dose should The second (booster dose) was given 6 months or more after the first dose. be given at least 2 weeks prior to expected exposure to HAV. The most common local adverse reactions and systemic adverse events CONTRAINDICATIONS (≥15%) reported in different clinical trials across different age groups when VAQTA was administered alone or concomitantly were: Do not administer VAQTA to individuals with a history of immediate and/or severe allergic or hypersensitivity reactions (e.g., anaphylaxis) after • Children — 12 through 23 months of age: injection-site pain/tenderness a previous dose of any hepatitis A vaccine, or to individuals who have (37.0%), injection-site erythema (21.2%), fever (16.4% when administered had an anaphylactic reaction to any component of VAQTA, including alone, and 27.0% when administered concomitantly). neomycin [see Description (11)]. • Children/Adolescents — 2 through 18 years of age: injection-site pain (18.7%) WARNINGS AND PRECAUTIONS • Adults — 19 years of age and older: injection-site pain, tenderness, or Prevention and Management of Allergic Vaccine Reactions soreness (67.0%), injection-site warmth (18.2%) and headache (16.1%) Appropriate medical treatment and supervision must be available to manage Allergic Reactions possible anaphylactic reactions following administration of the vaccine [see Contraindications (4)]. Local and/or systemic allergic reactions that occurred in <1% of over 10,000 children/adolescents or adults in clinical trials regardless of causality Hypersensitivity to Latex included: injection-site pruritus and/or rash; bronchial constriction; asthma; The vial stopper and the syringe plunger stopper and tip cap contain wheezing; edema/swelling; rash; generalized erythema; urticaria; pruritus; dry natural latex rubber that may cause allergic reactions in latex-sensitive eye irritation/itching; dermatitis [see Contraindications (4) and Warnings individuals [see How Supplied/Storage and Handling (16)]. And Precautions (5.1)]. Altered Immunocompetence Children — 12 through 23 Months of Age Immunocompromised persons, including individuals receiving Across five clinical trials, 4374 children 12 to 23 months of age received immunosuppressive therapy, may have a diminished immune response to one or two 25U doses of VAQTA, including 3885 children who received VAQTA and may not be protected against HAV infection after vaccination 2 doses of VAQTA and 1250 children who received VAQTA concomitantly [see Use in Specific Populations (8.6)]. with one or more other vaccines, including Measles, Mumps, and Limitations of Vaccine Effectiveness Rubella Virus Vaccine, Live (M-M-R II®), Varicella Vaccine, Live (VARIVAX®), Hepatitis A virus has a relatively long incubation period (approximately Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine, Adsorbed 20 to 50 days). VAQTA may not prevent hepatitis A infection in individuals (Tripedia or Infanrix), Measles, Mumps, Rubella, and Varicella Vaccine, Live who have an unrecognized hepatitis A infection at the time of vaccination. ® (ProQuad ), Pneumococcal 7-valent Conjugate Vaccine (Diphtheria CRM197, Vaccination with VAQTA may not result in a protective response in all Prevnar), or Haemophilus B Conjugate Vaccine (Meningococcal Protein susceptible vaccinees. Conjugate, PedvaxHIB®). Overall, the race distribution of study subjects DRUG INTERACTIONS was as follows: 64.7% Caucasian; 15.7% Hispanic-American; 12.3% Black; Use with Other Vaccines 4.8% other; 1.4% Asian; and 1.1% Native American. The distribution of subjects by gender was 51.8% male and 48.2% female. Do not mix VAQTA with any other vaccine in the same syringe or vial. Use separate injection sites and syringes for each vaccine. Please refer to In an open-label clinical trial, 653 children 12 to 23 months of age were package inserts of coadministered vaccines. In clinical trials in children, randomized to receive a first dose of VAQTA with ProQuad and Prevnar VAQTA was concomitantly administered with one or more of the following concomitantly (N=330) or a first dose of ProQuad and pneumococcal US licensed vaccines: Measles, Mumps, and Rubella Virus Vaccine, Live; 7-valent conjugate vaccine concomitantly, followed by a first dose of Varicella Vaccine, Live; Diphtheria and Tetanus Toxoids and Acellular VAQTA 6 weeks later (N=323). Approximately 6 months later, subjects Pertussis Vaccine, Adsorbed; Measles, Mumps, Rubella, and Varicella received either the second doses of ProQuad and VAQTA concomitantly Vaccine, Live; Pneumococcal 7-valent Conjugate Vaccine (Diphtheria or the second doses of ProQuad and VAQTA separately. The race distribution of the study subjects was as follows: 60.3% Caucasian; CRM197); and Haemophilus B Conjugate Vaccine (Meningococcal Protein Conjugate). Safety and immunogenicity were similar for concomitantly 21.6% African-American; 9.5% Hispanic-American; 7.2% other; 1.1% Asian; administered vaccines compared to separately administered vaccines. and 0.3% Native American. The distribution of subjects by gender was 50.7% male and 49.3% female. In clinical trials in adults, VAQTA was concomitantly administered with Table 1 presents rates of solicited local reactions at the VAQTA injection typhoid Vi polysaccharide and yellow fever vaccines [see Adverse site and rates of elevated temperatures (≥100.4°F and ≥102.2°F) that occurred Reactions (6.1) and Clinical Studies (14.2, 14.7)]. Safety and immunogenicity within 5 days following each dose of VAQTA and elevated temperatures were similar for concomitantly administered vaccines compared to >98.6°F for a total of 14 days after vaccination; occurrences of these events separately administered vaccines. were recorded daily on diary cards. Table 2 presents rates of unsolicited Use with Immune Globulin systemic adverse events that occurred within 14 days at ≥5% in any group VAQTA may be administered concomitantly with Immune Globulin, human, following each dose of VAQTA. using separate sites and syringes. The recommended vaccination regimen for VAQTA should be followed. Consult the manufacturer’s product circular for the appropriate dosage of Immune Globulin. A booster dose of VAQTA should be administered at the appropriate time as outlined in the recommended regimen for VAQTA [see Clinical Studies (14.5) ]. Immunosuppressive Therapy If VAQTA is administered to a person receiving immunosuppressive therapy, an adequate immunologic response may not be obtained. ® VAQTA (Hepatitis A Vaccine, Inactivated) Table 3: Incidences of Solicited Local Adverse Reactions at the VAQTA Injections Site and Elevated Suspension for Intramuscular Injection Temperatures Following Each Dose of VAQTA in Healthy Children 12-23 Months of Age Receiving VAQTA Alone or Concomitantly with PedvaxHIB With or Without Infanrix (Stage I) and those Table 1: Receiving VAQTA Alone or at Both Doses (Stage II) Incidences of Solicited Local Adverse Reactions at the VAQTA Injection Site and Elevated Stage I Stage II Temperatures Following Each Dose of VAQTA in Healthy Children 12-23 Months of Age Receiving Dose 1 Dose 2 Dose 1 Dose 2 VAQTA Alone or Concomitantly With ProQuad and Prevnar* Adverse VAQTA alone VAQTA + VAQTA alone VAQTA alone VAQTA alone Dose 1 Dose 2 Reaction: PedvaxHIB Days 1-5 and Infanrix Adverse VAQTA alone VAQTA + VAQTA alone VAQTA + unless noted or VAQTA + reaction: Days ProQuad + ProQuad PedvaxHIB 1-5 unless noted Prevnar concomitantly concomitantly concomitantly Injection Injection site site adverse adverse reactions N=274 N=311 N=251 N=263 N=256 N=302 N=503 N=647 N=599 reactions Injection site 11.7% 9.6% 12.7% 9.5% Injection site erythema 18.0% 19.9% 21.5% 11.7% 16.2% erythema Injection site 15.3% 20.9% 20.3% 17.5% Injection pain/tenderness site pain/ 21.9% 36.4% 27.4% 20.1% 22.9% Injection site tenderness 9.5% 6.8% 7.6% 6.1% swelling Injection site 10.2% 14.2% 10.1% 7.1% 7.0% Temperature > swelling 98.6ºF or feverish 12.4% 35.7% 10.8% 10.3% Temperature (Days 1-14) > 98.6ºF 10.2% 17.2% 10.7% 10.0% 8.2% N=243 N=285 N=221 N=237 or feverish (Days 1-14) Temperature ≥ 10.3% 16.8% 10% 4.2% 100.4ºF N=234 N=290 N=473 N=631 N=591 Temperature ≥ Temperature 2.1% 3.5% 2.3% 2.5% 9.0% 16.9% 9.1% 9.4% 8.6% 102.2ºF ≥ 100.4ºF Temperature * Pneumococcal 7-valent Conjugate Vaccine. 3.8% 3.1% 3.2% 2.9% 2.4% ≥ 102.2ºF N=number of subjects for whom data are available. N=number of subjects for whom data is available.

Table 2: Table 4: Incidences of Unsolicited Systemic Adverse Events ≥5% in Any Group Following Incidences of Unsolicited Systemic Adverse Events ≥5% in Any Group Following Each Dose of Each Dose of VAQTA in Healthy Children 12-23 Months of Age Receiving VAQTA Alone VAQTA in Healthy Children 12-23 Months of Age Receiving VAQTA Alone or Concomitantly with Infanrix or Concomitantly With ProQuad and Prevnar* PedvaxHIB With or Without (Stage I) and Those Receiving VAQTA Alone at Both Doses (Stage II) Dose 1 Dose 2 Stage I Stage II Adverse Event: VAQTA alone VAQTA + VAQTA alone VAQTA + Dose 1 Dose 2 Dose 1 Dose 2 Days 1-14 ProQuad + ProQuad Prevnar concomitantly Adverse VAQTA alone VAQTA + VAQTA alone VAQTA alone VAQTA alone concomitantly Event: Days PedvaxHIB 1-14 and Infanrix N=274 N=311 N=251 N=263 or VAQTA + General Disorders and Administration Site Conditions PedvaxHIB concomitantly Irritability 3.6% 6.1% 2.8% 2.7% N=256 N=302 N=503 N=647 N=599 Infections and Infestations Gastrointestinal Disorders Upper respiratory Diarrhea 3.9% 8.3% 3.8% 4.6% 3.8% 3.3% 6.1% 4.8% 5.7% tract infection Teething 3.1% 2.3% 1.4% 5.7% 4.3% Skin and Subcutaneous Tissue Disorders General Disorders and Administration Site Conditions Dermatitis diaper 1.1% 6.1% 2.4% 3.4% Irritability 6.3% 9.6% 4.0% 8.8% 6.5% Infections and Infestations * Pneumococcal 7-valent Conjugate Vaccine. Upper In Stage I of an open, multicenter, randomized study, children 15 months respiratory 2.3% 3.3% 3.0% 4.9% 5.2% of age were randomized to receive the first dose of VAQTA alone (N=151) tract infection or concomitantly with PedvaxHIB and Infanrix (N=155); another group of Respiratory, Thoracic and Mediastinal Disorders children 15 months of age were randomized to receive the first dose of Rhinorrhea 2.0% 4.0% 3.8% 6.2% 3.8% VAQTA alone (N=152) or concomitantly with PedvaxHIB (N=159). All groups received the second dose of VAQTA alone at least 6 months following Data presented in Tables 1 through 4 on solicited local reactions, and the first dose. The race distribution of Stage I study subjects was: 63.9% solicited and unsolicited systemic adverse events with incidence ≥5% Caucasian; 17.5% Hispanic-American; 14.7% Black; 2.6% other; and 1.3% following each dose of VAQTA are representative of other clinical trials Asian. The distribution of subjects by gender was 54.0% male and 46.0% of VAQTA in children 12 through 23 months of age. Across the five studies female. In Stage II of this study, an additional 654 children 12-17 months of conducted in children 12-23 months of age, ≥39.9% of subjects experienced age received the first dose of VAQTA alone followed by the second dose of local adverse reactions and ≥55.7% of subjects experienced systemic VAQTA 6 months later. The race distribution of Stage II of the study subjects adverse events. The majority of local and systemic adverse events were was: 66.1% Caucasian; 10.6% Hispanic-American; 16.8% Black; 4.7% other; mild to moderate in intensity. and 1.5% Asian. The distribution of subjects by gender was 51.2% male and The following additional unsolicited local adverse reactions and systemic 48.8% female. adverse events were observed at a common frequency of ≥1% to <10% in Table 3 presents rates of solicited local reactions at the VAQTA injection-site any individual clinical study. This listing includes only the adverse reactions and rates of elevated temperatures (≥100.4°F and ≥102.2°F) that occurred not reported elsewhere in the label. These local adverse reactions and within 5 days following each dose of VAQTA and elevated temperatures systemic adverse events occurred among recipients of VAQTA alone or >98.6°F for a total of 14 days following each dose of VAQTA. Occurrences VAQTA given concomitantly within 14 days following any dose of VAQTA of these events were recorded daily on diary cards. Table 4 presents rates across four clinical studies. of unsolicited systemic adverse events that occurred within 14 days at Eye disorders: Conjunctivitis ≥5% following each dose of VAQTA. Gastrointestinal disorders: Constipation; vomiting

General disorders and administration site conditions: Injection-site bruising; injection-site ecchymosis VAQTA® (Hepatitis A Vaccine, Inactivated) Adults — 19 Years of Age and Older In an open-label clinical trial, 240 healthy adults 18 to 54 years of age were Suspension for Intramuscular Injection randomized to receive either VAQTA (50U/1-mL) with Typhim Vi (Typhoid Vi Infections and infestations: Otitis media; nasopharyngitis; rhinitis; viral polysaccharide vaccine) and YF-Vax (yellow fever vaccine) concomitantly infection; croup; pharyngitis streptococcal; laryngotracheobronchitis; (N=80), typhoid Vi polysaccharide and yellow fever vaccines concomitantly viral exanthema; gastroenteritis viral; roseola (N=80), or VAQTA alone (N=80). Approximately 6 months later, subjects who Metabolism and nutrition disorders: Anorexia received VAQTA were administered a second dose of VAQTA. The race distribution of the study subjects who received VAQTA with or without Psychiatric disorders: Insomnia; crying typhoid Vi polysaccharide and yellow fever vaccine was as follows: 78.3% Respiratory, thoracic and mediastinal disorders: Cough; nasal congestion; Caucasian; 14.2% Oriental; 3.3% other; 2.1% African-American; 1.7% Indian; respiratory congestion 0.4% Hispanic-American. The distribution of subjects by gender was 40.8% Skin and subcutaneous tissue disorders: Rash vesicular; measles-like/ male and 59.2% female. Subjects were monitored for local adverse reactions rubella-like rash; varicella-like rash; rash morbilliform and fever for 5 days and systemic adverse events for 14 days after each Serious Adverse Events (Children 12 through 23 Months of Age): Across vaccination. In the 14 days after the first dose of VAQTA, the proportion of the five studies conducted in subjects 12-23 months of age, 0.7% (32/4374) subjects with adverse events was similar between recipients of VAQTA given of subjects reported a serious adverse event following any dose of VAQTA, concomitantly with typhoid Vi polysaccharide and yellow fever vaccines and 0.1% (5/4374) of subjects reported a serious adverse event judged to compared to recipients of typhoid Vi polysaccharide and yellow fever be vaccine related by the study investigator. The serious adverse events vaccines without VAQTA. were collected over the period defined in each protocol (14, 28, or 42 days). Table 6 summarizes solicited local adverse reactions and Table 7 summarizes Vaccine-related serious adverse events which occurred following any dose unsolicited systemic adverse events reported in ≥5% in adults who received of VAQTA with or without concomitant vaccines included febrile seizure one or two doses of VAQTA alone and for subjects who received VAQTA (0.05%), dehydration (0.02%), gastroenteritis (0.02%), and cellulitis (0.02%). concomitantly with typhoid Vi polysaccharide and yellow fever vaccines. Children/Adolescents — 2 Years through 18 Years of Age There were no solicited systemic complaints reported at a rate ≥5%. Fever In 11 clinical trials, 2615 healthy children 2 years through 18 years of age ≥101°F occurred in 1.3% of subjects in each group. received at least one dose of VAQTA. These studies included administration Table 6: of VAQTA in varying doses and regimens (1377 children received one or more Incidences of Solicited Local Adverse Reactions in Healthy Adults ≥19 Years of Age 25U doses). The race distribution of the study subjects who received at least Occurring at ≥5% After Any Dose one dose of VAQTA in these studies was as follows: 84.7% Caucasian; 10.6% Adverse Event VAQTA administered alone VAQTA + ViCPS* and Yellow American Indian; 2.3% African-American; 1.5% Hispanic-American; 0.6% (N=80) Fever vaccines administered † other; 0.2% Oriental. The distribution of subjects by gender was 51.2% male concomitantly and 48.8% female. (N=80) In a double-blind, placebo-controlled efficacy trial (i.e. The Monroe Efficacy Rate (Percent) Study), 1037 healthy children and adolescents 2 through 16 years of age were Injection-site‡ randomized to receive a primary dose of 25U of VAQTA and a booster dose of Pain/tenderness/soreness 78.8% 70.3% VAQTA 6, 12, or 18 months later, or placebo (alum diluent). All study subjects Warmth 23.7% 23.7% were Caucasian: 51.5% were male and 48.5% were female. Subjects were Swelling 16.2% 8.8% followed days 1 to 5 postvaccination for fever and local adverse reactions and days 1 to 14 for systemic adverse events. The most common adverse Erythema 17.5% 6.3% events/reactions were injection-site reactions, reported by 6.4% of subjects. N=Number of subjects enrolled/randomized. Table 5 summarizes local adverse reactions and systemic adverse events Percent=percentage of subjects with adverse event. reported in ≥1% of subjects. There were no significant differences in the * ViCPS=Typhoid Vi polysaccharide vaccine. † VAQTA administered concomitantly with typhoid Vi polysaccharide (ViCPS) and yellow fever vaccines. rates of any adverse events or adverse reactions between vaccine and ‡ Adverse Reactions at the injection site (VAQTA) Days 1-5 after vaccination. placebo recipients after Dose 1.

Table 5: Table 7: Local Adverse Reactions and Systemic Adverse Events (≥1%) in Healthy Children and Adolescents Incidences of Unsolicited Systemic Adverse Events in Adults ≥19 Years of Age from the Monroe Efﬁcacy Study Occurring at ≥5% After Any Dose Adverse Event VAQTA Placebo (Alum Body System VAQTA administered alone VAQTA + ViCPS* and Yellow Diluent)*†‡ (N=519) Adverse Event (N=80) Fever vaccines administered (N=518) concomitantly† Rate (Percent) (N=80) Dose 1* Booster Rate (Percent) Rate (Percent) Rate (Percent) General disorders and administration site reactions‡

Injection Site§ n=515 n=475 n=510 Asthenia/fatigue 7.5% 11.3% Pain 6.4% 3.4% 6.3% Chills 1.3% 7.5% Gastrointestinal disorders‡ Tenderness 4.9% 1.7% 6.1% Erythema 1.9% 0.8% 1.8% Nausea 7.5% 12.5% Musculoskeletal and connective tissue disorders‡ Swelling 1.7% 1.5% 1.6% Warmth 1.7% 0.6% 1.6% Myalgia 5.0% 10.0% Arm pain 0.0% 6.3% Systemic¶ n=519 n=475 n=518 Nervous system disorders‡ Abdominal pain 1.2% 1.1% 1.0% Headache 23.8% 26.3% Pharyngitis 1.2% 0% 0.8% Infections and infestations‡

Headache 0.4% 0.8% 1.0% Upper respiratory infection 7.5% 3.8% N=Number of subjects enrolled/randomized. Pharyngitis 2.5% 6.3% Percent=percentage of subjects for whom data are available with adverse event. N=Number of subjects enrolled/randomized with data available. n=number of subjects for whom adverse events available. Percent=percentage of subjects with adverse event for whom data are available. * No statistically significant differences between the two groups. * ViCPS=Typhoid Vi polysaccharide vaccine. † Second injection of placebo not administered because code for the trial was broken. † VAQTA administered concomitantly with typhoid Vi polysaccharide (ViCPS) and yellow fever ‡ Placebo (Alum diluent) = amorphous aluminum hydroxyphosphate sulfate. vaccines. § Adverse Reactions at the injection site (VAQTA) Days 1-5 after vaccination with VAQTA. ‡ Systemic Adverse Events reported Days 1-5 after vaccination, regardless of causality. ¶ Systemic adverse events reported Days 1-15 after vaccination, regardless of causality. VAQTA® (Hepatitis A Vaccine, Inactivated) investigator. Diarrhea/gastroenteritis, resulting in outpatient visits, was determined by the investigator to be the only vaccine-related nonserious Suspension for Intramuscular Injection adverse reaction in the study. There was no vaccine-related adverse In four clinical trials involving 1645 healthy adults 19 years of age and older reaction identified that had not been reported in earlier clinical trials who received one or more 50U doses of hepatitis A vaccine, subjects were with VAQTA. followed for fever and local adverse reactions 1 to 5 days postvaccination USE IN SPECIFIC POPULATIONS and for systemic adverse events 1 to 14 days postvaccination. One Pregnancy single-blind study evaluated doses of VAQTA with varying amounts of viral Pregnancy Category C: Animal reproduction studies have not been antigen and/or alum content in healthy adults ≥170 pounds and ≥30 years conducted with VAQTA. It is also not known whether VAQTA can cause of age (N=210 adults administered 50U/1-mL dose). One open-label study fetal harm when administered to a pregnant woman or can affect evaluated VAQTA given with immune globulin (IG) or alone (N=164 adults reproduction capacity. VAQTA should be given to a pregnant woman who received VAQTA alone). A third study was single-blind and evaluated only if clearly needed. 3 different lots of VAQTA (N=1112). The fourth study that was also Nursing Mothers single-blind evaluated doses of VAQTA with varying amounts of viral It is not known whether VAQTA is excreted in human milk. Because many antigen in healthy adults ≥170 pounds and ≥30 years of age (N=159 adults drugs are excreted in human milk, caution should be exercised when administered the 50U/1-mL dose). Overall, the race distribution of the VAQTA is administered to a nursing woman. study subjects who received at least one dose of VAQTA was as follows: 94.2% Caucasian; 2.2% Black; 1.5% Hispanic; 1.5% Oriental; 0.4% other; Pediatric Use 0.2% American Indian. 47.6% of subjects were male and 52.4% were female. The safety of VAQTA has been evaluated in 4374 children 12 through The most common adverse event/reaction was injection-site pain/soreness/ 23 months of age, and 2615 children/adolescents 2 through 18 years of age tenderness reported by 67.0% of subjects. Of all reported injection-site who received at least one 25U dose of VAQTA [see ADVERSE REACTIONS (6) reactions 99.8% were mild (i.e., easily tolerated with no medical intervention) and DOSAGE AND ADMINISTRATION (2) in full Prescribing Information]. or moderate (i.e., minimally interfered with usual activity possibly requiring Safety and effectiveness in infants below 12 months of age have not little medical intervention). Listed below in Table 8 are the local adverse been established. reactions and systemic adverse events reported by ≥5% of subjects, in Geriatric Use decreasing order of frequency within each body system. In the post-marketing observational safety study which included 42,110 Table 8: persons who received VAQTA [see Adverse Reactions (6.2) in full Prescribing Incidences of Local Adverse Reactions and Information], 4769 persons were 65 years of age or older and 1073 persons Systemic Adverse Events ≥5% in Adults 19 Years of Age and Older were 75 years of age or older. There were no adverse events judged by the Body System VAQTA (Any Dose) investigator to be vaccine-related in the geriatric study population. In other Adverse Events (N=1645) clinical studies, 68 subjects 65 years of age or older were vaccinated with Rate (n/total n) VAQTA, 10 of whom were 75 years of age or older. No overall differences Nervous system disorders* n=1641 in safety and immunogenicity were observed between these subjects and Headache 16.1% younger subjects; however, greater sensitivity of some older individuals General disorders and administration site n=1640 cannot be ruled out. Other reported clinical experience has not identified reactions† differences in responses between the elderly and younger subjects. Injection-site pain/tenderness/soreness 67.0% Immunocompromised Individuals Injection-site warmth 18.2% Immunocompromised persons may have a diminished immune response Injection-site swelling 14.7% to VAQTA and may not be protected against HAV infection. Injection-site erythema 13.7% For more detailed information, please read the Prescribing Information.

N=Number of subjects enrolled/randomized. n=Number of subjects in each category with data available. Manufactured and distributed by Merck Sharp & Dohme Corp., a subsidiary Percent=percentage of subjects for whom data are available with adverse event. of Merck & Co., Inc., Whitehouse Station, NJ 08889, USA * Systemic Adverse Events reported Days 1 to 14 after vaccination, regardless of causality. uspi-v251-i-1402r016 † Adverse Reactions at the injection site (VAQTA) and measured fever Days 1 to 5 after vaccination. For patent information: www.merck.com/product/patent/home.html The following additional unsolicited systemic adverse events were observed The trademarks depicted herein are owned by their respective companies. among recipients of VAQTA that occurred within 14 days at a common VACC-1106515-0000 06/14 frequency of ≥1% to <10% following any dose not reported elsewhere in the label. These adverse reactions have been reported across 4 clinical studies. Musculoskeletal and connective tissue disorders: Back pain; stiffness Copyright © 1996-2014 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. All rights reserved. Reproductive system and breast disorders: Menstruation disorders Post-Marketing Experience The following additional adverse events have been reported with use of the marketed vaccine. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency or establish a causal relationship to a vaccine exposure. Blood and lymphatic disorders: Thrombocytopenia. Nervous system disorders: Guillain-Barré syndrome; cerebellar ataxia; encephalitis. Post-Marketing Observational Safety Study In a post-marketing, 60-day safety surveillance study, conducted at a large health maintenance organization in the United States, a total of 42,110 individuals ≥2 years of age received 1 or 2 doses of VAQTA (13,735 children/ adolescents and 28,375 adult subjects). Safety was passively monitored by electronic search of the automated medical records database for emergency room and outpatient visits, hospitalizations, and deaths. Medical charts were reviewed when an event was considered to be possibly vaccine-related by the investigator. None of the serious adverse events identiﬁed were assessed as being related to vaccine by the Top 50 EHRs

Continued from page 48 FINANCIAL SUPPORT TOOLS DownloaD Offers a practice management system Find the Top 50 or interface list and other EHR reference materials at Offers revenue cycle management MedicalEconomics.com services

Ability to track ﬁnancial performance within the practice management system Physician EHR satisfaction 67% of physicians are dissatisfed with EHR 63% 26% system functionality of physicians would not of physicians are % purchase the same very confdent EHR system if they their EHR system 35 had a chance to do will still be viable of physicians believe it over again their EHR has in fve years improved the quality of patient care 31% 38% of physicians are of primary care % doubtful or very physicians believe doubtful their EHR will 69 their EHR system be viable in fve years has been worth the of physicians say effort, resources their EHR system and costs. has not improved coordination of care with hospitals

Source: 2014 EHR Survey; MPI Group/Medical Economics Top 50 EHRs continue on page 56

MedicalEconomics.com Medical econoMics ❚ OctOber 10, 2014 55

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T e following lists of er a deeper dive into EHR system of erings, including meaningful use 2 certif cation, and the availability of patient portals and revenue cycle management services.

Company System(s) Meaningful Use 2 Certification Bogardus Medical Systems, Inc. ONCOCHART *List only includes complete, ambulatory systems with 2014 certif cation. Bonafide Management Systems, Inc. Bonafide EHR Source: Oﬃ ce of the National Coordinator for Health Information Technology C Certif ed Health IT Product List, September 12, 2014 CaduRx, Inc. CaduRx Company System(s) Candelis, Inc. ImageGrid RIS A CareCloud Corp. CareCloud Charts ABEL Medical Software, Inc. ABELMed EHR/EMR/PM ChartLogic, Inc. ChartLogic Abeo Solutions, Inc. Crystal PM Clarkson Eyecare EyeCare 360 Accelecare Wound Centers, Inc. Accelechart ClaimTrak Systems, Inc. ClaimTrak Acumen Physician Solutions Acumen EHR ClinicMax, Inc. ClinicMax EHR Adaptamed, LLC Adaptamed EMR ClinixMD, LLC ClinixMD Advanced Data Systems Corp. MedicsDocAssistant Cloud Medical Software Corp. Cloud MD AdvantaChart, Inc. AdvantaChart CodoniX CodoniXnotes Agastha, Inc. Agastha Enterprise Healthcare Software Complete Medical Solutions, LLC MyWinmed EHR AllegianceMD software, Inc. Veracity CompuGroup Medical, Inc. (CGM US) CGM Clinical, CGM Enterprise EHR, AllMeds, Inc. AllMeds Specialty EHR CGM webEHR Allscripts Healthcare Solutions, Inc. Allscripts Enterprise EHR, Allscripts Compulink Compulink Advantage Professional, Sunrise Acute Care, Sunrise Ambulatory Care, Allscripts Touchworks Comtron Corp. Medgen EHR Alma Information Systems, Inc. TexTALK MD CorrecTek CorrecTek 2014 Amazing Charts, LLC Amazing Charts CPSI CPSI Medical Practice EMR AmkaiSolutions, LLC AmkaiCharts Credible Wireless, Inc. Credible Behavioral Health Aprima Medical Software, Inc. Aprima EHR (PRM 2014) Criterions, LLC Criterions EHR Arête Healthcare Services, LLC enCompass Cube Healthcare Cube EHR Artemis Health Group digiChart CureMD CureMD SMART Cloud Askesis Development Group, Inc. PsychConsult Provider Cyclops Vision Corp. Cyclops Eye Care Records athenahealth athenaClinicals Cyfluent Cyfluent

B D Benchmark Systems, Inc. Benchmark Clinical Data Strategies, Inc. MDsuite BizMatics, Inc. PrognoCIS Denttio Tio Practice Management Software

Continued on page 58

56 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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Company System(s) Elekta - IMPAC Medical Systems, Inc. MOSAIQ Meaningful Use 2 attestation EMD Wizard, Inc. emdwizard Emdeon Corp. Emdeon Clinical Exchange EHR-Lite Number of eligible professionals (EPs) eMedPractice, LLC eMedicalPractice AS OF AS OF Enable Healthcare, Inc. MDnet May 1, 2014 July 31, 2014 Epic Systems Corp. EpicCare Ambulatory 2014 Certified EHR Suite Evolve Exchange, Inc. AstralJet Exscribe, Inc. Exscribe EHR 50 1,898 Eyefinity OfficeMate/ExamWRITER, Eyefinity EHR ezEMRx, Inc. ezEMRxPrivate Number of eligible hospitals (EHs) F Family Health Centers of San Diego, CMIS Medical EHR AS OF AS OF Inc. May 1, 2014 July 31, 2014 First Insight Corp. MaximEyes Electronic Health Records Foothold Technology, Inc. AWARDS Future Health SmartCloud SmartServer 8 78 FutureNet Technologies Corp. FutureNet EHR G GE Healthcare Centricity EMR, Centricity Practice Solution, Enterprise Source: Centers for Medicare & Medicaid Services (CMS) GEMMS GEMMS ONE Genius Solutions, Inc. ehrTHOMAS

Continued from page 56 Genix Technology, Inc. gEMRpro Geriatric Practice Management gEHRiMed Company System(s) Dexter Solutions, Inc. eZDocs EHR Glenwood Systems, LLC GlaceEMR DigiDMS, Inc. DigiDMS gloStream, Inc. gloSuite Doc-tor.com Picasso gMed, Inc. gCardio, gGastro, gGastro Cloud, gMed Connect, gUro DoctorsPartner, LLC DoctorsPartner EHR/PM Greenway Health, LLC Greenway PrimeSUITE (also see Vitera) DocuTAP, Inc. DocuTAP H DOX EMR DOX EMR Health Systems Technology, Inc. MedPointe DR Systems, Inc. eHR Meaningful Use HealthFusion MediTouch drchrono, Inc. drchrono EHR Healthland Healthland Centriq Clinic DrMHope Softwares Pvt. Ltd. Dr.M Hello Health Hello Health

E Henry Schein Medical Systems MicroMD E-Health Partners, Inc. EHRez I e-MDs, Inc. e-MDs Solution Series, ICANotes, LLC ICANotes EHR/EMR for Behavioral Health e-MDs Cloud Solutions E-Z BIS, Inc. E-Z BIS Office ICS Software, Ltd. SammyEHR

eClinicalWorks, LLC eClinicalWorks iMedicWare iDOC Elation EMR, Inc. ElationEMR

58 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES503355_ME101014_058.pgs 09.23.2014 01:43 ADV Top 50 EHRs

Company System(s) Company System(s)

Indian Health Service Resource and Patient Management L System Electronic Health Record LeonardoMD Virtuoso Inforia, Inc. CaregiverDesktop Inmediata Health Group Corp. Secure EMR M MacPractice, Inc. MacPractice MD MU, MacPractice DC MU, Insight Software, LLC My Vision Express MacPractice 2020 MU, MacPractice DDS MU Integrated Practice Solutions, Inc. ChiroTouch MagView MagView Radiology EHR Integrated Systems Management, Inc. OmniMD ManagementPlus ManagementPlus IO Practiceware, Inc. IO Practiceware Marshfield Clinic Cattails Software Suite IOS Health Systems Medios McKesson Horizon Ambulatory Care, Paragon iPatientCare, Inc. iPatientCare with McKesson Quality eMeasures, Practice Partner, Practice Partner with IRCS, Inc. Vireo RelayClinical Solutions, Medisoft Clinical, Lytec MD, InteGreat EHR, McKesson iSALUS Healthcare OfficeEMR Practice Choice, iKnowMed EHR MD Logic, Inc. MD Logic World Wide EHR K Kareo, Inc. Kareo EHR MD On-Line, Inc. InSync PM/EMR Kirman Eye Kirman's EyeStudio MD Synergy Solutions, LLC ProEMR Knack BPO, LLC PhyChart MDLAND iClinic Comprehensive EHR KSB, Inc. DOX | Pedo EHR MDoffice, Inc. MDoffice

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Continued from page 59

Company System(s) Company System(s) MedConnect, Inc. MedConnect EHR Origin Healthcare Solutions Origin Healthcare Solutions EMRge MEDENT MEDENT OT EMR, Inc. OneTouch EMR MedEvolve MedEvolve EHR P Medflow, Inc. Medflow EHR Patagonia Health EHR Medical Informatics Engineering WebChart EHR Patient First PAS MEDITECH Medical and Practice Management Patterson Dental Supply, Inc. Eaglesoft Clinician (MPM), MPM Client/Server, MPM Magic PCE Systems PCE Care Management Medical Mastermind Mastermind EHR PCIS GOLD PCIS GOLD EHR MedicalMine, Inc. ChARM EHR Penn Medical Informatics Systems, Inc. EyeDoc EMR MedInformatix MedInformatix Complete EHR Plexus Information Systems, Inc. Anesthesia Touch Meditab Software, Inc. IMS Practice Fusion, Inc. Practice Fusion EHR MedMagic, LLC MedMagic Practice-Web, Inc. Practice-Web Medsphere Systems, Inc. OpenVista CareVue ProComp Software Consultants CATT Medstreaming EMR, LLC All In One Medstreaming EMR Professional Data Services, Inc. MDsuite MEDTRON Software Intelligence Corp. MEDEHR Professional Economics Bureau XLDent MU MedWorxs, LLC MedWorxs Evolution of America, Inc. Merge Healthcare, Inc. Merge RIS, Merge OrthoEMR Pulse Systems, Inc. Pulse Complete EHR MicroFour, Inc. PracticeStudio Q Modernizing Medicine, Inc. EMA QRS, Inc. PARADIGM ModuleMD, LLC ModuleMD WISE Quest Diagnostics, Inc. Care360 EHR MTBC MTBC WebEHR R ReLi Med Solutions ReLiMed EMR N NaphCare, Inc. TechCare RestorixHealth, Inc. WoundDocs NCG Medical Systems, Inc. Perfect Care EHR S Nemo Capital Partners 1 Connect BuildYourEMR ScriptRx, Inc. ScriptRx Net Health Agility EHR, WoundExpert Sequel Systems, Inc. SequelMed EHR Netsmart Technologies, Inc. Avatar, myEvolv, TIER, Insight, CMHC/MIS Sevocity (Conceptual MindWorks, Inc.) Sevocity Networking Technology (RxNT) RxNT EHR simplifyMD, Inc. simplifyMD Nextech NexTech with NexErx, SkyCare SkyCare NexTech with NewCropRx NextGen Healthcare NextGen Ambulatory EHR, NextGen EDR, SOAPware, Inc. SOAPware QSIDental CPS, QSIDental Web Spring Medical Systems SpringCharts 14 Nexus Clinical Nexus EHR SRSsoft SRS EHR Nth Technologies, Inc. nAbleMD STI Computer Services, Inc. ChartMaker Medical Suite O Stratus EMR, Inc. Stratus EMR OA Systems, Inc. Panacea SuccessEHS, Inc. (Vitera) MediaDent, Success EHS OCERIS, Inc. FlexMedical Systemedx, Inc. 2013 Systemedx Clinical Navigator Office Ally, LLC EHR 24/7 Open Dental Software Open Dental T Tech-Time, Inc. STAT! Enterprise Medical Management OptumInsight Optum PM and Physician EMR Continued on page 62

60 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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Company System(s) Vitera Healthcare Solutions, LLC Vitera Intergy Meaningful Use Edition % W WCH Service Bureau, Inc. iSmart EHR 40 Western Dental Services, Inc. WDS eChart of patients did not know Workflow.com, LLC workflowEHR that their physician % offered a patient portal, Wyoming Department of Health Wyoming Total Health Record according to a survey 25 Z from TechnologyAdvice. of patients would Z-Geoinfo, Inc. Hermes EMR prefer a physician who uses e-mail communication, Patient portal even if there was Source: Medical Economics EHR vendor survey a fee, according Company System(s) to a survey 4medica 4medica iEHR by Catalyst Acrendo Medical Software A.I.med Pro Healthcare ADP AdvancedMD AdvancedMD EHR Research. Agastha, Inc. Agastha Enterprise Healthcare Software Allscripts Healthcare Solutions, Inc. Touchworks EHR, Allscripts Professional EHR Amazing Charts, LLC Amazing Charts Aprima Medical Software Aprima EHR athenahealth athenaClinicals Benchmark Systems, Inc. Benchmark Clinical Bizmatics, Inc. PrognoCIS EMR CareCloud Corp. CareCloud Charts Cerner Corp. PowerChart Ambulatory Continued from page 60 ChartLogic, Inc. ChartLogic EHR Company System(s) CompuGroup Medical, Inc. (CGM US) CGM CLINICAL, CGM webEHR, The Echo Group Clinician's Desktop, Echo Visual Health CGM ENTERPRISE EHR Record CureMD CureMD All-in-One EHR TriMed Technologies Corp. e-Medsys EHR Cyfluent, Inc. Cyfluent U DoctorsPartner, LLC DoctorsPartner EHR/PM UC Charting Solutions, Inc. ProMentum DocuTAP, Inc. DocuTAP Ulrich Medical Concepts, Inc. Team Chart Concept, TCC 2014 e-MDs, Inc. Solution Series, Cloud Solutions V eClinicalWorks eClinicalWorks Varian Medical Systems ARIA Oncology Information System (for Radiation Oncology), Epic Systems Corp. myChart ARIA Oncology Information System EyeFormatics, Inc. EyeFormatics EMR (for Medical Oncology) Vericle, Inc. Vericle GE Healthcare Centricity Practice Solution / Centricity EMR VersaSuite VersaSuite Glenwood Systems, LLC GlaceEMR VIPA Health Solutions, LLC 24/7 smartEMR Greenway Health, LLC PrimeSUITE, Intergy, SuccessEHS VisionWeb Uprise HealthFusion, Inc. MediTouch Visual Outcomes USA, Inc. VISUAL OUTCOMES iPatientCare, Inc. iPatientCare Getty Images/iStock/360

62 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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of physician practices Company System(s) expected declining profts in Kareo, Inc. Kareo EHR % 2014 because of ineffcient KeyMedical Software, Inc. KeyChart 5.0 revenue cycle management MacPractice, Inc. MacPractice MD, MacPractice 20/20, 72 technology, according to a MacPractice DC, MacPractice DDS 2013 study by Black Book. McKesson Specialty Health iKnowMed (SM) EHR, (McKesson Corp.) iKnowMed (SM) Generation 2 MD On-Line, Inc. (MDOL) MDOL EMR Company System(s) MEDENT MEDENT Benchmark Systems, Inc. Benchmark Clinical Meditab Software, Inc. IMS Bizmatics, Inc. PrognoCIS EMR MedNet Medical Solutions emr4MD CareCloud Corp. CareCloud Charts Medsphere Systems, Inc. OpenVista Electronic Health Record Cerner Corp. PowerChart Ambulatory MedWorxs, LLC Evolution 6.1 ChartLogic, Inc. ChartLogic EHR MicroFour, Inc. PracticeStudioX16 CompuGroup Medical, Inc. (CGM US) CGM CLINICAL, CGM webEHR, CGM ENTERPRISE EHR Modernizing Medicine, Inc. Electronic Medical Assistant (EMA) CureMD CureMD All-in-One EHR NeoDeck Holdings Corp. NeoMed EHR 3.0 DocuTAP, Inc. DocuTAP Nextech Nextech e-MDs, Inc. Solution Series, Cloud Solutions NextGen Healthcare Information NextGen Ambulatory EHR eClinicalWorks eClinicalWorks Systems, Inc. GE Healthcare Centricity Practice Solution / Centricity EMR Patient Now, Inc. PatientNOW 7.0 Glenwood Systems, LLC GlaceEMR Practice Fusion, Inc. Practice Fusion Greenway Health, LLC PrimeSUITE, Intergy, SuccessEHS Practice Velocity, LLC VelociDoc Healthfusion, Inc. MediTouch Praxis EMR (Infor-Med) Praxis EMR v5 iPatientCare, Inc. iPatientCare Prime Clinical Systems, Inc. Patient Chart Manager Kareo, Inc. Kareo EHR Pulse Systems, Inc. Pulse Complete EHR KeyMedical Software, Inc. KeyChart 5.0 Quest Diagnostics Care360 EHR MacPractice, Inc. MacPractice MD, MacPractice 20/20, RazorInsights, LLC ONE-Electronic Health Record MacPractice DC, MacPractice DDS SOAPware, Inc. SOAPware and myHEALTHware McKesson Specialty Health iKnowMed (SM) EHR, (McKesson Corp.) iKnowMed (SM) Generation 2 SRSsoft SRS EHR MD On-Line, Inc. (MDOL) MDOL EMR Viztek Opal-EHR, Exa MEDENT MEDENT WCH Service Bureau, Inc. Ismart EHR Meditab Software, Inc. IMS MedNet Medical Solutions emr4MD Revenue cycle management Medsphere Systems, Inc. OpenVista Electronic Health Record MedWorxs, LLC Evolution 6.1 Source: Medical Economics EHR vendor survey Nextech Nextech Company System(s) NextGen Healthcare Information NextGen Ambulatory EHR 4medica 4medica iEHR Systems, Inc. Acrendo Medical Software A.I.med Pro Patient Now, Inc. PatientNOW 7.0 ADP AdvancedMD AdvancedMD EHR Practice Velocity, LLC VelociDoc Allscripts Healthcare Solutions, Inc. Touchworks EHR, Allscripts Professional EHR Prime Clinical Systems, Inc. Patient Chart Manager Aprima Medical Software Aprima EHR Pulse Systems, Inc. Pulse Complete EHR athenahealth athenaClinicals WCH Service Bureau, Inc. Ismart EHR

DownloaD Find the Top 50 list and other EHR reference materials at http://MedicalEconomics.com

MedicalEconomics.com Medical econoMics ❚ OctOber 10, 2014 63

magentablackcyanyellow ES503353_ME101014_063.pgs 09.23.2014 01:43 ADV EHRS OF THE FUTURE MOBILE HEALTH PATIENT PORTALS How vendors are building The benef ts and pitfalls of 5 ways to build a workf ow IN DEPTH more usable systems [74] the mHealth revolution [81] around your portal [91]

EXCLUSIVE INTERVIEW onc’s plan to solve the interoperability puzzle

by MEDICAL ECONOMICS EDITORS

HEALTHCARE IS A DECADE AWAY from a national, interoperable health information technology platform. And while infrastructure expansion and improvements will advance at a blistering pace over the next three years, more work is clearly needed, says Karen B. DeSalvo, MD, MPH, MSc, the national coordinator for Health Information Technology of the U.S. Department of Health and Human Services (HHS) in an exclusive interview with Medical Eco- nomics. In fact, despite dismal numbers of physicians and institutions attesting to the government’s meaningful use stage 2 of the electronic health record (EHR) incentive program so far in 2014 (see table, page 72), DeSalvo says the slow start isn’t indicative of a stalled program, rather one that is in a f uid state of development and policymaking. In doling out more than $24.6 billion in EHR incentives from 2011 to June 2014 to about 408,000 healthcare providers, the government is in this for the long haul. T e payof , DeSalvo says, will be an interconnected, digital health- Continued on page 70

MY GOAL IS THAT WE SET A PATH TOGETHER AND A ROAD MAP SO THAT EVERYONE CAN BE BROUGHT ALONG.” —KAREN B. DESALVO, MD, MPH, MSC, THE NATIONAL COORDINATOR FOR HEALTH INFORMATION TECHNOLOGY OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

68 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES503336_ME101014_068.pgs 09.23.2014 01:40 ADV Enter the New Era of Healthcare with an Experienced Partner • Over 400,000 customers worldwide • Ofﬁ ces in 19 countries • Over 4,200 employees worldwide

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the [needs of the] population and public The e-communIcaTIons dIvIde health at the same time.” The vision Percent of hospitals that notify primary care physicians Te government’s push to digitize health re- electronically of an emergency room entry cords is about public health. Digital medical records will help in gathering data for comparative efectiveness research; they will Routinely notiﬁes primary care physicians outside hospital systems help public health ofcials better respond to outbreaks or other health emergencies, and 2012 18% they will give physicians analytical and clinical tools to better assess their patient popu- 2013 24% lations to prevent disease, intervene before a major health event, or prevent unnecessary hospitalizations. And its success and failure relies on IT Routinely notiﬁes primary care physicians inside hospital system systems that have the ability to securely exchange healthcare data. Tat’s why the con- 2012 37% cept of interoperability is so crucial and so heavily tied to the government’s meaningful 2013 % 45 use 2 EHR incentive program and meaningful use 3. Ultimately, ONC says, a fully function- ing interoperable healthcare system would The majority of hospitals do not send and receive electronic messages make “the right data available to the right containing patient health information to and from external sources people, at the right time across products and organizations in a way that can be re- Percent lied upon and meaningfully used by recipi- of hospitals ents,” ONC says in a white paper detailing “A that do not 10-Year Vision to Achieve an Interoperable send/receive Health IT infrastructure.” So, what is in- % teroperability? Te Healthcare Information 41 % and Management Systems Society (HIMSS) 59 describes it this way: Percent “In healthcare, interoperability is the of hospitals able ability of diferent information technology to send/receive systems and software applications to communicate, exchange data, and use the information that has been exchanged.” Data could be shared by clinicians, labs, hospitals, Source: Ofce of the National Coordinator for Healthcare Information Technology pharmacies and patients regardless of the application or vendor. “Interoperability means the ability of Continued from page 68 health information systems to work togeth- care platform built to share and learn to im- er within and across organizational bound- prove healthcare delivery and, ultimately, aries in order to advance the health status better protect public health. An interoperable of, and the efective delivery of healthcare technological infrastructure will cut dupli- for, individuals and communities.” cation of testing, streamline the gathering In practice, an interoperable system and dissemination of medical information would allow physicians to easily transfer or all contributing to the inefciencies of a U.S. view patient health information from other healthcare system fragmented by size and physicians or healthcare organizations in- specialty. volved in the care of their patients, receive “It is very important for our country to hospital notifcations regarding their pa- digitize one-ffth of this economy,” DeSalvo tients, or review recommendations from a says, “and have a much better way to address Continued on page 71

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Continued from page 70 nurse practitioner in a retail clinic if treatment was initiated, and much more. “Health is more than getting people to ONC’s technology goals a doctor,” DeSalvo says. “It’s about where they live, learn, work and play. It’s about the choices our patients make when they leave our of ces.” Technology has the ability, for the f rst time, to free providers from the 3-year vision conf nes of the examination room and help Improve interoperability so providers can send, receive, f nd and use essential health guide health decisions in ways physicians information. would think unimaginable just a decade ago. Remote monitoring and telehealth are Examples of some tasks include: ❚ Rec eive automated hospital electronic just two examples that of er promising and ❚ L ook up immunization histories notif cation care summaries following novel approaches to care delivery, DeSalvo ❚ Shar e basic patient information between discharge. says, and it’s the technological innovation primary care physicians and specialists that will make it a reality. British writer Arthur C. Clarke was cred- ited with three laws of prediction. In this case, the third law applies, DeSalvo says: Any 6-year vision suf ciently advanced technology is indistin- Technology’s evolution will better enable patients to be “active participants in managing guishable from magic. their care, especially as it relates to patient experience, self-rated health, and self- generated data.” Individuals, care providers, and public health departments will send, The ReALiTY receive, f nd and use an expanded set of health information across the care continuum to In 2014, HIT hasn’t been able to wave its support team-based care. wand to make interoperability appear for most of ce-based practices. Examples of some tasks include: levels. They will be able to see how often While there have been successes related ❚ Patients routinely contribute information those patients have been hospitalized to tasks like e-prescribing, development to their health records based on standardized information from of healthcare information exchanges, and ❚ adoption and use by larger healthcare sys- P atients integrate data from their health multiple sources. tems, DeSalvo says, of ced-based practices records into apps and other health tools ❚ Clinical settings and public health are feeling the growing pains associated ❚ Primary care providers and researchers are connected through bi-directional with time to input data, workf ows, costs, access and take action on metrics about interfaces that enable seamless reporting patient engagement, or simply do not yet see their diabetic patient population’s glucose to public health departments. the benef ts to patient care. Many primary care physicians are frus- trated, according to recent Medical Econom- ics surveys about the current state of EHR 10-year vision technology. Physicians are pressed for time “Advanced, more functional technical tools will enable innovation and broader uses and money, and this new technology seems of health information to further support health research and public health.” Data to be placing even more demands on both. collection will be more standardized, and health information technology systems will While health information technology enable analysis of aggregated data and use of local data the point of care through is in its adolescence, DeSalvo says, the ad- targeted clinical decision support. Clinical trial recruitment, data collection and analysis vancement of cell phone technology of ers a will be accelerated and automated. glimpse of the future. In the early days, cell phones were cum- ❚ P atients manage information from their ❚ “Individuals, care providers, public health bersome, the batteries died far too quickly, own devices and share the information and researchers contribute information and coverage was limited in most cases, De- Salvo says. T e introduction and adoption of seamlessly across multiple platforms. shared across the health IT ecosystem, smart phones not only happened quickly, it ❚ C hoose medications based on genetic with rapid advancement in methods for was transformative, and represents the kind prof les and comparative eﬀ ectiveness deriving meaning from data without of magic technology can deliver. research sharing PHI.” “My expectation and hope for the e- health environment is that we let innova- Continued on page 73 Source: Connecting Health and Care for the Nation: A Ten Year Vision to Achieve Interoperable Health IT Infrastructure

MedicalEconomics.com Medical econoMics ❚ OctOber 10, 2014 71

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Medicare ehR incentive Payment schedule for eligible Professionals (eP)

Medicare eP Medicare eP Medicare eP Medicare eP Medicare eP Qualifies to Receive Qualifies to Receive Qualifies to Receive Qualifies to Receive Qualifies to Receive First Payment in 2011 First Payment in 2012 First Payment in 2013 First Payment in 2014 First Payment in 2015

2011 $18,000 – – – –

2012 $12,000 $18,000 – – –

2013 $8,000 $12,000 $15,000 – –

2014 $4,000 $8,000 $12,000 $12,000 –

2015 $2,000 $4,000 $8,000 $8,000 –

2016 – $2,000 $4,000 $4,000 –

Total $44,000 $44,000 $39,000 $24,000 –

Medicaid ehR incentive Payment schedule for eligible Professionals

Medicaid eP Medicaid eP Medicaid eP Medicaid eP Medicaid eP Medicaid eP Qualifies to Receive Qualifies to Receive Qualifies to Receive Qualifies to Receive Qualifies to Receive Qualifies to Receive First Payment First Payment First Payment First Payment First Payment First Payment in 2011 in 2012 in 2013 in 2014 in 2015 in 2016

2011 $21,250 – – – – – 2012 $8,500 $21,250 – – – –

2013 $8,500 $8,500 $21,250 – – –

2014 $8,500 $8,500 $8,500 $21,250 – –

2015 $8,500 $8,500 $8,500 $8,500 $21,250 –

2016 $8,500 $8,500 $8,500 $8,500 $8,500 $21,250

2017 – $8,500 $8,500 $8,500 $8,500 $8,500

2018 – – $8,500 $8,500 $8,500 $8,500

2019 – – – $8,500 $8,500 $8,500

2020 – – – – $8,500 $8,500

2021 – – – – – $8,500

Total $63,750 $63,750 $63,750 $63,750 $63,750 $63,750

SOURCE: ONC

72 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES503335_ME101014_072.pgs 09.23.2014 01:40 ADV Interoperability 0DFKLQH

Continued from page 71 basic infrastructure, the fundamen- tion happen in such a way that we are tals in place. making the care experience as magical According to DeSalvo, while that as it should be, so the joy of medicine work is happening, technological comes out and electronic health re- advances are posing many other ques- cords are part of a larger portfolio of tions related to portability, contract- support for electronic health informa- ing, care coordination, physician tion, [and so] that doctors and other payments, and patient-generated providers really focus on patients and health data. Ultimately, “technology health as opposed to technology,” she is pushing us to consider that this is says. also coming faster than we thought.” “My goal is that we set a path to- Technology’s great evolution will gether and a road map so that every- be used to help build tools to enhance one can be brought along,” she says. the relationship between patients and “At the end of 10 years, this country physicians, to improve access to care will have built an interconnected data and their knowledge about care deci- Medical waste removal has cast and communications system. In the sions, DeSalvo says. physicians thousands of dollars over the next three years, we have to get the But it will take time. year with the charges going up every year and their business having nothing to show for their expense. There is now a cost-effective, professionaly recognized alternative. The Medical Waste Machine system 3 Types of Interoperability replaces an expensive, ongoing medical waste removal cost, which increases “In healthcare, interoperability is the ability of diferent regularly and incurs a cost to the doctors forever. The system can save small and information technology systems and software applications large businesses up to 80% yearly. to communicate, exchange data, and use the information The Medical Waste Machine system that has been exchanged.” –HIMSS improves the liability situation because there are no sharps (needles and syringes, lancets, blades, broken glass The three types of interoperability include: capsules, etc.) and other medical waste onsite due to the sterilization process that converts the medical waste to Foundational interoperability ordinary waste immediately. 1 allows data exchange, but not interpretation from the Also, the system makes an important receiving party environmental contribution because the waste going to the landfi ll is not only reduced in volume by an average of 75% but is sterile as well. Structural data 2 defines the format of data exchange and ensures that data Due to the monoply that has occured exchanges between systems can be interpreted at the data in the medical waste removal industry, field level. prices are increasing considerably and regularly. By saving physicians money, eliminating their liability, which they are responsible forever (from cradle to Semantic interoperability grave), eliminating their paperwork and 3 provides interoperability at the highest level, which is the improving the environment, the Medical ability of two or more systems or elements to exchange Waste Machine offers an unequivocal information and to use the information that has been number of advantages over medical exchanged. waste carriers and mail back services.

Source: HIMSS For more information: Telephone: 508-358-8099; Fax: 508-358-2131 E-Mail: [email protected] Medical econoMics ❚ OctOber 10, 2014 73 www.medicalinnovationsinc.com

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EHR 2.0: 4 ways vendors are building better systems While vendors have focused most of their development efforts on meaningful use and ICD-10 readiness, innovations are on the way to improve system functionality for physicians

by Ken Terry Contributing editor

hysicians continue to ex- ly because the bulk of MU incentive pay- press dissatisfaction with ments have gone to hospitals. HIGHLIGHTS the usability and the work- At the same time, he points out, more fow features of electronic and more physicians have gone to work 01 The ideal scenario for health records (EHRs), yet for hospitals, and “the employed pro- doctors would be to speak these information systems viders have become disenfranchised to the computer and have don’t seem to improve. in terms of their choice of information it convert their speech into One reason, experts say, is technology. Teir choices, particularly in structured data that would that vendors have poured primary care, count for very little in the automatically input into the most of their research and decisions made by those big corporate proper EHR ﬁelds. development budgets into meeting the entities with respect to EHRs.” 02 Direct messaging can requirements for meaningful use (MU) Tompson believes that EHR vendors increase the usefulness of and the International Classifcation of have improved their product designs over EHRs by allowing physicians Diseases-10th revision (ICD-10). time. But today’s EHRs are more compli- to attach documents to “Tey have only so much of a de- cated because of their increased func- messages they exchange velopment budget, and anything that’s tionality, he adds, and can be difcult to with their colleagues, such required by government regulations customize. as care summaries, notes might take away from something else,” Small to medium-sized physician and lab results. says Doug Tompson, MBA, senior re- practices may not be equipped to deal search director for Te Advisory Board with the technical aspects of these sys- Company, a healthcare consulting frm. tems. “Tey’re probably stuck with EHRs Te poor usability of ambulatory care that are not customized enough, that are EHRs also can be attributed to shifts in not easy to use, and that they don’t under- the marketplace, notes David Kibbe, MD, stand very well,” he says. president and chief executive ofcer of Despite all of this, however, some in- DirectTrust, a trade association for secure novations are starting to enhance the messaging networks. During the past few usability of EHRs. Tese include refne- years, he says, the big EHR vendors have ments in natural language processing, ad- increasingly focused on hospital systems vances in EHRs designed for at the expense of ambulatory EHRs, part- mobile devices, the addition 76

74 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES502547_ME101014_074.pgs 09.22.2014 20:24 ADV Electronic Medical Records Practice Management MEDENT Patient Portal • Leaders in Direct Messaging • Accounts Receivable • Messaging • Progress Notes, Templates Electronic Claim Submission • Documents & Forms and Documents with our • Appointment and • eStatements Medical Content Library Surgical Scheduling • Demographics Specialty-specific Content • Personal Calendar • Medication & Allergies • Integrated Speech Recognition • Practice Management Reports • Patient Hx • Labs, Orders, X-rays, • Talksoft Appointment • Chart Summaries Immunizations, Therapy Reminders Interface and ePrescribing • DM/HM Medical Reports and Meaningful Use Dashboards MEDENT is an “All-In-One” solution for the medical practice • Chart Central that excels in INTEROPERABILITY. • Message Central Visit our website at www.medent.com • Triage, To-do and Intra Office E-mail for more information and to request a demonstration. • Referrals • Mobile Access

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magentablackcyanyellow ES501477_ME101014_075_FP.pgs 09.18.2014 22:12 ADV EHR 2.0

of context to clinical decision would go into the assessment section,” In- EHR vendors 74 support (CDS), and the spread gram says. of direct clinical messaging. Read on to fnd For now, Prime Speech cannot extract have improved out how these developments could beneft newly entered data from the note and export you, either now or in the future. it back to the correct felds in the face sheet, their product but Ingram says that’s where the technology designs over 1/ Natural language is heading. In the future, Prime Speech will processing also assist evaluation and management cod- time. But Te biggest problem that physicians have ing and trigger clinical alerts. with EHRs is the way that these applications Other vendors, including Allscripts and today’s EHRs force them to enter data. eClinicalWorks, have integrated aspects of Encounter documentation with point- NLP into their EHRs. But so far, none of these are more and-click templates can be excruciatingly companies has had a breakthrough that slow and difcult. Physicians don’t like to would signifcantly improve EHR usability. complicated type, and many doctors also have trouble using speech recognition programs, Tomp- 2/ Mobility because of son points out. Even if they can overcome Most physicians now use smartphones and/ these barriers, free text does not create the or computer tablets at work, and they would their increased structured data that is required for MU and like to be able to use their EHRs on these quality improvement. mobile devices. functionality, Te ideal scenario for doctors would be Te leading vendors have accommodat- and can be to speak to the computer and have it convert ed them to some degree by allowing their their speech into structured data that would applications to run on an iPad or a smart- difﬁcult to automatically go into the proper felds in the phone, says Kenneth Kleinberg, MD, man- EHR. Tat technology, known as “natural aging director for health IT at Te Advisory customize. language processing” (NLP), has been under Board. But more progress has been made in development for years. Te speech recogni- ambulatory care than in acute care EHRs, tion engines used in transcription have be- and there’s a signifcant diference between come fairly accurate, but the ability of com- iPad-native EHRs and mobile versions based puters to “understand” medical terms in the on EHRs designed for desktops and laptops. context of speech and categorize them is One problem with trying to use the desk- still fairly limited. top model of an EHR on a mobile device is Greenway Health, an ambulatory EHR that the latter’s screen is smaller, so some in- vendor, is making use of NLP in its Prime formation may be cut of, Kleinberg notes. In Speech module, which it co-developed with addition, if a clinician tries to use the pop-up M*Modal, a vendor of speech recognition virtual keyboard on an iPad, it can cover up software. Prime Speech allows physicians essential information, including alerts. to “dictate and place content into existing Allscripts, Epic, and Cerner—along with custom clinical templates,” according to Gre- a number of smaller EHR vendors—have enway’s website. But Jim Ingram, MD, chief all created native apps for iPads, Kleinberg medical ofcer of Greenway, admits that says. Allscripts’ approach is to pick the 20% Prime Speech is not yet able to transform of functions that physicians use 80% of the speech into discrete data automatically. time and include that in its iPad-native Prime Speech can take information from Wand EHR, “recognizing that they’ll prob- the Greenway EHR’s patient “face sheet”— ably have to return to the desktop to com- including medications, allergies, and plete their work.” Allscripts Wand gives problems—and export it into the “speech physicians the ability to review and add to document” that a doctor dictates into. Te documentation, prescribe electronically, NLP application can slot the past medical and communicate with staf. history data into one of six categories that Not all vendors with mobile-native are part of the visit note. As the physician EHRs have focused on the Apple iOS. Some, dictates, he can pull parts of the medical like Meditech and Siemens, have used the history into the appropriate sections as he HTML5 browser approach to format their goes along. EHRs to run on any platform, including “Vital signs go into the physical exam iOS, Android and Windows. But section, for example, and the problem list some parts of the EHR function- 78

76 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

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tabs using speech; you can do almost all of it Direct messaging using speech,” Kleinburg says. Find an accreditted DirectTrust network service provider Noting that cloud storage of data fles is essential when using mobile devices, Klein- Accredited providers burg adds: “I believe you can do everything you need to do on an iPad, especially the ❚ CareAccord ❚ MaxMD large ones they have now.” ❚ Cerner Corp. ❚ MedAllies ❚ Covisint ❚ MRO Corp. 3/ Clinical decision support ❚ Data Motion, Inc. ❚ NextGen/Mirth Ideally, EHR alerts and reminders can help ❚ digiCert, Inc. ❚ New Uork eHealth Collaborative prevent harm to patients or remind physi- ❚ EMR Direct ❚ Relay Health cians to provide essential care. Other kinds ❚ Infomedtrix, LLC ❚ Secure Exchange Solutions of CDS built into the EHR’s structure can ❚ Informatics Corp. of America ❚ Surescripts help doctors follow evidence-based guide- ❚ Inpriva, Inc. ❚ Truven Health Analytics lines. ❚ IOD, Inc. ❚ Updox Te drawback of alerts and reminders— the most visible form of CDS--is that they Candidates for accreditation can pop up unnecessarily or erroneously. “In most systems, they’re at a very simple level,” ❚ Alere Accountable Care Solutions ❚ Michiana Health Information Network says Dean Sittig, Ph.D., a professor at the ❚ Cozeva (Applied Research Works, Inc.) ❚ Nitor Group University of Texas Health Sciences Center ❚ athenahealth ❚ Optum in Houston. “Most doctors would say they’re ❚ Axesson ❚ Orion Health overly simplistic and are often wrong.” ❚ eClinicalworks ❚ Pulse Systems, Inc. Frequently, alerts are based on insuf- ❚ Glenwood Systems ❚ Qsource cient information. For example, the program ❚ GlobalSign, Inc. ❚ Quest Diagnostics might tell the doctor that Valium should not ❚ Healthcare Information Xchange of New ❚ Rochester RHIO be prescribed to the elderly, although the York, Inc. ❚ Safety Net Connect patient in question is not old. As a result of ❚ Health Companion, Inc. ❚ San Diego Regional Health Information such mistakes, Sittig says, physicians ignore ❚ HealtheConnections RHIO Exchange the vast majority of alerts in EHRs. “Tey ❚ Healthunity Corp. ❚ Siemens Medical Solutions USA, Inc. think they’re almost all wrong, or that they ❚ iMedicor ❚ Simplicity Health Systems don’t matter, or that they don’t apply.” ❚ Integrated Care Collaboration ❚ Utah Health Information Network In some cases, he points out, the EHR ❚ Medicity ❚ Vitalz Technology, LLC alerts create confusion because they don’t include the context of why a physician made Source: DirectTrust a particular medical decision. For example, perhaps the physician is prescribing a small dose of Valium to an elderly patient to ease ality can get lost with HTML5, his or her anxiety before an MRI test. 76 Kleinberg says. “A lot of the decision support we give is of Some physicians have told Kibbe that that type: It’s true and it’s right, but it doesn’t they prefer the touch screens on iPads to us- pertain to this patient,” Sittig says. “To get ing a mouse to point and click on desktops the decision support to pertain to the pa- or laptops. Kleinberg acknowledges that tient, you usually need more context about this can be an advantage, but points out that patient.” that typing is still much more difcult on an Intermountain Healthcare, based in Salt iPad than on a desktop. Tat’s why speech Lake City, Utah, has developed a context- recognition is an important technology for sensitive alerting system over many years, mobile devices, he says. Sittig notes. As a result, he says, “Its physi- While NLP hasn’t yet achieved its mobile cians accept decision support more than use potential, Kleinberg believes it’s moving 95% of the time.” in the right direction. Intermountain is replacing its home- “When you talk to the device, it’s navigat- grown EHR with a system from Cerner, ing to the right template. Some systems can which plans to integrate Intermountain’s recognize the feld you’re talking about just context-sensitive alerts into its from what you’re saying. You can go between own EHR, he says. But most 80

78 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES502550_ME101014_078.pgs 09.22.2014 20:23 ADV You know the drill: faxes, forms, phone calls, web portals, and the long wait before you get the prescription approved.

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Ask your EHR to get CompletEPA For more information, visit Surescripts.com/CompletEPA Prior Authorization without the Frustration

magentablackcyanyellow ES501133_ME101014_079_FP.pgs 09.18.2014 01:52 ADV EHR 2.0

other vendors aren’t moving rect embedded in their EHRs is a boon to To avoid alert 78 in this direction because they physicians, because they don’t have to leave haven’t seen customer demand for it. the EHR to view or download information fatigue, some Meanwhile, researchers are seeking ways from other providers. to improve alerts. A recent paper that Sittig But there are also disadvantages. For vendors have co-authored proposes a system for improv- example, Direct can’t be used to search for ing CDS by using web-based monitoring information across the community. Sec- designed tools and an interactive dashboard for eval- ondly, it’s designed only for point-to-point uating alert and response appropriateness. exchanges. Also, the data in the attached their systems To avoid alert fatigue, Tompson points documents can’t fow into the structured out, some vendors have designed their sys- felds of the receiving EHR. to present tems to present information to doctors Greenway has found that to be a problem information to about medication safety and dosing at the for ob/gyn customers, who want the EHR to point of prescribing. Only if a prescribing de- consume data attached to Direct messages, doctors about cision is truly dangerous would “the fashing and vice versa, notes Mark Janiszewski, the light go on,” he says. company’s senior vice president of prod- medication uct management. To make this happen, he 4/ Interoperability notes, Greenway has built limited interfaces safety and Despite billions of government dollars for medications, problems and allergies for poured into EHR incentives and health in- use with with EHRs from vendors such as dosing at formation exchanges, a recent Health Afairs Epic, Cerner, McKesson, Meditech, and CPSI. article notes, the amount of data exchanged the point of among providers is still very modest. WoRks in pRogREss To jump-start these communications, While the innovations described above are prescribing. which are vital to care coordination, the all works in progress, they seem destined government joined with the private sector to beneft physicians in the long run. In the a few years ago to create the Direct secure meantime, Tompson points out, there are messaging protocol. Direct is supposed to some signifcant diferences among EHRs, be embedded in all EHRs that have been cer- including ease of customization, whether tifed for use in the second stage of the MU they allow physicians to move easily among program. It can be used to meet the stage 2 templates, and how many clicks are required requirement that providers exchange care to accomplish a particular task. summaries at transitions of care. If you’re shopping for your frst EHR or Te use of Direct is starting to grow and considering a switch, pay close attention is expected to increase rapidly in 2015, Kibbe to what these systems can actually do, and says. His own organization, DirectTrust, per- don’t depend on demonstrations by experi- forms an important function in this feld. By enced users. Try them out yourself and visit accrediting health information service pro- other practices to see how specifc EHRs are viders (HISPs), which carry secure messages being used. between physicians with Direct addresses, Meanwhile, keep your eye on the innova- DirectTrust enables the HISPs to trust each tions that will eventually make EHRs more other enough to exchange secure messages. usable. Tey may be arriving sooner than As of the end of July, the two dozen HISPs you expect. in the DirectTrust community were serving 13,000 healthcare organizations and had provided over 400,000 Direct addresses, according to Kibbe. More online Direct messaging can increase the usefulness of EHRs by enabling physicians to Physician outcry on EHR functionality, cost attach documents, such as care summaries, will shake the health information technology notes, and lab results, to messages they ex- sector change with their colleagues. Hospitals can http://bit.ly/1cDPQsI also use Direct to send discharge summaries and notices of admission and discharge to EHRs continue to hinder physician job doctors. satisfaction From a workfow standpoint, having Di- http://bit.ly/1jrghWk

80 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES502546_ME101014_080.pgs 09.22.2014 20:24 ADV mHealth

Embracing the mobile health revolution How physicians can navigate the growing number of health-related apps and meet patient demand for more connected care

by KEN TERRY Contributing editor

ore than one-third of venture capital f rm, agrees. “T e mobile physicians have rec- health world has been around for a couple ommended the use of of years, and we’ve had a lot of experimen- mobile health apps to tation and there are a lot of apps out there,” their patients in the he points out. “So it’s not surprising that a past year, according to subset of these apps are quite valuable and a recent Manhattan Re- that doctors are recommending them.” search survey. Experts On the other hand, Manhattan Re- hIGhlIGhTs say that the bulk of search found that only about half of the 01 these apps are related to diet and f tness, physicians who recommended apps sug- While there is little and that few physicians are “prescribing” gested specif c ones to their patients. published evidence of clinical apps with the expectation of receiving “Some doctors are going to be more savvy effectiveness for mhealth follow-up data. Nevertheless, physicians’ about what apps are around—particularly, apps, that’s not essential acceptance of mHealth apps and related younger ones who are more pro-technol- to doctors when they tracking devices is clearly growing along ogy,” Kaushal explains. “T ose doctors are recommend apps that help with mobile’s inf uence on everyday life. more likely to prescribe and suggest a par- patients exercise or diet or “T e mobile revolution is everywhere ticular app.” quit smoking. around us,” notes Joseph Kvedar, MD, With more than 40,000 health-related 02 In the next few years, president of the Center for Connected apps available, most doctors are unsure most apps and devices that Health (CCH), a unit of Partners Health- of which ones to prescribe, notes Kvedar. help doctors diagnose and care in Boston. “It’s all about mobile “T ere’s a fear of liability if they don’t know treat patients will undergo now, and physicians can’t help but no- what they’re talking about. So they tend clinical trials to get fda

Getty Images/iStock/360Getty tice that, and they feel they have to get to be very general and say, ‘It’s probably approval. involved in some way.” worth looking at this category to help you Mohit Kaushal, MD, a partner in Ab- track something because you need to lose erdare Ventures, a San Francisco-based 10 pounds or you need to be more active.’”

MedicalEconomics.com Medical econoMics ❚ OctOber 10, 2014 81

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The mobile revolution is everywhere around us. It’s all about mobile now, and physicians can’t help but notice that, and they feel they have to get involved in some way.” —Joseph Kvedar, Md, presIdenT of The CenTer for ConneCTed healTh

CCH has a website called Wellocracy.com Another physician who recommended that rates several trackers and apps. IMS an app to one of her patients had less luck. Health has started a much more ambitious Leslie Kernisen, a geriatrician in Oakland, project to curate the 16,000 apps in the Apple Calif., was trying to help the patient get his Store that it considers relevant. A group of hypertension under control. Te elderly experts, in a recent JAMA commentary, pro- man and his family had been writing down posed that independent or government-com- his thrice-daily blood pressure readings on a missioned bodies review and certify mHealth piece of paper, and Kernisen suggested they apps. But right now, not much is available instead use an app. Unfortunately, the app to help doctors evaluate the efectiveness of they selected didn’t record the time of day mHealth apps before prescribing them to pa- when he took his blood pressure. Tat data tients. had aided her analysis, so she had him drop the app and return to paper reports. Physician exPerience Kernisen has also found medication Te vast majority of mHealth apps on the management apps to be difcult for older market focus on wellness and ftness, but patients to use, because they require the that doesn’t mean they can’t be prescribed patient or their caregiver to enter their to patients with chronic diseases. medications. “Some of my patients have Internist Rajani LaRocca, who practices long medication lists that frequently at a Massachusetts General Hospital clinic change. So that makes it almost a non- in Boston, conducted group visits last year starter,” she says. with nine elderly patients, most of whom “It will take a while for app developers had diabetes. To encourage them to be- to refne the design and usability of apps so come more active, she prescribed the FitBit they’re truly useful in most cases,” refects Zip, a $50 tracker that measured their steps Kernisen. “So while apps are easy to pre- each day. All of the patients increased their scribe, they may not be helpful to the pa- activity for the frst six weeks, and after a tient.” year, more than half were still using their trackers, LaRocca told Medical Economics. Where’s the evidence? FitBit users can download a related app While there is little published evidence of to their smartphones or tablets that displays clinical efectiveness for mHealth apps, that information about their exercise trends. information isn’t essential to doctors for rec- Tis data can be transmitted to a physician’s ommending apps to help patients exercise, ofce. LaRocca is having her patients share diet or quit smoking, notes Kaushal. their data at group visits rather than trans- But such evidence is critically important mit it to her her ofce; CCH is working on a to physicians who are considering prescrib- program that will allow FitBit data to be sent ing apps for chronic conditions, Kvedar directly into an ofce’s electronic health re- says. Te Food and Drug Administration cord (EHR) system. (FDA), which has so far approved about 100 LaRocca looks forward to this new capa- mHealth apps, has a key role to play here, he bility. “It would be helpful. It’s an indicator of points out. how active somebody is in general,” she says, Last September, the FDA issued a guid- adding that she’d recommend the activity ance document that described the types of tracker to any patient. “It’s useful for just mHealth apps it would regulate (See sidebar, about everybody who is interested in getting page 84). Tose include apps healthy or healthier.” that convert a mobile platform 84

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such as a smartphone into a In the meantime, some physicians are 82 device that already requires eager to try out apps that promise to help FDA approval, such as an app that turns an their chronic disease patients. For example, iPhone into an electro-cardiogram (ECG) LaRocca says, it could be useful to get reg- machine. In addition, the FDA said it would ular blood pressure readings on patients regulate apps that are designed to be used whose blood pressure goes up and down as accessories to an FDA-regulated device, during of ce visits. “If you could get accu- such as a application that enables a mobile rate, easily transmitted BP readings on those device to display X-rays stored in a picture people, it would be fantastic.” archiving and communications system. T e same could be true for glucometer In the next few years, Kvedar forecasts, readings transmitted from mobile devices, most apps and devices that help doctors she says. “Especially when the patient is just diagnose and treat patients will undergo starting insulin, or they have an acute health clinical trials to get FDA approval. In the problem where their blood sugar is f uctuat- past year, he observes, CCH has seen an in- ing a lot—for those categories, it would be creased demand from corporate clients who helpful to see [mobile glucometer data].” want the center to test their apps so they can She cautions, however, that physicians take the evidence to the FDA. must prescribe such apps judiciously so

HEALTH APPS FOR PHYSICIANS WILL FACE NEW FDA REGULATIONS

By Alison Ritchie Content Specialist

n recent years, the mobile new regulatory requirements and why application market has they are important for app developers been ﬂ ooded with mobile and patients. health apps (mHealth) “As is the case with traditional that do everything from medical devices, certain mobile count calories to perform apps can post potential risks to electrocardiography. public health,” the document states. The Epocrates 2013 Mobile “Moreover, certain mobile medical Trends Report showed that apps may pose risks that are unique about 4 out of 5 physicians, to the characteristics of the platform nurse practitioners, and on which the mobile medical app is physician assistants are using run. For example, the interpretation smart phones every day, and more of radiological images on a mobile than 50% of physicians use tablets device could be adversely affected daily. by the smaller screen size, lower But now the Food and Drug contrast ratio, and uncontrolled Administration (FDA) has announced ambient light of the mobile that it will start regulating medical platform.” apps that physicians may be using Not all medical apps will be on smart phones and tablets. subject to regulation. The FDA will Its guidelines, “Mobile Medical focus on apps meant for physicians Applications Guidance for Industry and other healthcare providers to use and Food and Drug Administration as diagnostic tools and to facilitate Staff,” offer information regarding the patient care. Getty Images/iStock/360

84 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES503503_ME101014_084.pgs 09.23.2014 02:03 ADV mHealth MU2 Got You that they’re not overwhelmed by a collect patient data and transmit it food of data. to physicians. All Tied Up? Kvedar goes further, noting that remote monitoring the distinction between home and Te experts point out that doctors mobile monitoring is rapidly disap- must fnd a way to screen this kind pearing. In recent years, he notes, of data and accommodate it in their devices used in remote patient mon- workfow before they’ll be willing to itoring have become sensor-based, use it. so that data on patients’ vital signs Home monitoring of patients can be automatically recorded in- with chronic diseases presents a stead of being manually entered by similar challenge, yet the Manhat- patients. Te use of sensors makes tan Research survey found that the information more objective and about a ffth of physicians monitor clinically useful. some of their patients remotely. “All of the [remote patient moni- Kaushal, Kvedar and other observ- toring] manufacturers now have ra- ers agree that home monitoring dio transmitters in their devices, and might be a stepping stone to the ac- all of them have a mobile app,” he ceptance of mHealth apps used to observes. “It’s moving rapidly in the CONVERT NOW! Time is Running Out. mobile medical aPPs discretions and will not expect the Fda Will regulate manufacturers to submit The FDA is taking a tailored, premarket review applications or • 08&HUWLîHG&ORXG%DVHG risk-based approach that focuses to register and list their apps with (+5 3+5PRQWK on the small subset of mobile the FDA. This includes mobile apps that meet the regulatory medical apps that: • 1R6WDUW8S&RVWV definition of “device” and that: ❚ Help patients/users self-manage :DLYHG&RQYHUVLRQ)HHV ❚ • are intended to be used as their disease or condition without /LPLWHGWLPHRQO\ an accessory to a regulated providing specific treatment medical device, or suggestions; • 3URYHQLPSOHPHQWDWLRQLQ ❚ transform a mobile platform ❚ Provide patients with simple tools DPDWWHURIGD\V into a regulated medical to organize and track their health device. information; • 8VHRXU&RQFLHUJH $WWHVWDWLRQ6HUYLFHV ❚ Mobile apps span a wide range Provide easy access to DWWHVWDWLRQVXFFHVVUDWH of health functions. While many information related to health mobile apps carry minimal risk, conditions or treatments; those that can pose a greater risk to patients will require FDA ❚ Help patients document, show review. or communicate potential medical conditions to health care mobile medical aPPs providers; the Fda Will regulate 800-648-4836 based on agency ❚ VDOHV#&ïXHQWFRP Automate simple tasks for health ZZZF\ïXHQWFRP discretion care providers; or For many mobile apps that meet the regulatory definition of a ❚ Enable patients or providers to “device” but pose minimal risk interact with Personal Health to patients and consumers, the Records (PHR) or Electronic FDA will exercise enforcement Health Record (EHR) systems. &\ïXHQWYHUVLRQ&HUWLîFDWH

Medical econoMics ❚ OctOber 10, 2014 85

magentablackcyanyellow ES503504_ME101014_085.pgs 09.23.2014 02:03 ADV mHealth

direction of being seamless in that regard.” age of physicians who embrace these digital Overall, Manhattan Research reported, technologies will rise to 50% or 60%. Ten, % 40% of physicians now believe that digital suddenly, it will jump to 100% “because the communications technologies of various people who don’t want to deal with it will be kinds—including mobile apps, remote pa- retiring.” 40 tient monitoring, secure messaging via patient portals, and telehealth consults—can of physicians help improve patient outcomes. MORE ONLINE believe digital Kvedar fnds this statistic a bit amazing. “Forty percent is extraordinary. When I was Mobile health apps hold big potential for communications a medical student, we used computers to diabetes management look up lab values. Now everything is elec- http://bit.ly/1qRogmi technologies— tronic, from lab values and X-rays and notes mobile apps, to videoconferencing with patients and HIMSS 2014 survey: Cost still a barrier for looking at their home readings.” mobile adoption in healthcare remote patient In coming years, he predicts, the percent- http://bit.ly/1fwUdWH monitoring, secure messaging said that reduced productivity was via patient EHR users investing a major or moderate challenge. portals, and Integrating their EHR systems with more in patient portals, other systems was reported as a telehealth major or moderate challenge by mobile access 55% of users. Though meeting consults—can meaningful use requirements help improve By Donna Marbury Content Specialist has been a big debate, only 9% of survey respondents see it as a major patient outcomes. hough practitioners are still having challenge, and 30% see it as a moderate —ManhaTTan researCh productivity complications with challenge. their electronic health record (EHR) “One possible explanation is that the systems, they continue to invest challenges users associate with meaningful in them so that they work more use have more to do with staf preparedness Tefciently for staf and patients. and executing requirements with patients Two areas physicians are focusing on are than with the actual software itself. Without patient portals and mobile devices. an EHR, meaningful use couldn’t be achieved Thirty-fve percent of EHR users say they at all, and it’s possible respondents are are investing more money in patient portals thinking of the question in those terms,” the in 2014, according to the initial fndings of study’s authors say. an ongoing survey by Software Advice, a The vast majority of EHR users said that consulting frm. Respondents report that they their system gave them easy access to records will be investing more resources in patient (87%), and ofered more legible and robust portals than any other EHR application, records (86%). including e-prescribing, lab integration and “Overall, respondents rated challenges health information exchanges. less highly than they did benefts—in other Also, more EHR users are using mobile words, a greater percentage of people said devices including tablets and smartphones their EHRs delivered on key benefts ‘well’ to access records. More than 80% of users or ‘very well’ than said their EHRs presented access their EHR systems through desktop challenges to a ‘major’ or ‘moderate’ degree,” computers, almost 70% of users access their say the study’s authors. EHR system using a laptop, 35% use tablets, Almost half of the respondents surveyed and 20% use smartphones (respondents are from practices with three or fewer were able to choose more than one option.) physicians. Twenty six percent are from A growing percentage (17%) use mobile and practices with four to 10 physicians, and portable devices exclusively. 27% are from practices with 11 or more More than half of EHR users surveyed physicians.

86 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES503505_ME101014_086.pgs 09.23.2014 02:03 ADV Covered for more than 80% of commercially insured patients without prior authorization1

The recommended starting dose of INVOKANA® (canagliﬂ ozin) is 100 mg once daily.2 INVOKANA® is indicated as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus. INVOKANA® is not recommended in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis. IMPORTANT SAFETY INFORMATION CONTRAINDICATIONS >> History of a serious hypersensitivity reaction to INVOKANA®. >> Severe renal impairment (eGFR <30 mL/min/1.73 m2), end stage renal disease, or patients on dialysis. WARNINGS and PRECAUTIONS >> Hypotension: INVOKANA® causes intravascular volume contraction. Symptomatic hypotension can occur after initiating INVOKANA®, particularly in patients with impaired renal function (eGFR <60 mL/min/1.73 m2), elderly patients, and patients on either diuretics or medications that interfere with the renin-angiotensin-aldosterone system (eg, angiotensin-converting- enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs]), or patients with low systolic blood pressure. Before initiating INVOKANA® in patients with one or more of these characteristics, volume status should be assessed and corrected. Monitor for signs and symptoms after initiating therapy. Please see additional Important Safety Information and brief summary of full Prescribing Information on the following pages.

magentablackcyanyellow ES501106_ME101014_A86_FP.pgs 09.18.2014 01:49 ADV INVOKANA® 300 mg vs Januvia® 100 mg at 52 weeks, each in combination with metformin + a sulfonylurea (SU) 2

Greater reductions in A1C2

Adjusted Mean Change in A1C From Baseline (%)

–0.66

–1.03

Januvia® 100 mg + metformin INVOKANA® 300 mg + metformin and an SU (n=378) and an SU (n=377)

Diﬀ erence from Januvia® (sitagliptin): –0.37% (95% CI: –0.50, –0.25); P<0.05

INVOKANA® (canagliﬂ ozin) starting dose: 100 mg once daily. In patients tolerating the starting dose who have an eGFR ≥60 mL/min/1.73 m2 and require additional glycemic control, the dose can be increased to 300 mg once daily.2 Indicated trademarks are registered trademarks of their respective owners. IMPORTANT SAFETY INFORMATION (cont’d) >> Impairment in Renal Function: INVOKANA® increases serum creatinine and decreases eGFR. Patients with hypovolemia may be more susceptible to these changes. Renal function abnormalities can occur after initiating INVOKANA®. More frequent renal function monitoring is recommended in patients with an eGFR below 60 mL/min/1.73 m2. >> Hyperkalemia: INVOKANA® can lead to hyperkalemia. Patients with moderate renal impairment who are taking medications that interfere with potassium excretion, such as potassium-sparing diuretics, or medications that interfere with the renin- angiotensin-aldosterone system are more likely to develop hyperkalemia. Monitor serum potassium levels periodically after initiating INVOKANA® in patients with impaired renal function and in patients predisposed to hyperkalemia due to medications or other medical conditions.

magentablackcyanyellow ES501120_ME101014_B86_FP.pgs 09.18.2014 01:50 ADV INVOKANA® 300 mg demonstrated greater reductions in A1C vs Januvia® 100 mg...... as well as greater reductions in body weight† and systolic blood pressure2†

Greater reductions Incidence of hypoglycemia2 2 in body weight *† INVOKANA® 300 mg: 43.2%; Januvia® 100 mg: 40.7% Diff erence from Januvia® 100 mg: The incidence of hypoglycemia increases when used –2.8%; P<0.001 in combination with insulin or an insulin secretagogue. Greater reductions in Adverse reactions (ARs)3 3 systolic blood pressure *† Incidences of ARs were similar between groups except for: Diff erence from Januvia® 100 mg: Male/female genital mycotic infection, –5.9 mm Hg; P<0.001 INVOKANA® 300 mg: 9.2%/15.3%; Januvia® 100 mg: 0.5%/4.3% Increased urine frequency/volume, INVOKANA® is not indicated for weight INVOKANA® 300 mg: 1.6%/0.8%; Januvia® 100 mg: 1.3%/0% loss or as antihypertensive treatment. *Adjusted mean. Learn more and register for updates at †Prespecifi ed secondary endpoint. INVOKANAhcp.com

A randomized, double-blind, active-controlled, 52-week study of patients with type 2 diabetes inadequately controlled on maximum doses of metformin (≥2000 mg/day, or ≥1500 mg/day if higher dose not tolerated) and near-maximally or maximally eﬀ ective doses of an SU.2 >> Hypoglycemia With Concomitant Use With Insulin and Insulin Secretagogues: Insulin and insulin secretagogues are known to cause hypoglycemia. INVOKANA® can increase the risk of hypoglycemia when combined with insulin or an insulin secretagogue. Therefore, a lower dose of insulin or insulin secretagogue may be required to minimize the risk of hypoglycemia when used in combination with INVOKANA®. >> Genital Mycotic Infections: INVOKANA® increases the risk of genital mycotic infections. Patients with a history of genital mycotic infections and uncircumcised males were more likely to develop genital mycotic infections. Monitor and treat appropriately. >> Hypersensitivity Reactions: Hypersensitivity reactions (eg, generalized urticaria), some serious, were reported with INVOKANA® treatment; these reactions generally occurred within hours to days after initiating INVOKANA®. If hypersensitivity reactions occur, discontinue use of INVOKANA®; treat per standard of care and monitor until signs and symptoms resolve. Please see additional Important Safety Information and brief summary of full Prescribing Information on the following pages.

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>> Increases in Low-Density Lipoprotein (LDL-C): Dose-related than that in maternal plasma. Data in juvenile rats directly increases in LDL-C occur with INVOKANA® (canagliflozin). exposed to INVOKANA® showed risk to the developing Monitor LDL-C and treat per standard of care after initiating kidney (renal pelvic and tubular dilatations) during INVOKANA®. maturation. Since human kidney maturation occurs in >> Macrovascular Outcomes: There have been no clinical studies utero and during the first 2 years of life when lactational establishing conclusive evidence of macrovascular risk reduction exposure may occur, there may be risk to the developing with INVOKANA® or any other antidiabetic drug. human kidney. Because many drugs are excreted in human milk, and because of the potential for serious DRUG INTERACTIONS adverse reactions in nursing infants from INVOKANA®, a >> UGT Enzyme Inducers: Rifampin: Co-administration decision should be made whether to discontinue nursing of canagliflozin with rifampin, a nonselective inducer or to discontinue INVOKANA®, taking into account the of several UGT enzymes, including UGT1A9, UGT2B4, importance of the drug to the mother. decreased canagliflozin area under the curve (AUC) by 51%. This decrease in exposure to canagliflozin may >> Pediatric Use: Safety and effectiveness of INVOKANA® decrease efficacy. If an inducer of these UGTs (eg, in pediatric patients under 18 years of age have not rifampin, phenytoin, phenobarbital, ritonavir) must been established. be co-administered with INVOKANA® (canagliflozin), >> Geriatric Use: Two thousand thirty-four (2034) consider increasing the dose to 300 mg once daily if patients 65 years and older, and 345 patients 75 years patients are currently tolerating INVOKANA® 100 mg and older were exposed to INVOKANA® in nine clinical once daily, have an eGFR greater than 60 mL/min/1.73 m2, studies of INVOKANA®. Patients 65 years and older and require additional glycemic control. Consider other had a higher incidence of adverse reactions related to antihyperglycemic therapy in patients with an eGFR of reduced intravascular volume with INVOKANA® (such as 45 to less than 60 mL/min/1.73 m2 receiving concurrent hypotension, postural dizziness, orthostatic hypotension, therapy with a UGT inducer and requiring additional syncope, and dehydration), particularly with the glycemic control. 300-mg daily dose, compared to younger patients; more >> Digoxin: There was an increase in the area AUC and mean prominent increase in the incidence was seen in patients who were ≥75 years of age. Smaller reductions in HbA1C peak drug concentration (Cmax) of digoxin (20% and 36%, respectively) when co-administered with INVOKANA® with INVOKANA® relative to placebo were seen in older 300 mg. Patients taking INVOKANA® with concomitant (65 years and older; -0.61% with INVOKANA® 100 mg and digoxin should be monitored appropriately. -0.74% with INVOKANA® 300 mg relative to placebo) compared to younger patients (-0.72% with INVOKANA® 100 mg and -0.87% with INVOKANA® 300 mg relative USE IN SPECIFIC POPULATIONS to placebo). >> Pregnancy Category C: There are no adequate and well- controlled studies of INVOKANA® in pregnant women. >> Renal Impairment: The efficacy and safety of INVOKANA® Based on results from rat studies, canagliflozin may affect were evaluated in a study that included patients with renal development and maturation. In a juvenile rat study, moderate renal impairment (eGFR 30 to <50 mL/min/ increased kidney weights and renal pelvic and tubular 1.73 m2). These patients had less overall glycemic efficacy dilatation were evident at ≥0.5 times clinical exposure and had a higher occurrence of adverse reactions related from a 300-mg dose. to reduced intravascular volume, renal-related adverse reactions, and decreases in eGFR compared to patients These outcomes occurred with drug exposure during with mild renal impairment or normal renal function (eGFR periods of animal development that correspond to the late ≥60 mL/min/1.73 m2); patients treated with INVOKANA® second and third trimester of human development. During 300 mg were more likely to experience increases in pregnancy, consider appropriate alternative therapies, potassium. especially during the second and third trimesters. INVOKANA® should be used during pregnancy only if the The efficacy and safety of INVOKANA® have not been potential benefit justifies the potential risk to the fetus. established in patients with severe renal impairment < 2 >> (eGFR 30 mL/min/1.73 m ), with end-stage renal disease Nursing Mothers: It is not known if INVOKANA® is (ESRD), or receiving dialysis. INVOKANA® is not expected excreted in human milk. INVOKANA® is secreted in the to be effective in these patient populations. milk of lactating rats, reaching levels 1.4 times higher

Janssen Pharmaceuticals, Inc. Canagliﬂozin is licensed from Mitsubishi Tanabe Pharma Corporation. © Janssen Pharmaceuticals, Inc. 2014 June 2014 013143-140404

magentablackcyanyellow ES501118_ME101014_D86_FP.pgs 09.18.2014 01:50 ADV INVOKANA™ (canagliflozin) tablets, for oral use >> Hepatic Impairment: No dosage Brief Summary of Prescribing Information. INDICATIONS AND USAGE adjustment is necessary in patients with INVOKANA™ (canagliflozin) is indicated as an adjunct to diet and exercise to mild or moderate hepatic impairment. The improve glycemic control in adults with type 2 diabetes mellitus [see Clinical use of INVOKANA® has not been studied Studies (14) in full Prescribing Information]. Limitation of Use: INVOKANA is not recommended in patients with type 1 in patients with severe hepatic impairment diabetes mellitus or for the treatment of diabetic ketoacidosis. and it is therefore not recommended. CONTRAINDICATIONS • History of a serious hypersensitivity reaction to INVOKANA [see Warnings OVERDOSAGE and Precautions]. >> There were no reports of overdose during • Severe renal impairment (eGFR less than 30 mL/min/1.73 m2), end stage renal disease or patients on dialysis [see Warnings and Precautions and the clinical development program of Use in Specific Populations]. INVOKANA® (canagliflozin). WARNINGS AND PRECAUTIONS Hypotension: INVOKANA causes intravascular volume contraction. In the event of an overdose, contact the Symptomatic hypotension can occur after initiating INVOKANA [see Adverse Poison Control Center. It is also reasonable Reactions] particularly in patients with impaired renal function (eGFR less than 60 mL/min/1.73 m2), elderly patients, patients on either diuretics or to employ the usual supportive measures, medications that interfere with the renin-angiotensin-aldosterone system eg, remove unabsorbed material from (e.g., angiotensin-converting-enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs]), or patients with low systolic blood pressure. Before the gastrointestinal tract, employ clinical initiating INVOKANA in patients with one or more of these characteristics, monitoring, and institute supportive volume status should be assessed and corrected. Monitor for signs and treatment as dictated by the patient’s symptoms after initiating therapy. Impairment in Renal Function: INVOKANA increases serum creatinine and clinical status. Canagliflozin was negligibly decreases eGFR. Patients with hypovolemia may be more susceptible to these removed during a 4-hour hemodialysis changes. Renal function abnormalities can occur after initiating INVOKANA [see Adverse Reactions]. More frequent renal function monitoring is session. Canagliflozin is not expected to recommended in patients with an eGFR below 60 mL/min/1.73 m2. be dialyzable by peritoneal dialysis. Hyperkalemia: INVOKANA can lead to hyperkalemia. Patients with moderate renal impairment who are taking medications that interfere with potassium ADVERSE REACTIONS excretion, such as potassium-sparing diuretics, or medications that interfere >> The most common (≥5%) adverse with the renin-angiotensin-aldosterone system are more likely to develop hyperkalemia [see Adverse Reactions]. reactions were female genital mycotic Monitor serum potassium levels periodically after initiating INVOKANA in infections, urinary tract infections, and patients with impaired renal function and in patients predisposed to increased urination. Adverse reactions hyperkalemia due to medications or other medical conditions. Hypoglycemia with Concomitant Use with Insulin and Insulin Secretagogues: in ≥2% of patients were male genital Insulin and insulin secretagogues are known to cause hypoglycemia. mycotic infections, vulvovaginal pruritus, INVOKANA can increase the risk of hypoglycemia when combined with insulin or an insulin secretagogue [see Adverse Reactions]. Therefore, a lower dose of

thirst, nausea, and constipation. 003180-130920 insulin or insulin secretagogue may be required to minimize the risk of hypoglycemia when used in combination with INVOKANA. Please see brief summary of full Prescribing Genital Mycotic Infections: INVOKANA increases the risk of genital mycotic Information on the following pages. infections. Patients with a history of genital mycotic infections and uncircumcised males were more likely to develop genital mycotic infections [see Adverse Reactions]. Monitor and treat appropriately. References: 1. Data on file. Janssen Pharmaceuticals, Inc., Hypersensitivity Reactions: Hypersensitivity reactions (e.g., generalized Titusville, NJ. 2. INVOKANA® [prescribing information]. urticaria), some serious, were reported with INVOKANA treatment; these Titusville, NJ: Janssen Pharmaceuticals, Inc.; 2013. reactions generally occurred within hours to days after initiating INVOKANA. 3. Schernthaner G, Gross JL, Rosenstock J, et al. If hypersensitivity reactions occur, discontinue use of INVOKANA; treat per Canagliflozin compared with sitagliptin for patients with standard of care and monitor until signs and symptoms resolve [see type 2 diabetes who do not have adequate glycemic Contraindications and Adverse Reactions]. control with metformin plus sulfonylurea: a 52-week Increases in Low-Density Lipoprotein (LDL-C): Dose-related increases in randomized trial [published correction appears in LDL-C occur with INVOKANA [see Adverse Reactions]. Monitor LDL-C and treat per standard of care after initiating INVOKANA. Diabetes Care. 2013;36(12):4172]. Diabetes Care. Macrovascular Outcomes: There have been no clinical studies establishing 2013;36(9):2508-2515. conclusive evidence of macrovascular risk reduction with INVOKANA or any other antidiabetic drug. ADVERSE REACTIONS The following important adverse reactions are described below and elsewhere in the labeling: • Hypotension [see Warnings and Precautions] • Impairment in Renal Function [see Warnings and Precautions] • Hyperkalemia [see Warnings and Precautions] • Hypoglycemia with Concomitant Use with Insulin and Insulin Secretagogues [see Warnings and Precautions] • Genital Mycotic Infections [see Warnings and Precautions] • Hypersensitivity Reactions [see Warnings and Precautions] • Increases in Low-Density Lipoprotein (LDL-C) [see Warnings and Precautions] Clinical Studies Experience: Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared to the rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice. Pool of Placebo-Controlled Trials: The data in Table 1 is derived from four 26-week placebo-controlled trials. In one trial INVOKANA was used as monotherapy and in three trials INVOKANA was used as add-on therapy [see Clinical Studies (14) in full Prescribing Information]. These data reflect exposure of 1667 patients to INVOKANA and a mean duration of exposure to

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INVOKANA of 24 weeks. Patients received INVOKANA 100 mg (N=833), 100 mg, and INVOKANA 300 mg, respectively. Upper extremity fractures INVOKANA 300 mg (N=834) or placebo (N=646) once daily. The mean age of occurred more commonly on INVOKANA than comparator. the population was 56 years and 2% were older than 75 years of age. In the pool of eight clinical trials, hypersensitivity-related adverse reactions Fifty percent (50%) of the population was male and 72% were (including erythema, rash, pruritus, urticaria, and angioedema) occurred in Caucasian, 12% were Asian, and 5% were Black or African American. At 3.0%, 3.8%, and 4.2% of patients receiving comparator, INVOKANA 100 mg, baseline the population had diabetes for an average of 7.3 years, had and INVOKANA 300 mg, respectively. Five patients experienced serious a mean HbA1C of 8.0% and 20% had established microvascular adverse reactions of hypersensitivity with INVOKANA, which included complications of diabetes. Baseline renal function was normal or mildly 4 patients with urticaria and 1 patient with a diffuse rash and urticaria impaired (mean eGFR 88 mL/min/1.73 m2). occurring within hours of exposure to INVOKANA. Among these patients, Table 1 shows common adverse reactions associated with the use of 2 patients discontinued INVOKANA. One patient with urticaria had INVOKANA. These adverse reactions were not present at baseline, recurrence when INVOKANA was re-initiated. occurred more commonly on INVOKANA than on placebo, and occurred Photosensitivity-related adverse reactions (including photosensitivity in at least 2% of patients treated with either INVOKANA 100 mg or reaction, polymorphic light eruption, and sunburn) occurred in 0.1%, 0.2%, INVOKANA 300 mg. and 0.2% of patients receiving comparator, INVOKANA 100 mg, and Table 1: Adverse Reactions From Pool of Four 26−Week Placebo-Controlled INVOKANA 300 mg, respectively. Studies Reported in ≥ 2% of INVOKANA-Treated Patients* Other adverse reactions occurring more frequently on INVOKANA than on comparator were: INVOKANA INVOKANA Placebo 100 mg 300 mg Volume Depletion-Related Adverse Reactions: INVOKANA results in an Adverse Reaction N=646 N=833 N=834 osmotic diuresis, which may lead to reductions in intravascular volume. In clinical studies, treatment with INVOKANA was associated with a dose- Female genital mycotic 3.2% 10.4% 11.4% † dependent increase in the incidence of volume depletion-related adverse infections reactions (e.g., hypotension, postural dizziness, orthostatic hypotension, Urinary tract infections‡ 4.0% 5.9% 4.3% syncope, and dehydration). An increased incidence was observed in patients Increased urination§ 0.8% 5.3% 4.6% on the 300 mg dose. The three factors associated with the largest increase in Male genital mycotic 0.6% 4.2% 3.7% volume depletion-related adverse reactions were the use of loop diuretics, infections¶ moderate renal impairment (eGFR 30 to less than 60 mL/min/1.73 m2), and age Vulvovaginal pruritus 0.0% 1.6% 3.0% 75 years and older (Table 2) [see Dosage and Administration (2.2) in full Prescribing Information, Warnings and Precautions, and Use in Specific Thirst# 0.2% 2.8% 2.3% Populations]. Constipation 0.9% 1.8% 2.3% Table 2: Proportion of Patients With at Least One Volume Depletion-Related Nausea 1.5% 2.2% 2.3% Adverse Reaction (Pooled Results from 8 Clinical Trials) * The four placebo-controlled trials included one monotherapy trial and Comparator INVOKANA INVOKANA three add-on combination trials with metformin, metformin and Group* 100 mg 300 mg sulfonylurea, or metformin and pioglitazone. Baseline Characteristic % % % † Female genital mycotic infections include the following adverse reactions: Overall population 1.5% 2.3% 3.4% Vulvovaginal candidiasis, Vulvovaginal mycotic infection, Vulvovaginitis, 75 years of age and older† 2.6% 4.9% 8.7% Vaginal infection, Vulvitis, and Genital infection fungal. Percentages calculated with the number of female subjects in each group as eGFR less than denominator: placebo (N=312), INVOKANA 100 mg (N=425), and INVOKANA 60 mL/min/1.73 m2† 2.5% 4.7% 8.1% 300 mg (N=430). Use of loop diuretic† 4.7% 3.2% 8.8% ‡ Urinary tract infections include the following adverse reactions: Urinary tract * Includes placebo and active-comparator groups infection, Cystitis, Kidney infection, and Urosepsis. † Patients could have more than 1 of the listed risk factors § Increased urination includes the following adverse reactions: Polyuria, Impairment in Renal Function: INVOKANA is associated with a dose- Pollakiuria, Urine output increased, Micturition urgency, and Nocturia. ¶ dependent increase in serum creatinine and a concomitant fall in estimated Male genital mycotic infections include the following adverse reactions: GFR (Table 3). Patients with moderate renal impairment at baseline had larger Balanitis or Balanoposthitis, Balanitis candida, and Genital infection mean changes. fungal. Percentages calculated with the number of male subjects in each group as denominator: placebo (N=334), INVOKANA 100 mg (N=408), and Table 3: Changes in Serum Creatinine and eGFR Associated with INVOKANA 300 mg (N=404). INVOKANA in the Pool of Four Placebo-Controlled Trials and # Thirst includes the following adverse reactions: Thirst, Dry mouth, and Moderate Renal Impairment Trial Polydipsia. INVOKANA INVOKANA Abdominal pain was also more commonly reported in patients taking Placebo 100 mg 300 mg INVOKANA 100 mg (1.8%), 300 mg (1.7%) than in patients taking placebo (0.8%). N=646 N=833 N=834 Creatinine (mg/dL) 0.84 0.82 0.82 Pool of Placebo- and Active-Controlled Trials: The occurrence of adverse Baseline reactions was also evaluated in a larger pool of patients participating in eGFR (mL/min/1.73 m2) 87.0 88.3 88.8 placebo- and active-controlled trials. Pool of Four Creatinine (mg/dL) 0.01 0.03 0.05 The data combined eight clinical trials [see Clinical Studies (14) in full Week 6 Placebo- Change 2 Prescribing Information] and reflect exposure of 6177 patients to Controlled eGFR (mL/min/1.73 m ) -1.6 -3.8 -5.0 INVOKANA. The mean duration of exposure to INVOKANA was 38 weeks Trials End of Creatinine (mg/dL) 0.01 0.02 0.03 with 1832 individuals exposed to INVOKANA for greater than 50 weeks. Treatment Patients received INVOKANA 100 mg (N=3092), INVOKANA 300 mg (N=3085) Change* eGFR (mL/min/1.73 m2) -1.6 -2.3 -3.4 or comparator (N=3262) once daily. The mean age of the population was INVOKANA INVOKANA 60 years and 5% were older than 75 years of age. Fifty-eight percent (58%) of Placebo 100 mg 300 mg the population was male and 73% were Caucasian, 16% were Asian, and N=90 N=90 N=89 4% were Black or African American. At baseline, the population had Creatinine (mg/dL) 1.61 1.62 1.63 diabetes for an average of 11 years, had a mean HbA1C of 8.0% and 33% Baseline eGFR (mL/min/1.73 m2) 40.1 39.7 38.5 had established microvascular complications of diabetes. Baseline renal Moderate 2 Creatinine (mg/dL) 0.03 0.18 0.28 function was normal or mildly impaired (mean eGFR 81 mL/min/1.73 m ). Renal Week 3 The types and frequency of common adverse reactions observed in the Impairment Change eGFR (mL/min/1.73 m2) -0.7 -4.6 -6.2 Trial pool of eight clinical trials were consistent with those listed in Table 1. In End of Creatinine (mg/dL) 0.07 0.16 0.18 this pool, INVOKANA was also associated with the adverse reactions of Treatment fatigue (1.7% with comparator, 2.2% with INVOKANA 100 mg, and 2.0% Change* eGFR (mL/min/1.73 m2) -1.5 -3.6 -4.0 with INVOKANA 300 mg) and loss of strength or energy (i.e., asthenia) (0.6% with comparator, 0.7% with INVOKANA 100 mg, and 1.1% with * Week 26 in mITT LOCF population INVOKANA 300 mg). In the pool of four placebo-controlled trials where patients had normal or In the pool of eight clinical trials, the incidence rate of pancreatitis (acute or mildly impaired baseline renal function, the proportion of patients who chronic) was 0.9, 2.7, and 0.9 per 1000 patient-years of exposure to experienced at least one event of significant renal function decline, defined as comparator, INVOKANA 100 mg, and INVOKANA 300 mg, respectively. an eGFR below 80 mL/min/1.73 m2 and 30% lower than baseline, was 2.1% with In the pool of eight clinical trials with a longer mean duration of exposure to placebo, 2.0% with INVOKANA 100 mg, and 4.1% with INVOKANA 300 mg. At INVOKANA (68 weeks), the incidence rate of bone fracture was 14.2, 18.7, the end of treatment, 0.5% with placebo, 0.7% with INVOKANA 100 mg, and and 17.6 per 1000 patient years of exposure to comparator, INVOKANA 1.4% with INVOKANA 300 mg had a significant renal function decline.

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In a trial carried out in patients with moderate renal impairment with a 2 Table 4: Incidence of Hypoglycemia* in Controlled Clinical Studies baseline eGFR of 30 to less than 50 mL/min/1.73 m (mean baseline eGFR (continued) 39 mL/min/1.73 m2) [see Clinical Studies (14.3) in full Prescribing Information], the proportion of patients who experienced at least one event of significant In Combination Sitagliptin + INVOKANA 300 mg + with Metformin + Metformin + Metformin + renal function decline, defined as an eGFR 30% lower than baseline, Sulfonylurea Sulfonylurea Sulfonylurea was 6.9% with placebo, 18% with INVOKANA 100 mg, and 22.5% with (52 weeks) (N=378) (N=377) INVOKANA 300 mg. At the end of treatment, 4.6% with placebo, 3.4% with Overall [N (%)] 154 (40.7) 163 (43.2) INVOKANA 100 mg, and 3.4% with INVOKANA 300 mg had a significant renal † function decline. Severe [N (%)] 13 (3.4) 15 (4.0) In a pooled population of patients with moderate renal impairment (N=1085) In Combination Placebo + INVOKANA 100 mg + INVOKANA 300 mg + 2 with Metformin + Metformin + Metformin + Metformin + with baseline eGFR of 30 to less than 60 mL/min/1.73 m (mean baseline eGFR Pioglitazone Pioglitazone Pioglitazone Pioglitazone 48 mL/min/1.73 m2), the overall incidence of these events was lower than in (26 weeks) (N=115) (N=113) (N=114) the dedicated trial but a dose-dependent increase in incident episodes of Overall [N (%)] 3 (2.6) 3 (2.7) 6 (5.3) significant renal function decline compared to placebo was still observed. In Combination Use of INVOKANA was associated with an increased incidence of renal- with Insulin Placebo INVOKANA 100 mg INVOKANA 300 mg related adverse reactions (e.g., increased blood creatinine, decreased (18 weeks) (N=565) (N=566) (N=587) glomerular filtration rate, renal impairment, and acute renal failure), Overall [N (%)] 208 (36.8) 279 (49.3) 285 (48.6) particularly in patients with moderate renal impairment. Severe [N (%)]† 14 (2.5) 10 (1.8) 16 (2.7) In the pooled analysis of patients with moderate renal impairment, the incidence of renal-related adverse reactions was 3.7% with placebo, 8.9% * Number of patients experiencing at least one event of hypoglycemia with INVOKANA 100 mg, and 9.3% with INVOKANA 300 mg. Discontinuations based on either biochemically documented episodes or severe hypoglycemic events in the intent-to-treat population due to renal-related adverse events occurred in 1.0% with placebo, 1.2% † with INVOKANA 100 mg, and 1.6% with INVOKANA 300 mg [see Warnings Severe episodes of hypoglycemia were defined as those where the patient and Precautions]. required the assistance of another person to recover, lost consciousness, or experienced a seizure (regardless of whether biochemical Genital Mycotic Infections: In the pool of four placebo-controlled clinical documentation of a low glucose value was obtained) trials, female genital mycotic infections (e.g., vulvovaginal mycotic infection, vulvovaginal candidiasis, and vulvovaginitis) occurred in 3.2%, 10.4%, and Laboratory Tests: Increases in Serum Potassium: Dose-related, transient 11.4% of females treated with placebo, INVOKANA 100 mg, and INVOKANA mean increases in serum potassium were observed early after initiation of 300 mg, respectively. Patients with a history of genital mycotic infections INVOKANA (i.e., within 3 weeks) in a trial of patients with moderate renal were more likely to develop genital mycotic infections on INVOKANA. impairment [see Clinical Studies (14.3) in full Prescribing Information]. In this Female patients who developed genital mycotic infections on INVOKANA trial, increases in serum potassium of greater than 5.4 mEq/L and 15% above were more likely to experience recurrence and require treatment with oral baseline occurred in 16.1%, 12.4%, and 27.0% of patients treated with or topical antifungal agents and anti-microbial agents [see Warnings and placebo, INVOKANA 100 mg, and INVOKANA 300 mg, respectively. More Precautions]. severe elevations (i.e., equal or greater than 6.5 mEq/L) occurred in 1.1%, In the pool of four placebo-controlled clinical trials, male genital mycotic 2.2%, and 2.2% of patients treated with placebo, INVOKANA 100 mg, and infections (e.g., candidal balanitis, balanoposthitis) occurred in 0.6%, 4.2%, INVOKANA 300 mg, respectively. In patients with moderate renal and 3.7% of males treated with placebo, INVOKANA 100 mg, and INVOKANA impairment, increases in potassium were more commonly seen in those with 300 mg, respectively. Male genital mycotic infections occurred more elevated potassium at baseline and in those using medications that reduce commonly in uncircumcised males and in males with a prior history of potassium excretion, such as potassium-sparing diuretics, angiotensin- balanitis or balanoposthitis. Male patients who developed genital mycotic converting-enzyme inhibitors, and angiotensin-receptor blockers [see infections on INVOKANA were more likely to experience recurrent Warnings and Precautions]. infections (22% on INVOKANA versus none on placebo), and require Increases in Serum Magnesium: Dose-related increases in serum treatment with oral or topical antifungal agents and anti-microbial agents magnesium were observed early after initiation of INVOKANA (within 6 than patients on comparators. In the pooled analysis of 8 controlled trials, weeks) and remained elevated throughout treatment. In the pool of four phimosis was reported in 0.3% of uncircumcised male patients treated with placebo-controlled trials, the mean change in serum magnesium levels was INVOKANA and 0.2% required circumcision to treat the phimosis [see 8.1% and 9.3% with INVOKANA 100 mg and INVOKANA 300 mg, respectively, Warnings and Precautions]. compared to -0.6% with placebo. In a trial of patients with moderate renal Hypoglycemia: In all clinical trials, hypoglycemia was defined as any event impairment [see Clinical Studies (14.3) in full Prescribing Information], serum regardless of symptoms, where biochemical hypoglycemia was documented magnesium levels increased by 0.2%, 9.2%, and 14.8% with placebo, (any glucose value below or equal to 70 mg/dL). Severe hypoglycemia was INVOKANA 100 mg, and INVOKANA 300 mg, respectively. defined as an event consistent with hypoglycemia where the patient Increases in Serum Phosphate: Dose-related increases in serum phosphate required the assistance of another person to recover, lost consciousness, or levels were observed with INVOKANA. In the pool of four placebo controlled experienced a seizure (regardless of whether biochemical documentation of trials, the mean change in serum phosphate levels were 3.6% and 5.1% with a low glucose value was obtained). In individual clinical trials [see Clinical INVOKANA 100 mg and INVOKANA 300 mg, respectively, compared to Studies (14) in full Prescribing Information], episodes of hypoglycemia 1.5% with placebo. In a trial of patients with moderate renal impairment [see occurred at a higher rate when INVOKANA was co-administered with Clinical Studies (14.3) in full Prescribing Information], the mean serum insulin or sulfonylureas (Table 4) [see Warnings and Precautions]. phosphate levels increased by 1.2%, 5.0%, and 9.3% with placebo, INVOKANA 100 mg, and INVOKANA 300 mg, respectively. Table 4: Incidence of Hypoglycemia* in Controlled Clinical Studies Increases in Low-Density Lipoprotein Cholesterol (LDL-C) and non-High- Monotherapy Placebo INVOKANA 100 mg INVOKANA 300 mg Density Lipoprotein Cholesterol (non-HDL-C): In the pool of four placebo- (26 weeks) (N=192) (N=195) (N=197) controlled trials, dose-related increases in LDL-C with INVOKANA were Overall [N (%)] 5 (2.6) 7 (3.6) 6 (3.0) observed. Mean changes (percent changes) from baseline in LDL-C relative In Combination Placebo + INVOKANA 100 mg + INVOKANA 300 mg + to placebo were 4.4 mg/dL (4.5%) and 8.2 mg/dL (8.0%) with INVOKANA with Metformin Metformin Metformin Metformin 100 mg and INVOKANA 300 mg, respectively. The mean baseline LDL-C (26 weeks) (N=183) (N=368) (N=367) levels were 104 to 110 mg/dL across treatment groups [see Warnings and Overall [N (%)] 3 (1.6) 16 (4.3) 17 (4.6) Precautions]. Severe [N (%)]† 0 (0) 1 (0.3) 1 (0.3) Dose-related increases in non-HDL-C with INVOKANA were observed. In Combination Glimepiride + INVOKANA 100 mg + INVOKANA 300 mg + Mean changes (percent changes) from baseline in non-HDL-C relative to with Metformin Metformin Metformin Metformin placebo were 2.1 mg/dL (1.5%) and 5.1 mg/dL (3.6%) with INVOKANA 100 mg (52 weeks) (N=482) (N=483) (N=485) and 300 mg, respectively. The mean baseline non-HDL-C levels were 140 to Overall [N (%)] 165 (34.2) 27 (5.6) 24 (4.9) 147 mg/dL across treatment groups. Severe [N (%)]† 15 (3.1) 2 (0.4) 3 (0.6) Increases in Hemoglobin: In the pool of four placebo-controlled trials, mean In Combination Placebo + INVOKANA 100 mg INVOKANA 300 mg changes (percent changes) from baseline in hemoglobin were -0.18 g/dL with Sulfonylurea Sulfonylurea + Sulfonylurea + Sulfonylurea (-1.1%) with placebo, 0.47 g/dL (3.5%) with INVOKANA 100 mg, and 0.51 g/dL (18 weeks) (N=69) (N=74) (N=72) (3.8%) with INVOKANA 300 mg. The mean baseline hemoglobin value was Overall [N (%)] 4 (5.8) 3 (4.1) 9 (12.5) approximately 14.1 g/dL across treatment groups. At the end of treatment, In Combination Placebo + INVOKANA 100 mg + INVOKANA 300 mg + 0.8%, 4.0%, and 2.7% of patients treated with placebo, INVOKANA 100 mg, with Metformin + Metformin + Metformin Metformin + and INVOKANA 300 mg, respectively, had hemoglobin above the upper limit Sulfonylurea Sulfonylurea + Sulfonylurea Sulfonylurea of normal. (26 weeks) (N=156) (N=157) (N=156) DRUG INTERACTIONS Overall [N (%)] 24 (15.4) 43 (27.4) 47 (30.1) UGT Enzyme Inducers: Rifampin: Co-administration of canagliflozin Severe [N (%)]† 1 (0.6) 1 (0.6) 0 with rifampin, a nonselective inducer of several UGT enzymes, including

black ES501141_ME101014_G86_FP.pgs 09.18.2014 01:53 ADV INVOKANA™ (canagliﬂozin) tablets INVOKANA™ (canagliﬂozin) tablets

UGT1A9, UGT2B4, decreased canagliflozin area under the curve (AUC) by overdosage 51%. This decrease in exposure to canagliflozin may decrease efficacy. If There were no reports of overdose during the clinical development program an inducer of these UGTs (e.g., rifampin, phenytoin, phenobarbital, ritonavir) of INVOKANA (canagliflozin). must be co-administered with INVOKANA (canagliflozin), consider In the event of an overdose, contact the Poison Control Center. It is also increasing the dose to 300 mg once daily if patients are currently reasonable to employ the usual supportive measures, e.g., remove tolerating INVOKANA 100 mg once daily, have an eGFR greater than unabsorbed material from the gastrointestinal tract, employ clinical 60 mL/min/1.73 m2, and require additional glycemic control. Consider other monitoring, and institute supportive treatment as dictated by the patient’s antihyperglycemic therapy in patients with an eGFR of 45 to less than clinical status. Canagliflozin was negligibly removed during a 4-hour 60 mL/min/1.73 m2 receiving concurrent therapy with a UGT inducer and hemodialysis session. Canagliflozin is not expected to be dialyzable by require additional glycemic control [see Dosage and Administration (2.3) peritoneal dialysis. and Clinical Pharmacology (12.3) in full Prescribing Information]. PaTIeNT CoUNseLINg INForMaTIoN digoxin: There was an increase in the AUC and mean peak drug concen- See FDA-approved patient labeling (Medication Guide). tration (Cmax) of digoxin (20% and 36%, respectively) when co-administered Instructions: Instruct patients to read the Medication Guide before starting with INVOKANA 300 mg [see Clinical Pharmacology (12.3) in full Prescribing INVOKANA (canagliflozin) therapy and to reread it each time the Information]. Patients taking INVOKANA with concomitant digoxin should be prescription is renewed. monitored appropriately. Inform patients of the potential risks and benefits of INVOKANA and of Use IN sPeCIFIC PoPULaTIoNs alternative modes of therapy. Also inform patients about the importance of Pregnancy: Teratogenic Effects: Pregnancy Category C: There are no adherence to dietary instructions, regular physical activity, periodic blood adequate and well-controlled studies of INVOKANA in pregnant women. glucose monitoring and HbA1C testing, recognition and management of Based on results from rat studies, canagliflozin may affect renal hypoglycemia and hyperglycemia, and assessment for diabetes development and maturation. In a juvenile rat study, increased kidney complications. Advise patients to seek medical advice promptly during weights and renal pelvic and tubular dilatation were evident at greater than periods of stress such as fever, trauma, infection, or surgery, as medication or equal to 0.5 times clinical exposure from a 300 mg dose [see Nonclinical requirements may change. Toxicology (13.2) in full Prescribing Information]. Instruct patients to take INVOKANA only as prescribed. If a dose is missed, These outcomes occurred with drug exposure during periods of animal advise patients to take it as soon as it is remembered unless development that correspond to the late second and third trimester of it is almost time for the next dose, in which case patients should human development. During pregnancy, consider appropriate alternative skip the missed dose and take the medicine at the next regularly scheduled therapies, especially during the second and third trimesters. INVOKANA time. Advise patients not to take two doses of INVOKANA at the same time. should be used during pregnancy only if the potential benefit justifies the Inform patients that the most common adverse reactions associated with potential risk to the fetus. INVOKANA are genital mycotic infection, urinary tract infection, and Nursing Mothers: It is not known if INVOKANA is excreted in human milk. increased urination. INVOKANA is secreted in the milk of lactating rats reaching levels 1.4 times Inform female patients of child bearing age that the use of INVOKANA higher than that in maternal plasma. Data in juvenile rats directly exposed during pregnancy has not been studied in humans, and that INVOKANA to INVOKANA showed risk to the developing kidney (renal pelvic and should only be used during pregnancy only if the potential benefit justifies tubular dilatations) during maturation. Since human kidney maturation the potential risk to the fetus. Instruct patients to report pregnancies to their occurs in utero and during the first 2 years of life when lactational exposure physicians as soon as possible. may occur, there may be risk to the developing human kidney. Because Inform nursing mothers to discontinue INVOKANA or nursing, taking into many drugs are excreted in human milk and because of the potential for account the importance of drug to the mother. serious adverse reactions in nursing infants from INVOKANA, a decision Laboratory Tests: Due to its mechanism of action, patients taking INVOKANA should be made whether to discontinue nursing or to discontinue will test positive for glucose in their urine. INVOKANA, taking into account the importance of the drug to the mother [see Nonclinical Toxicology (13.2) in full Prescribing Information]. Hypotension: Inform patients that symptomatic hypotension may occur with INVOKANA and advise them to contact their doctor if they experience such Pediatric Use: Safety and effectiveness of INVOKANA in pediatric patients symptoms [see Warnings and Precautions]. Inform patients that dehydration under 18 years of age have not been established. may increase the risk for hypotension, and to have adequate fluid intake. geriatric Use: Two thousand thirty-four (2034) patients 65 years and older, Genital Mycotic Infections in Females (e.g., Vulvovaginitis): Inform female and 345 patients 75 years and older were exposed to INVOKANA in nine patients that vaginal yeast infection may occur and provide them with clinical studies of INVOKANA [see Clinical Studies (14.3) in full Prescribing information on the signs and symptoms of vaginal yeast infection. Advise Information]. them of treatment options and when to seek medical advice [see Warnings Patients 65 years and older had a higher incidence of adverse reactions and Precautions]. related to reduced intravascular volume with INVOKANA (such as Genital Mycotic Infections in Males (e.g., Balanitis or Balanoposthitis): hypotension, postural dizziness, ortho static hypotension, syncope, and Inform male patients that yeast infection of penis (e.g., balanitis or dehydration), particularly with the 300 mg daily dose, compared to younger balanoposthitis) may occur, especially in uncircumcised males and patients patients; more prominent increase in the incidence was seen in patients with prior history. Provide them with information on the signs and symptoms who were 75 years and older [see Dosage and Administration (2.1) in full of balanitis and balanoposthitis (rash or redness of the glans or foreskin of Prescribing Information and Adverse Reactions]. Smaller reductions in the penis). Advise them of treatment options and when to seek medical HbA1C with INVOKANA relative to placebo were seen in older (65 years and advice [see Warnings and Precautions]. older; -0.61% with INVOKANA 100 mg and -0.74% with INVOKANA 300 mg Hypersensitivity Reactions: Inform patients that serious hypersensitivity relative to placebo) compared to younger patients (-0.72% with INVOKANA reactions such as urticaria and rash have been reported with INVOKANA. 100 mg and -0.87% with INVOKANA 300 mg relative to placebo). Advise patients to report immediately any signs or symptoms suggesting renal Impairment: The efficacy and safety of INVOKANA were evaluated in allergic reaction or angioedema, and to take no more drug until they have a study that included patients with moderate renal impairment (eGFR 30 to consulted prescribing physicians. 2 less than 50 mL/min/1.73 m ) [see Clinical Studies (14.3) in full Prescribing Urinary Tract Infections: Inform patients of the potential for urinary tract Information]. These patients had less overall glycemic efficacy and had a infections. Provide them with information on the symptoms of urinary tract higher occurrence of adverse reactions related to reduced intravascular infections. Advise them to seek medical advice if such symptoms occur. volume, renal-related adverse reactions, and decreases in eGFR compared to patients with mild renal impairment or normal renal function (eGFR Active ingredient made in Belgium greater than or equal to 60 mL/min/1.73 m2); patients treated with Manufactured for: INVOKANA 300 mg were more likely to experience increases in potassium Janssen Pharmaceuticals, Inc. [see Dosage and Administration (2.2) in full Prescribing Information, Titusville, NJ 08560 Warnings and Precautions, and Adverse Reactions]. Finished product manufactured by: The efficacy and safety of INVOKANA have not been established in patients Janssen Ortho, LLC with severe renal impairment (eGFR less than 30 mL/min/1.73 m2), with ESRD, Gurabo, PR 00778 or receiving dialysis. INVOKANA is not expected to be effective in these Licensed from Mitsubishi Tanabe Pharma Corporation patient populations [see Contraindications and Clinical Pharmacology (12.3) © 2013 Janssen Pharmaceuticals, Inc. in full Prescribing Information]. Hepatic Impairment: No dosage adjustment is necessary in patients with 10282402 mild or moderate hepatic impairment. The use of INVOKANA has not 007425-131210 been studied in patients with severe hepatic impairment and is therefore not recommended [see Clinical Pharmacology (12.3) in full Prescribing Information].

black ES501107_ME101014_H86_FP.pgs 09.18.2014 01:49 ADV Patient communication

Technology opens new avenues for patient communication Portals, e-visits offer convenience and increased satisfaction

by Jeffrey Bendix Senior Editor

n the Friday evening of pital, family members, and care coor- Labor Day weekend, dinators to get him out of the hospital HIGHLIGHTS Mark Collins, MD, was earlier, that was a big win for him and notifed that a patient his family.” 01 Video visits offer had been unexpect- Collins’ experience is one example physicians another form of edly hospitalized for of the value new forms of communica- technology for extending worsening dementia tion technology are bringing to primary their reach and improving and congestive heart care physicians and their patients. Pa- communication with patients, failure. It soon became tient portals give patients 24/7 access although its potential is clear that the patient to information such as lab results and limited by laws prohibiting would require home diagnostic tests and allow them to re- doctors from practicing health services after being discharged. view medication lists and request pre- across state lines. Normally, fnding a hospital bed and scription reflls. Tey also enable secure arranging for its delivery and the nec- e-mail communication with doctors, 02 Most patient portals essary home support services would representing the most common form of now include a system for take several days, even without an in- the new technologies. Tat’s due in part routing incoming emails so tervening holiday. But working through to physicians having to use them to at- that they can be handled his practice’s electronic health record test to meaningful use stage 2. by the appropriate staff (EHR) and its patient portal, Collins But other forms of technology, such member. was able to coordinate with the pa- as telehealth, are making rapid inroads tient’s wife and his practice’s care coor- into the nation’s healthcare delivery dinator to fnd a home hospital bed and system. And just over the horizon is be ready for the patient to return home the expected widespread use of remote the following Tuesday. monitoring devices and their ability to “Even three years ago, that type of gather and transmit large quantities of coordinated care would never have real-time health data to physicians’ of- happened,” says Collins, a family practi- fces. tioner with Novant Health in suburban As with any new form of technology, Charlotte, North Carolina. “To be able however, the new communication and to coordinate the bed, home health diagnostic tools have costs associated services, and lab results among the hos- with them, ranging from patients mis-

MedicalEconomics.com Medical econoMics ❚ OctOber 10, 2014 87

magentablackcyanyellow ES502514_ME101014_087.pgs 09.22.2014 20:11 ADV Patient communication

understanding results of lab tests to physi- tients who prefer telephone communication cian fears of e-mail encroaching on their free to reach their physicians’ ofce. “It helps even time to the possibility that they will lead to the patients who aren’t using the portal have less of the all-important face-to-face contact a better experience,” he says. between doctors and their patients. adjusting workflow Patient education In common with many physicians, Collins Physicians and healthcare systems face the was concerned that a patient portal would challenge of making patients aware of these bring with it a food of e-mails to which he new tools, and educating them in their use. would have to respond during evenings and A recent survey by the website weekends. technologyadvice.com found that just under So far that has not happened, in part be- 50% of patients knew that their doctor ofers cause the practice tells patients that doctors a patient portal, 40% didn’t know if their will respond to non-emergent messages re- doctor did or did not ofer it, and 11% knew ceived through the portal during weekday for certain that their doctor did not ofer a business hours. Collins notes that “tele- portal. phone tag” was also time-consuming, and Among patients who know about and often meant patients had to wait days to get use portals, enthusiasm for them generally is lab results or a question answered. strong. “We found out early on that patients Moreover, telephone messages from pa- were hungry for the kind of interaction with tients generally would go frst to a nurse, who providers that portals give them,” says R. would then relay them to the doctor, opening Henry Capps, MD, senior vice president and the possibility of misunderstanding or mis- chief medical information ofcer at Novant. communication. “Now it’s a much quicker re- When Novant introduced its MyChart sponse, and eliminates the need for third-par- portal it thought the service would appeal ty interpretation of the message because it’s most to mothers of young children, who coming directly to me,” he says. “Tat makes would use it to schedule appointments and us much more efcient.” request prescription reflls online. “What we Most patient portals now include a system didn’t anticipate were the large numbers of for routing incoming e-mails so that they can 50-to-70-year-olds who thought this was just be handled by the appropriate staf member, the coolest thing since sliced bread,” Capps says John Sharp, MSSA, FHIMSS, senior man- says. Novant currently receives 55,000 e-mails ager, information systems for the Health In- per month to its 400 primary care practices. formation Management Systems Society. “If Novant rolled out MyChart via its Epic you prioritize which messages should go to EHR system in 2011, at frst using it just for whom in the ofce, then it can be pretty much e-mails. Subsequently it added other features, the way you now handle phone calls, and not such as online appointments, open sched- be an undue burden on physicians,” he says. uling and, most recently, e-check in, which Another possible drawback of patient por- allows patients to update clinical and non- tals is that patients will misunderstand their clinical information in their records before lab results or outcome of a diagnostic test. It’s coming in for an appointment. In all, 360,000 a problem that Mark Friedberg, MD, MPP, a patients, or about one-third of patients seen Boston-area internist and senior natural sci- in an ambulatory setting, have used the portal entist with the Rand Corp. has encountered. in some form, Capps says. “My patients can see their lab results, but Collins says about 40% of his patients use the way the results are displayed would only the portal. “It’s been a great tool,” he says. “My make sense to a doctor,” he says. “Every result patients ranging from teenagers to people in is there, and every abnormality, no matter their 90s are on the MyChart account. Tey how minor, is fagged. And that can cause a use it for asking follow-up questions after a lot of anxiety, even though an experienced visit, getting lab results, checking prescrip- healthcare professional would look at it and tions, and numerous other things.” say everything’s fne.” An unexpected beneft of the portal, says Novant encourages physicians to ap- Capps, has been a reduction in the number pend a personal message to a patient’s lab of phone calls to Novant’s primary care prac- results before releasing them. tices. Tat, in turn, has made it easier for pa- “Patients basically just want to 90

88 Medical econoMics ❚ OctOber 10, 2014 MedicalEconomics.com

magentablackcyanyellow ES502513_ME101014_088.pgs 09.22.2014 20:11 ADV WEBINAR New Approaches in Enhancing Patient Access: A Focus on Steroid Responsive Dermatoses and Severe Recalcitrant Nodular Acne

Featuring Mark D. Kaufmann, MD Associate Clinical Professor, Department of Dermatology Icahn School of Medicine at Mount Sinai

Promius Pharma is exploring new ways to enhance patient access, including the implementation of a specialized distribution platform and an authorized generic version of one of their products.

In this free, 60-minute webinar, Dr. Kaufmann will discuss with you the potential beneﬁts of these developments.

Wednesday, November 5, 2014 6:00 PM - 7:00 PM EST